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V 



MEDICAL DIAGNOSIS 



GREENE 



MEDICAL DIAGNOSIS 

FOR THE 

STUDENT AND PRACTITIONER 



BY 

CHARLES LYMAN GREENE, M. D., 

ST. PAUL 

LECTURER IN APPLIED ANATOMY, UNIVERSITY OF MINNESOTA, 1 892-4. PROFESSOR OF APPLIED 
ANATOMY AND INSTRUCTOR IN CLINICAL MEDICINE, 1 894-7. PROFESSOR OF CLINICAL 
MEDICINE AND PHYSICAL DIAGNOSIS, 1897-1903. PROFESSOR OF THE THEORY AND 
PRACTICE OF MEDICINE, I9O3-9. PROFESSOR OF MEDICINE, CHIEF OF THE 
DEPARTMENT OF MEDICINE AND CHIEF OF MEDICAL CLINIC IN THE UNI- 
VERSITY HOSPITALS, 1909-15. AUTHOR OF THE MEDICAL EXAMINATION 
FOR LIFE INSURANCE AND ITS ASSOCIATED CLINICAL METHODS. 
ATTENDING PHYSICIAN, ST. LUKE'S HOSPITAL AND MILLER 
HOSPITAL; CONSULTING PHYSICIAN, STATE HOSPITAL 
FOR CRIPPLED AND DEFORMED CHILDREN; 
MEMBER OF THE ASSOCIATION OF 
AMERICAN PHYSICIANS, AMERICAN 
THERAPEUTIC SOCIETY, 
ETC., ETC. 



FIFTH EDITION REVISED AND ENLARGED 

WITH 14 COLORED PLATES AND 

623 OTHER ILLUSTRATIONS 



PHILADELPHIA 

P. BLAKISTON'S SON & CO. 

1012 WALNUT STREET 






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v 



v 



Copyright December, 1922, by P. Blakiston's Son & Co. 



. 



©GI.A(J92aiO 



PRINTED IN U. S. A. 
IY THE MAPLE PRESS YORK PA 



Dfi!ii22 



PREFACE TO THE FIFTH EDITION 

The author regrets that the obligations of military service in the Great 
War and the concentration upon private affairs necessarily following it have 
delayed the issuance of this volume. 

He has made full use, however, of the opportunity afforded for a delib- 
erate, painstaking and thorough revision. 

Every section has been expanded by important additions and no effort 
spared to make the present volume a thoroughly practical and up to date 
treatise upon modern medical diagnosis. The rise of diseases of the heart 
and blood-vessels to first place on the list of causes of premature death makes 
imperatively necessary a better understanding of the now unrealized possi- 
bilities along the lines of their early recognition, prevention, and retardation. 

The author has endeavored, therefore, to further emphasize in this volume 
the means of early and accurate diagnosis now available to the physician. 

This has involved not only an amplification of those sections dealing 
specifically with etiology and clinical technic, but also a more extended 
reference to and discussion of the adoption of better standards and a more 
helpful view point. 

In the preceding edition considerable space was devoted to the clinical 
use of instruments of precision in the diagnosis of heart disease, but the great 
and growing interest in these newer aids to the detection and efficient manage- 
ment of heart lesions has led the author to expand greatly the sections 
dealing with polygraphic and electrocardiographic technic and interpretation. 

Among the many additions to the text, the author would call attention 
especially to the discussion of " influenza" and the interesting and unique 
radiograms of Dr. John Hunter Selby, illustrating the development and 
course of that "hemorrhagic pneumonitis" which gave to the epidemic of 
1 918 its terrific mortality. 

The " Symptom Index" incorporated in this Edition must greatly increase 
the usefulness of the volume. 

The author would express his grateful appreciation of the assistance 
rendered by his valued associate Dr. Harold E. Richardson, by Dr. Frank S. 
Bissell, Dr. Wm. Hunter Selby and many others. 

He would acknowledge also the courtesy of his -publishers and the 
generous cooperation which has made possible the addition of 105 pages to 
the text and the introduction of 74 new illustrations at a time when 
publishing costs have risen to hitherto undreamed of heights. 

The author hopes sincerely that this new volume will merit a continuance 
of the kind reception accorded it through so many years by student and 
practitioner alike. 

Chas. Lyman Greene. 
914 Lowry Building, 
St. Paul, Minnesota. 



CONTENTS 



Page 
CERTAIN FUNDAMENTAL PRINCIPLES AND SPECIAL PROBLEMS ... i 

CASE-TAKING n 

The value of the case-book; the subjective vs. the objective; "hearsay evidence," 
ii. 

The Outward Signs of Disease. n 

Facial expression, 12; syphilis; recent weight-loss or gain; edema, 13; voice and 
speech, 14; the color of the skin, 15; cyanosis; local vasomotor relaxation or 
paralysis, 16; other abnormal color variations, 17; jaundice, 18; dry and moist 
skin; edema, 20; lymphangitis and phlebitis; ascites, 23; subcutaneous emphy- 
sema; subcutaneous hemorrhages, 26; collateral venous circulation, 27; drug 
eruptions, desquamations, scars, 28; the head, 30; the eyelids; the eyes, 31; the 
nose; the ear, ^3', the lips; the buccal cavity, 34; stomatitis, 35; the tongue, 
36; the gums; the teeth, 38; the jaws; the soft palate; the hands, 40; the finger- 
nails, 41; the arm and leg, 42; the back; the joints, 43; tremor, 45; spasms, 
cramps, and convulsive seizures, 46; infantile convulsions, 49; station, attitude, 
gait, 49; orthopnea, 50; gait, 51; weight and height, 54; the attitude of life 
insurance companies, 56. 

Age — Race — Sex — Habits — Social State and Residence 58 

Age, 58; sex; race; habits and environment, 60; drug habit; marriage, 62; occu- 
pation, 63; mineral poisoning, 64; occupational stigmata, 65; residence, 66; family 
history, 67; the nervous system in heredity, 68; tuberculosis, 69; previous 
illnesses, 70. 

History and Analysis of the "Present Ailment" 71 

Fever, 71; pathologic variations in temperature, 72; the phenomena of fever, 75; 
coma and its congeners, 79; pain, 83; paroxysmal pain, 85; colic, 86; acute 
intestinal obstruction, 87; headache, 90; sinus headaches, 91; neuralgia, 94; 
neuritis; muscular rheumatism,, 98; general comment, 99; tenderness, 100; 
perversions of sensation, 101; insomnia; vertigo, 103; dyspnea, 105; variations 
in respiratory rhythm, 107; shock and collapse, 109. 
DISEASES DEPENDENT UPON OR ASSOCIATED WITH CHANGES IN THE 

BLOOD OR BLOOD-MAKING ORGANS AND DUCTLESS GLANDS. . no 
Examination of the blood; Hematology, no; hemoglobin, 116; Erythrocytes and 
leucocytes, 122; Unusual or abnormal forms, 123; the red blood cell, 126; the 
blood cell count, 128; the red count, 129; the leucocyte count, 131; the hemato- 
crit, 136; leucocytosis and lymphocytosis, 137; cytodiagnosis, 143; inoscopy, 143. 
The anemias: types of anemia, 144; general considerations, 145; general etio- 
logic factors, 147; chlorosis, 148; the Addisonian pernicious anemia, 151; aplastic 
pernicious anemia, 154; splenic anemia, 154; splenomegaly with hepatic cirrhosis 
and anemia; splenomegaly of the Gaucher type, 155; congenital hemolytic 
jaundice, 155; leukemia, 156; myeloid leukemia; symptoms, 157; lymphatic 
leukemia; symptoms, 158; blood findings; acute lymphatic leukemia, 159; 
differential diagnosis of the anemias, 160; chloroma; Still's syndrome; myeloma; 
leukanemia, 161; prognosis in the anemias, 162. 

The polycythemias: polycythemia (erythrocytosis), 162; erythrocytosis 
megalosplenica, 163; 

Certain obscure diseases associated with anemia: Hodgkin's disease, 164; 
differential diagnosis, 167; purpura, 168; hemophilia, 169; scorbutus, 171; 
Barlow's disease, 171. 

vii 



Vlll CONTENTS 

Page 
DISEASES OF THE GLANDS OF INTERNAL SECRETION 173 

Addison's disease, 173; symptoms, 174; status thymicolymphaticus, 175; 
myxedema and cretinism, 176; symptoms of sporadic cretinism, 177; endemic 
cretinism, 178; hyperthyroidism, 179; etiology; symptoms, 180; tests of impor- 
tance, 181; acromegaly, 184; symptoms, 185; gigantism; hypopituitarism; infan- 
tilism; pancreatic infantilism; exogenous obesity, 187; endogenous obesity, 188. 

CERTAIN DISEASES OF UNKNOWN CAUSATION 188 

Osteitis deformans; leontiasis ossea; micromegaly, 188; plumonary hypertrophic 
osteoarthropathy, 189; achondroplasia, 189. 

URINALYSIS AND DISEASES OF THE KIDNEY.- 189 

Polyuria, 190; oliguria; anuria, 191; the color; indican, 192; indol, 193; skatol; 
uroerythrin; melanin; urobilin; the oxyacids; alcaptone, 194; hydrochinon and 
pyrocatechin; urochrome and hematoporphyrin ; test of Weiss; Salkowski's test; 
creatinin, 195; milky urine; transparency; odor; reaction, 196; specific gravity, 
197; urinary solids; total nitrogen, 198; estimation of total nitrogen, 199; urea; 
urea in Bright's disease, 201; uric acid, 210; urinary chlorides, 212; the phos- 
phates, 213; the sulphates; the oxalates; iron, ammonia, 214; albuminuria; 
nucleoalbumin; albumoses; 215; the Bence-Jones protein; the significance of 
albuminuria, 216; tests for. albumin, 217; quantitative tests for albumin, 220; 
pus; blood, 222; bile; tests for glucose in urine, 224; Allen's test; 225; the fer- 
mentation test; quantitative estimation with Whitney's reagent, 226; the 
polarimeter; levulose, 227; lactose; pentose; maltose; glycuronic acid; ace- 
tone, diacetic acid and oxybutyric acid, 228; diacetic acid — test; acetone — 
Legal's test, Lieben's test, 229. 

The examination of urinary sediments, 230; urates, 231; uric acid, 233; 
blood, 234; pus; varying significance of pus in the urine, 235; epithelium, 236; 
casts; true casts, 239; typical forms; cylindroid storms; the gonococcus, 244; 
Ehrlich's typhoid diazo reaction, 245; uremia, 246; cryoscopy, 249. 
The classification of renal diseases; renal inefficiency, 250: the phenolsul- 
phonephthalein test, 251; chronic passive congestion of the kidney, 253; general 
symptoms, 253; the kidney of pregnancy; acute severe congestion and acute 
nephritis, 254; general symptoms, 256; urinary findings, 257; acute focal glomeru- 
lonephritis; acute interstitial non-suppurative nephritis; chronic parenchymatous 
nephritis, 258; urinary findings, 259; the small white kidney, 260; focal arterio- 
sclerotic form, 261; chronic interstitial nephritis, 261; urinary findings, 264; 
trench nephritis, 266; amyloid kidney, 266; movable and floating kidney, 266; 
pyelitis and pyelonephritis, 268; renal tuberculosis, 269; renal infarct, 270; renal 
tumors; renal syphilis; renal cysts, 271; cystic degeneration of the kidney, 272; 
hydronephrosis, 272; acute cystitis; chronic cystitis, 273; Tuberculosis of the 
bladder, 273; tumors of the bladder; acute prostatitis; chronic prostatitis; 
urinary calculus, 274; chemic examination of urinary calculi, 275. 

METHODS AND MEANS EMPLOYED IN THE DIAGNOSIS OF THE DIS- 
EASE OF THE THORACIC VISCERA 762 

The preparation of the patient; the topographic anatomy of the chest, 277; the 
thoracic viscera, 278; the liver; the pleurae, 279; the lobes of the lung, 281. 
Examination of the chest, with especial reference to the lungs and 
pleura, 282; inspection; essential points, 282; chest measurements; chest 
movements, 285; the diaphragm phenomenon; palpation, 286; percussion, 289; 
percussion sounds, 292; the normal percussion sounds, 293; spinal percussion 
zones, 296; special modifications of the percussion note, 298; auscultation, 301; 
vesicular breathing; puerile or harsh respiration, 305; bronchial breathing, 306; 
tubular breathing, 307; vocal resonance, 308; diminished vocal resonance, 308; 
bronchophony; pectoriloquy; egophony, 309; rales; dry rales; moist rales, 310; 
sounds apart; friction sounds, 312; bronchoscopy, 313. 



CONTENTS IX 

Page 
INTRATHORACIC RADIOGRAPHY AND FLUOROSCOPY: THE ROENT- 
GENOGRAPHS EXAMINATION OF T.HE LUNGS AND PLEURA, 

FRANK S. BISSELL, M. D 314 

The hilus shadows; method of examination; tuberculosis, 314; advanced tuber- 
culosis, 317; cavities; resolution, 319; apical tuberculosis; differential diagnosis, 
320; pneumonoconiosis, chalicosis, anthracosis, 320; characteristics of other 
pulmonary lesions; chronic bronchitis; bronchiectasis; tumors; foreign bodies in 
the bronchi; exudative pleuritis, 321; pleuritic adhesions, 323; pneumothorax, 
323; artificial pneumothorax; pneumonia; broncho-pneumonia, 324; lung 
abscess; gangrene; empyema; emphysema, 326. 

Cough and sputum: cough; diverse causes; reflex cough, 326; hysteric, dyspep- 
tic, tobacco, dry and moist and paroxysmal cough, 327; pressure cough; various 
types, 328. The sputum, 328; reaction; color, 329; heart disease cells; air 
content; macroscopic appearance, 329; amount; odor; albumin content; Zenoni's 
differential color test, 330; microscopic findings, 331; the tubercle bacillus; 
concentrated sediment — the antiformin method, 332; Loeffler's modification 
of Uhlenhuth's antiformin procedure; Ziehl-Neelsen method, 332; Gabbett's 
method, 333. 

RHINOLOGY, PHARYNGOLOGY AND LARYNGOLOGY 334 

Diagnosis at sight; technic; larynx; naso-pharynx, 334. 

Diseases of the nose: acute coryza; hypertrophic rhinitis; exostoses and 

ecchondroses; septal deviation; septal hematoma; septal abscess, 335; atrophic 

rhinitis; necrosing ethmoiditis; hay fever; nasal polypi; sarcoma and carcinoma; 

nasal syphilis, 336; epistaxis; the accessory sinuses, 337; the frontal sinuses; the 

ethmoidal sinuses; the sphenoidal sinuses, 338. 

Diseases of the pharynx: acute pharyngitis; chronic pharyngitis; atrophic 

pharyngitis, 339; post-nasal adenoids, 340; syphilitic pharyngitis; retro-pharyn- 

geal abscess; paralysis and tumors, 341. 

Diseases of the tonsils: acute tonsillitis, 341; suppurative tonsillitis; chronic 

tonsillitis, 342. 

Diseases of the larynx: simple, acute and subacute laryngitis, 342; edema of 

the glottis; croup, 343; laryngismus stridulus; membranous croup; syphilitic 

laryngitis; tuberculous laryngitis; tumors of the larynx, 344. 

DISEASES OF THE BRONCHI, LUNGS AND PLEURA 345 

Bronchitis; acute tracheo-bronchitis, 345; rationale of acute bronchitis, 346; 
chronic bronchitis; eosinophilic bronchitis; obliterative bronchitis; putrid 
bronchitis; fibrinous bronchitis; syphilitic bronchitis, 347; trench gas poisoning 
(chlorine "gassing"), 348; bronchiectasis, 349; foreign bodies in the bronchi, 
350; emphysema; vesicular emphysema, 351; localized, acute and compensatory, 
acute bilateral, interstitial, and subcutaneous emphysema, 351; vesicular 
hypertrophic emphysema, 352; rationale of emphysema, 353; atrophic or senile 
emphysema; spasmodic asthma, 355; sensitization tests, 357; spurious spasmodic 
asthma, renal asthma; aneurysmal asthma; cardiac asthma, 359; rationale of 
spasmodic asthma, 360; pleurisy, 361; etiology, 362; symptoms of acute fibrinous 
pleurisy; pleuris}' with effusion, 363; physical signs, 365; Grocco's triangle, 367; 
rhythmic lateral displacement of the heart, 368; rationale of pleurisy, 369; serous 
effusion, 370; diaphragmatic pleurisy, 373; empyema, 374; pleuritic adhesions, 
375; interlobar pleurisy; chronic pleurisies; purulent exudate; encapsulated em- 
pyema; pneumothorax, 376; symptoms and rationale of pneumothorax, 378; 
physical signs, 378; displacement of sheltered viscera, 379; hippocratic succus- 
sion, 379; cardinal signs, 379; hydrothorax, 382. 

Lobar pneumonia, 383; pneumococcus types, 384; morbid anatomy, 384; vari- 
eties of pneumonia, 386; traumatic, migratory, and massive forms; afebrile and 
senile pneumonia; central pneumonias, 387; symptoms, 388; the blood; the urine;, 
gastrointestinal tract; headache and delirium, 389; physical signs of frank 
lobar pneumonia, 390; diagnosis, 391; rationale of lobar pneumonia; toxemia; 



X CONTENTS 

Page 
sputum; congestion; bronchial and tubular breathing; the crepitant rale; blocked 
bronchi, 392; cyanosis and dyspnea; complication; prognosis; septic pneumonia, 
393; broncho-pneumonia; inhalation pneumonias; morbid anatomy of lobular 
pneumonia, 394; two chief divisions of broncho-pneumonia; subdivisions, 395; 
acute congestive broncho-pneumonia; acute disseminated broncho-pneumonia; 
common form of broncho-pneumonia, 396; physical signs of the chief types of 
broncho-pneumonia, 397; rationale of broncho-pneumonia; atelectasis, 398; 
massive collapse, 399; congestion of the lungs, 399; active congestion; passive 
congestion, hypostasis and edema; pulmonary edema, 400; important comment, 
401. 

Tuberculosis of the lungs, 401; morbid anatomy, 402; etiology, 403; chronic 
congenital asthenia, 404; acute miliary tuberculosis, 405; physical signs; 
acute pneumonic tuberculosis, 406; chronic ulcerative tuberculosis, 407; 
hemorrhage; bronchiectases; phthisiophobia; symptoms, 409; hemoptysis; 
fluoroscopy; tuberculin, 411; preparation of tuberculin for subcutaneous use, 
412; modifications of the tuberculin test; von Pirquet test, 413; physical signs, 
416; pulmonary infarct, 418; pulmonary abscess, 419; pulmonary gangrene, 420; 
pulmonary tumors, 421; malignant growths of the pleura; diseases of the bron- 
chial glands, 422; mediastinal abscess; chronic interstitial pneumonia, 423; 
pulmonary syphilis, 424; pulmonary actinomycosis; aspergillomycosis; oidio- 
mycosis; nocardiosis; pulmonary distomatosis; pulmonary and pleural hydatids, 
425; dermoid cysts of the lung; chylous pleurisy, 426. 

EXAMINATION OF HEART AND BLOOD VESSELS 427 

The heart, 427; variations in size of the heart, 429; the aorta; mobility of the 
heart, 431; the heart valves; the clinical valvular areas; inspection; facies, 433; 
inspection of the neck and trunk, 435; the apex beat; various precordial retrac- 
tions, 436; precordial lifting; position and displacement of the apex beat, 437; 
precordial bulging; epigastric pulsation, 438; palpation; thrills; percussion, 
439; superficial cardiac area; changes in percussion area, 440; area of relative 
dulness; sensation of resistance; threshold percussion, 441 ; orthopercussion, 
442; the author's preference; auscultation, 443; heart sounds, 444; "the diastolic 
echo;" changes in timbre, 445; murmurish sounds; displaced heart, 446; re- 
duplication of heart sounds, 447; fetal rhythm; auscultation areas; heart mur- 
murs, 449; postural modifications, 450; the intensity of the' murmur; asthenic 
and "hemic" murmurs, 451; other forms of accidental murmurs, 453; pleuro- 
pericardial murmurs; curious crackles; splashing, 454; the rationale of organic 
heart murmurs, 455; practical synchronism, 456; systole; blended sounds; 
diastole, 457; presphygmic period, 458; important deductions; presystolic mur- 
murs in mitral or tricuspid stenosis; against the stream, 459; hypertrophy; 
secondary mitral leakage; consecutive involvement of the right heart, 460; 
differential points; rhythm, 461; hypertrophy and dilatation, 462. 

CERTAIN FACTORS BASIC IN THE CONSIDERATION OF THE DIS- 
ORDERS OF THE HEART AND BLOOD VESSELS 462 

What the heart must do; arteries auxiliary hearts; arterial conservation of 
initial energy; the role of the vasomotor system, 462; speed of the blood stream; 
extreme vasodilatation; excessive vasoconstriction; the heart's capacity for work, 
463; metabolism in insufficiency; what the normal heart must possess; myogenic 
theory, 464; rhythmicity; restoring the heart beat post-mortem; efficient con- 
traction; Gaskell's bridge, 465; auriculo-ventricular bundle; heart block; the 
pace maker of the heart, 466; extrasystoles; stimulus conduction; tonus; the 
neurogenic theory; independence of the heart; influence of the vagus and sympa- 
thetic cardiac nerves, 469; vagus overstimulation; remarkable anatomic structure 
of the heart; coordination of function; cardiac reserve, 470. 
Blood pressure: factors basic in its determination and interpretation; adap- 
tive cardiovascular automatism; systolic and diastolic pressure in the aorta, 471 ; 
pulse pressure; regulation of rate of flow; determination of blood pressure, 472; 



CONTEXTS XI 

Page 
the older technic of blood pressure determinations, 473; Koratknow's method, 
474; normal readings, 475; age, 476; important statistical data, 477; abnormally 
high pressure, 478; intracranial pressure, 479; abnormally low pressure, 480; 
acute infections with persistent hypotension, 481 ; hypotension attending the 
sudden relief of abdominal pressure, 484; blood pressure determinations in 
pregnancy, 485; chief clinical significance of high diastolic pressure; blood 
pressure estimations in the arrhythmias; pulse deficit; venous pressure, 487. 
The radial pulse: "taking" the pulse; pulse palpation, points to be deter- 
mined, 488; the recurrent pulse; unilateral variations, 489; pulse frequency, 
490; slow and rapid pulse; tachycardia; bradycardia, 491 ; sinus arrhythmias, 492; 
irregularity and intermittency, 493; pulsus irregularis perpetuus; "the paradoxic 
pulse;'' pulsus celer and pulsus tardus; pulsus magnus, vacuus, and parvus, 
pulsus durus; dicrotic pulse; capillary pulse; the bizarre in pulse terminology, 
495; Mouse-tail pulse; water-hammer pulse, 495; venous pulsations; diastolic 
jugular venous collapse; venous pulse; visible respiratory venous phenomena; 
carotid vs. jugular pulsation, 496. 

Instrumental methods: the true value of instrumental methods, 496; the 
spygmograph and sphygmogram, 497; the polygraph, 498; interpretation of 
venous tracings, 500; the auricular venous pulse, 502; events of the venous pulse 
cycle, 503; registration of the venous waves; marking and interpretation of the 
polygram, 506; special conditions, 508; auricular flutter; paroxysmal tachycardia, 
512; venous record, 513; radial record, 514; the electrocardiograph; basic prin- 
ciples, 517; sensitivity and responsiveness, 518; extracardial sources of deflection, 
519; accidental vibrations; the electrocardiographic leads, 520; the auricular 
complex; the ventricular complex, 521; various interpretations of the electro- 
cardiogram, 522; summary; the phonocardiograph, 524; marking and interpreta- 
tion of electrocardiographic records, 525; extrasystoles, 527; fibrillation, 529; 
block, 531 ; arborization defect, 534; abnormalities in the P-wave; the P-R inter- 
val, 536; ventricular preponderance; auricular flutter; paroxysmal tachycardia, 
539; alternation, 542; cardiac arrhythmias ; classification and analysis of arrhy- 
thmias; extrasystolic arrhythmia; frequency of extrasystolic contractions and 
their direct cause, 543; frustrated contraction, 544; intermittent pulse; ventri- 
cular extrasystoles, 545; clinical significance of extrasystoles; miniature murmurs; 
extrasystoles of ventricular origin, 546; electrocardiographic differentiation of 
extrasystoles, 547; the auricular extrasystoles; extrasystoles from bundle of His, 
548; auricular and ventricular extrasystole, 549; auricular fibrillation, 551; 
auricular flutter, 555; physiologic heart block; paroxysmal tachycardia, 559; 
alternating pulse, 561; sinus irregularities, 563; simple bradycardia, 563; heart 
block; acute cerebral anemia, 565; acute infections, 566; recognition of heart 
block by simple means, 567; simultaneous auricular and ventricular systoles, 569; 
Adams-Stokes' syndrome; latent heart block; prognosis in heart block, 570. 

ROEXTGEX DIAGNOSIS OF CARDIAC LESIOXS, FRAXK S. BISSELL, 

M. D 571 

Orthodiagraphy, 571; teleroentgenography; the "drop" or pendulum heart, 
572; the normal heart, 574; mitral insufficiency, 575; mitral stenosis, 577; 
aortic insufficiency, 578; combined aortic and mitral regurgitation; aortic 
stenosis; pericarditis exudativa, 581; the normal aorta, 582; diffuse dilatation of 
the aortic arch, 584; aneurysm; aneurysm of the ascending aorta aneurysm of 
the descending aorta, 585; "Fatty heart; heart silhouette in nephritis, 586. 

THE DISEASES OF THE HEART AND BLOOD VESSELS 586 

Importance of prophylaxis and early diagnosis; advance in knowledge; syphilis, 
586;- rheumatism; foci of infection; the chief etiologic factor, 587; misleading 
delayed onset; physical debility and cardiac weakness; heart muscle vs. skeletal 
muscle, 588; percussion outlines; abnormal heart sounds and bruits; the vital 
point, 589; phasic changes in co-existent lesions; chronic myocarditis, 590; 
cardiovascular reserve; cardiovascular "sufficiency" and "insufficiencv;" obliga- 



Xll CONTENTS 

Page 
tory and morbid dilatation, 591; normal dimensions of the heart; the "drop" 
heart of the congenitally asthenic individual, 594; the heart of congenital 
asthenia, 598; effect of environment and sex, 601; misleading bruits, 602; thera- 
peutic test; 603; concurrence of "drop" heart and visceroptosis, 605; "neuras- 
thenia;" psychasthenia, 606; the rest cure; "soldier's heart,' 607; failures in pri- 
mary selection; vital points; adaptation and self-protection, 609; period of break- 
down, 610; leading characteristics, 611; obligatory exposure to adverse influences, 
616; myocardial toxemia, 618; fundamentals in treatment, 620; minor insuffi- 
ciencies, 621; compensation and incompensation, 625; a cardiovascular paradox, 
629; progressive diminution of cardiac reserve, 630; the laboring heart, 631; early 
diagnosis, 632; retardation and rehabilitation the primary need, 634; early recog- 
nition of failing reserve; tests of cardiac sufficiency, 635; skillful percussion, 638; 
cardinal factors in timely diagnosis; proper valuation of subjective symptoms; 
recognition of subjective symptoms; dyspnea, 639; pain or discomfort due to 
muscle fatigue and overstrain, 640; multiple factors; minor crises; extracardial 
factors; referred pain and discomfort, 641; epigastric, substernal, and precordial 
discomfort, 642; tenderness; major anginal pain; paroxysmal pain of sciatic type; 
obiective symptoms of decided cardiovascular insufficiency, 647; jaundice; 
edema, 648; cyanosis, 649; heart sounds; cardiac outline; truly effective therapy, 
650; neither drugs nor rest adequate, 651 ; adaptation vs. "perfect compensation;" 
causative agents and portals of infection; the "abandoned" heart case, 652; after 
lifetime of the cardiopath; futile forecasts,. 653. 

Myocardial overstrain 653 

Acute cardiac overstrain; fundamental factors, 653; physical fitness and habitu- 
ation, 654; minor heart strain, 655; the asthenic heart, 656; common cause of 
overstrain, 657; subjective weakness, 658; split second sound, 663; acute over- 
strain; preexistent lesions; overstrains of adolescence; the heart in laborious 
occupations, 664. 

Acute parenchymatous myocardial degeneration: acute myocarditis, 665; 
septic myocarditis; symptoms of acute simple myocarditis; weakness; dyspnea; 
facies; dilatation; heart sounds, 666; pulse; decompensation; pain; epigastric 
distress, vasomotor and urinary signs, 667. 

Chronic myocardial degenerations: chronic residual myocarditis; sclerotic 
changes; myomalacia cordis; fatty overgrowth; obesity and sedentary pursuits, 
668; pathology; obesity and cardiac overstrain; insurability; associated patho- 
logic conditions, 669; symptoms and physical signs; cardiac outline; prognosis, 
670; cardiac insufficiency of the glutton and the sot; brewery drivers and ice 
cart men; human vats; fatty degeneration, 671. 

Endocardial lesions: endocarditis, 672; verrucose, ulcerative, and sclerotic 
forms; symptoms of simple endocarditis, 675; subacute endocarditis, 676; 
recurrences of acute simple endocarditis; malignant endocarditis, 677; recurrent 
malignant septic endocarditis; mitral insufficiency; the typical case, 678; the 
murmur, 679; rationale, 681; etiology; secondary effects; pulmonary circuit, 682; 
compensation, 683; variation in lesions; variations in murmur, 684; murmurs of 
relative insufficiency; temporary absences of murmur, 685; transmission of 
murmur; cardiac area; associated signs; accentuation of pulmonary second 
sound; pulmonary stasis, 686; diminished pulmonary accentuation; subjective 
symptoms; prognosis, 687. 

Mitral stenosis, 687; anatomic types, 689; the typical case; murmurs, 690; 
characteristic first sound at apex; thrill, 691 ; pulmonary second sound, 692; effect 
of posture and exertion; changes in cardiac outline, 693; associated bruits, 694. 
Rationale. — The murmur of mitral stenosis, 694; blood pressure; thrill, 696; 
clinical division; cases lacking excessive pulse rapidity and extreme irregularity; 
cases characterized by fibrillation or flutter-arrhythmia, 697; distribution of 
overload, 698; changes in cardiac outline; effect upon heart sounds, 700; secon- 
dary systemic effects, 701. 



CONTENTS Xlll 

Page 
Tricuspid insufficiency (tricuspid regurgitation, tricuspid incompetence); 
etiology; endocarditic cases, 701; the typical case; the murmur, 702; rationale of 
tricuspid regurgitation; the murmur, 704; the second pulmonary tone; venous 
stasis, 705; a vicious circle, 706; slight or silent leakage; direct expansile hepatic 
pulsation; systolic jugular pulse; extreme examples, 707. 

Aortic insufficiency (aortic regurgitation, aortic incompetence) ; the murmur, 
708; areas of maximal audibility, 709; area of maximal transmission; cardiac 
outline; associated signs; heart tones, 710; rationale — the mental picture. 711; 
five cardinal symptoms; murmur of aortic insufficiency, 715; transmission 
of the murmur, 716; increase of cardiac area, 717; aortic dilatation; hearts with 
small leaks; alternating high and low pressures; Corrigan pulse; arterial tones, 
718; capillary pulse; sight diagnosis; modifications of heart sounds, 719; the Flint 
murmur; pallor; nutrition and temperament; pain, 720; dyspnea; sources of dan- 
ger, 721. 

Aortic stenosis, 721; the murmur; thrill, 723; aortic second sound; cardiac 
outline; the apex-beat; the pulse; rationale, 725; arrhythmia, 726. 
Tricuspid stenosis, 726; murmur; thrill; percussion area; subsidiary signs; 
rationale, 727; prognosis, 728. 

Pulmonary insufficiency (pulmonary regurgitation, pulmonary incompe- 
tence); etiology, 728; clinical signs and symptoms; murmur; pulmonary, pulse, 
and blood pressure, 729; rationale, 730; pain; differential diagnosis, 731. 
Pulmonary stenosis and atresia: etiology, 732; fetal endocarditis rare; 
extraordinary combinations, 733; murmur; thrill; pulmonary second sound; 
cardiac area, 734; cyanosis; clubbing of the fingers; secondary erythremia; differ- 
ential diagnosis; comment; prognosis, 736; patent foramen ovale, 738; patent 
ductus Botalli, 739; the murmur, 740. 

Stenosis or atresia of the aorta and coarctation of the arch: defec- 
tive ventricular septum, 741; congenital heart lesions in general, 742. 
The commoner combined valvular lesions, 742; multiple murmurs; differ- 
entiation, 743; common diastolic bruits; the Flint murmur; tricuspid and pul- 
monary stenosis; tricuspid regurgitation, 744; pulmonary insufficiency; thrills; 
the cardiac outline; paradoxic right heart pulsations, 745; rationale; mitral 
stenosis and regurgitation, 746; aortic stenosis and regurgitation, 747. 
Cardiovascular syphilis: enormous cardiovascular field; cerebrospinal syphilis; 
paresis, 748; luetic aortitis; astounding figures, 750; reduction of life expectancy; 
chronic productive mesaortitis, 751; Francis Welch aortitis, 752; early recogni- 
tion, 753; general symptoms, 754; pressure pain, 755; dyspnea; narrowing the 
cardiovascular field of response; physical signs, 756; many "Wassermann 
tests" valueless, 759; summary, 760. 

ARTERIOSCLEROSIS 761 

Atherosclerosis; etiology; heredity; physical work; interstitial nephritis, 761; 
vicious complication; lesions; physical signs. — Inspection, 762; retinal arter- 
ies; palpation; auscultation; mesenteric arteriosclerosis, 763; limited ausculta- 
tory field, 764; general symptoms; cerebral symptoms; gastro-intestinal symp- 
toms, 765; cerebral seizures; pulmonary block; thoracic ailments commonly 
associated with arteriosclerosis; rationale, 766; arteries lesser hearts; storage 
power plant, 767. 

PAROXYSMAL SPASTICITY OF THE CORONARY ARTERIES AND 
ANGINA PECTORIS WITH OR WITHOUT CORONARY ARTERIO- 
SCLEROSIS 768 

Claudication of the heart; morbid anatomy; symptoms, 768; the pulse; incon- 
stancy of pain; angina pectoris, major, 769; distribution and degree of pain, 
771; rationale; minor anginas, 772; prognosis, 773. 

Aneurysm of the thoracic aorta: etiology; difficulties in diagnosis, 773; clini- 
cal divisions; statistics, 774; favorite sites; termination; symptoms, 775; physical 
signs; inspection, 776; palpation; the pulse; percussion; auscultation, 777; 



XIV CONTENTS 

Page 

aneurysm of the ascending aorta, 778; aneurysm of the transverse portion of the 
arch; aneurysm of the descending portion of the arch, 779; differential diagnosis, 
780; final considerations and conclusions, 781. 

Pericarditis, 781; etiology, 782; dry vs. wet cases, 784; silent and unrecognized 
cases; idiopathic cases; symptoms common to both dry and wet cases; fever; 
pain, 786; the pulse; dyspnea and cyanosis, 787; the friction rub; pericardial mur- 
murs; pericardial friction; stethoscopic pressure effect, 788; failure of definite 
transmission; symptoms characteristic of effusion, 789; changes in the level of 
dulness; pressure symptoms; precordial and epigastric bulging, 790; hydroperi- 
cardium; pyopericardium; pneumopericardium; the rationale of pericarditis; 
pericardial relationships, 791; diaphragm and cervical fascia; pathology, 792; 
adhesions; genesis of friction sounds; modifying influences, 793; postural varia- 
tions in murmurs; absorption of exudate and return and recession of friction 
sounds; pleuro-pericardial friction, 794; resolution and repair; adhesions; poly- 
serositis; mediastino-pericarditis and indurative mediastinitis, 795; polyserositis 
proper; myocardial involvement, 796; calcification; serous exudates; cardiac out- 
line in effusion, 797; large vs. small effusions; pressure effects; compression of the 
lung and displacement of the liver, 798; diagnostic value of the quality of the 
percussion note; factor fundamental in diagnosis; dry pericarditis; obscure peri- 
carditis with effusion, 799; technic of aspiration; prognosis, 800; aneurysm of 
the heart; rupture of the heart; foreign bodies in the heart; new growths of the 
heart; situs viscerum inversus, 802. 

DISEASE OF THE ABDOMINAL ORGANS 803 

The abdomen: abdominal examinations, 803; points to be determined, 805; 
topography and regional divisions, 807; the liver, 808; the gall-bladder, 809, 811; 
the spleen, 811; the kidneys, 813, 819; the pancreas; helpful data relating to 
abdominal tumors, 815; differential points relating to tumors, 818. 
The stomach, 820; physical examination — inspection, 822; direct inspection; 
the esophagoscope and gastroscope, 824; palpation of the gastric area, 831; 
percussion, 832; auscultation; Revidtzef's sign, 833. 
ROENTGENOGRAPHY AND ROENTGENOSCOPY IN THE DIAGNOSIS 

OF GASTRIC AND DUODENAL DISEASE— DR. FRANK S. BISSELL 834 
Technic, 834; motility; peristalsis, 836; bulbus duodeni, 837; gastroptosis; 
dilatation; carcinoma ventriculi, 838; pyloric patency or obstruction, 840; gastric 
ulcer, 841; duodenal ulcer, 842; the colon; ileocecal tuberculosis, 847; chronic 
ulcerative colitis, 848; gall-bladder; the stomach tube and its uses, 849; the diges- 
tive ferments, 851 ; the examination of the duodenal contents, 852; examination of 
gastric contents, 856; gastric contents — chemical tests; qualitative tests, 860; 
quantitative test for hydrochloric acid; end reactions, 864; recapitulation, 866; 
normal acidity (Euchlorhydria); hyperchlorhydria, 867; chronic hypersecretion, 
869; hypochlorhydria; anachlorhydria; certain prominent gastro-intestinal 
symptoms, 870; appetite, 871; nausea and vomiting, 872; examination of the 
vomitus, 873; hematemesis, 874; general microscopic findings, 877. 

DISORDERS CHARACTERIZED BY SENSORY, MOTOR AND SECRETORY 

DISTURBANCES , 878 

Gastric spasm, 878; anorexia nervosa; achylia gastrica, 879; simple achylia, 880; 
heterochylia, 882; gastroptosis, 884; disordered motility; gastric atony and 
chronic dilatation, 885; gross atony, 888; asthenic dyspepsia, 893; chronic 
congenital asthenia, 895; acute atonic dilatation, 897; post-stenotic motor 
insufficiency; symptoms, 898; differentiation, 900; hour-glass contraction, 901. 

DISEASES OF THE ESOPHAGUS 901 

The chief organic esophageal lesions; varices; acute esophagi tis; esophgeaal 
strictures, 901; esophageal dilatations, 902; diverticulum; acute esophagitis, 903; 
syphilis; esophageal neuroses; carcinoma of the esophagus; esophageal spasm, 
904. 



CONTENTS XV 

Page 
ORGANIC DISEASES OF THE STOMACH 905 

Acute gastritis; chronic gastric catarrh, Q05; hypertrophic chronic gastritis, 906. 
Gastric and duodenal (post-pyloric) ulcer: gastric ulcer; etiology, 907; 
pathology and morbid anatomy, 908; location; healing; perforation, 909; acute 
ulcer, 910; hemorrhage, 912; vomiting; acidity, 913; chronic gastric and post- 
pyloric (duodenal) ulcer; "hunger-pain;" hemorrhage, 914; hyperacidity; 
hypersecretion, 915; tenderness and defensive rigidity; radiography in gastric 
and duodenal ulcer, 916; secretion, 917; spasm of the pyloric antrum, 918; acute 
pyloric obstruction; post-pyloric (duodenal) ulcer; dyspeptic symptoms; fever; 
anemia, 919; differential diagnosis, 920; circumscribed pressure tenderness, 921; 
retention and hypersecretion, 922; ulcer with adhesions, 923; perforation, 925; 
differential diagnosis; gastric hyperesthesia, 926; hypersecretion. 927; operative 
cases of gastric ulcer, 929; gastric erosions, 930. 

Gastric carcinoma: etiology, 930; varieties and preferential sites; symptoms, 
931; stomach contents; chemical and microscopic findings, 933; diagnosis, early 
and differential, 934; gastric crises, 935; spastic splanchnic abdominal crises; 
syphilis of the stomach, 936; tuberculosis of the stomach; congenital stenosis of 
the stomach. 937. 

THE FECES 937 

Lines of investigation; character of the stools, 937; clinical significance of ab- 
normal findings; normal content; form; food remnants; blood, 938; mucus; pus; 
collecting the specimen; microscopic examination, 939; Schmidt's method; 
Steele's method; macroscopic findings, 940; chemical examination; inferences 
from the tests; value of results obtained, 941; concretions; hemorrhoids, 942; 
Meckel's diverticulum, 943. 

ENTERITIS . . 943 

Clinical varieties; morbid anatomy, 943; acute intestinal indigestion; acute 
fermentative diarrhea; chronic enteritis; cholera infantum; membranous enter- 
itis, 944; dysentery; etiology; the cause of amebic dysentery; laboratory diagno- 
sis, 945; Walker's differential table, 947; acute specific dysentery; acute catarrhal 
dysentery; diphtheritic dysentery; symptomatology of dysentery; chronic 
dysentery, 948; differential diagnosis; mortality and general comment, 949. 

MISCELLANEOUS INTESTINAL NEUROSES 949 

Rectal spasm; peristaltic unrest; meteorism, 949; enteralgia; hypogastric neu- 
ralgia; hyperesthesia, paresthesia, anesthesia; intestinal neurasthenia; paralysis 
of the intestines; chronic intestinal obstruction, 950; chronic intussusception; 
Lane's kink; constipation, 951; fecal accumulation, 952; thrombosis and embol- 
ism; tuberculosis of the intestines; syphilis of the intestines; enteroptosis 
(Glenard's disease), 953. 

APPENDICITIS 953 

Mortality; etiology; symptoms, 954; physical signs; perforation and general 
peritonitis, 955; differential diagnosis of acute appendicitis, 956; prognosis; 
chronic appendicitis, 957; roentgenologic aids to diagnosis, 958; the exploratory 
operation; acute intestinal obstruction, 959. 

Acute peritonitis, 959; symptoms, 960; localized peritonitis; subphrenic 
abscess; differential diagnosis, 961; chronic peritonitis; proliferative peritonitis; 
tuberculous peritonitis, 962; -symptoms; differential diagnosis; cancer of the 
peritoneum, 963. 

DISEASES OF THE PANCREAS 964 

Acute hemorrhagic pancreatitis; acute suppurative pancreatitis; gangrenous 
pancreatitis; chronic pancreatitis; pancreatic cysts; carcinoma of the pancreas, 
964; pancreatic calculi; the Cammidge test and Loewi's test, 965. 

DISEASES OF THE LIVER AND THE BILIARY PASSAGES 965 

Congenital anomalies; inflammation of the liver, 965; abscess of the liver; 
complications, 966; differential diagnosis; hepatic hyperemia, 967; tumors of the 
liver; parasitic involvement; echinococcus (hyatid) cysts, 968; cirrhosis of the 



XVI CONTENTS 

Page 
liver; basic pathology and varieties Laennec's cirrhosis; morbid anatomy, 969; 
symptoms of Laennec's cirrhosis, 970; diagnostic summary, 971; nutmeg liver; 
fatty cirrhotic liver; hypertrophic biliary cirrhosis (Hanot's disease), 972; 
syphilitic cirrhosis; syphilitic gummata of the liver; acute perihepatitis; capsular 
cirrhosis, 973; amyloid liver, 974. 

Acute yellow atrophy: differential diagnosis; Weil's disease, 974. 
Diseases of the gall-bladder: catarrhal jaundice; acute cholecystitis, 975; 
typical and atypical cases, 976; cholelithiasis, 977; biliary colic; obstruction 
of the common duct, 978; cystic duct; general comment, 979. 
INFECTION AND IMMUNITY— A BRIEF SUMMARY OF SOME OF THE 
IMPORTANT PRINCIPLES UNDERLYING THE "WASSERMANN" 
REACTION AND CERTAIN OTHER TESTS INVOLVING COMPLE- 
MENT-FIXATION, AGGLUTINATION, PRECIPITATION AND 

ALLERGY 980 

Present status of the doctrine of immunity; nature of the Wassermann test; 
infection; bacterial toxins; exotoxins and endotoxins, 980; leucocytosis and 
chemotaxis; bacterial hemolysis; ptomains; immunity; 981; antibodies; opsonins; 
antigens, 982; bacteriolysis; substance sensibilatrice, 983; complement (alexin 
fixation); hemolysis; application to syphilis, 984; the Wassermann reaction — 
titration of hemolytic amboceptor or sensitizer, 985; fresh guinea-pig serum; 
scheme for Wassermann test after scheme of Noguchi, 986; Noguchi's method 
of complement fixation for the serum diagnosis of syphilis; controls, 988; addition 
of hemolytic system; results obtainable with the Wassermann test, 989; Schick's 
test of diphtheria immunity; true reaction; precipitin test for human blood, 
990; meningococcus test; agglutination reaction, 991; anaphylaxis, 992; serum 
disease; symptoms, 993; opsonic theory, 994; technic, 996; measuring the dose of 
the vaccines, 999. 
THE INFECTIOUS DISEASES— TYPHOID FEVER (Enteric Fever, Typhus 

Abdominalis) 1000 

Definition; etiology; distribution of the germs in the body, 1000; modes of 
entrance; incubation period; varieties, 1001; pathologic anatom)-, 1002; symp- 
toms and diagnosis; complications, 1003; the typical case, 1004; fever; the 
so-called abortive typhoid; rose spots, 1005; enlargement of the spleen; recovery 
of the bacillus from the stools, blood, or urine; nervous symptoms; important 
factors in accurate diagnosis, 1006; Ehrlich's diazo-reaction, 1007; agglutination 
test of Widal, 1008; the blood culture, 1009; differential diagnosis of typhoid 
fever, 1010; prognosis, 1013; colon bacillus infections, 1014. 
Influenza: epidemic variants, 1015; etiology, 1016; contagiosity; immunity; 
incubation types, 1017; symptomatology, 1018; the acute hemorrhagic pneu- 
monitis of the epidemic of 1918, 1021; symptoms of influenzal pneumonia; Roent- 
genographic findings, 1022; prognosis, 1030. 

Asiatic cholera: etiology; morbid anatomy; incubation, 1031; stages; the 
blood; prognosis; diagnosis; differential symptoms, 1032. 

Bubonic plague, 1032; etiology; morbid anatomy; pestis major, 1033; the 
blood; pestis minor; diagnosis; pathognomonic sign; mortality, 1034. 
Dengue: definition; etiology, 1034; symptoms; differential diagnosis, 1035. 
Yellow fever: etiology, 1035; morbid anatomy; symptoms; physiognomy, 
1036; diagnosis; differential diagnosis; prognosis, 1037. 

Malaria: historic note, 1037; characteristics of the mosquito, 1038; classifi- 
cation of the organism, 1039; tertian organism; quartan, 1040; estivo-autumnal 
Plasmodium; evolution of the organism in the mosquito, 1042; cultivation of the 
parasites, 1043; examination of the blood for malarial organisms; immunity; 
symptoms, 1045; classification of pernicious forms; malaria in infants; chronic 
malaria, 1048. 

Relapsing fever: etiology; morbid anatomy; symptoms, 1049. 
Typhus fever: etiology; transmission, 1051; historic note; morbid anatomy 



CONTENTS XV11 

Page 
incubation period; immunity; symptoms, 1052; variants; physiognomy and 
odor; Brill's disease, 1053. 

Malta fever: etiology, 1053; morbid anatomy; history; symptoms; differential 
diagnosis, prognosis, 1054. 

Rocky mountain spotted fever: causal agent; symptoms, 1055; differential 
diagnosis; prognosis, 1056. 

Tularemia: symptoms and course; prognosis, 1056. 

Milk fever; mountain fever; epidemic dropsy; epidemic gangrenous 
rectitis; miliary fever; foot-and-mouth disease, i os 7; flood fever; 
glandular fever; pappataci fever, io58; slx-day fever; seven-day fever; 
leishmaniasis, io59; infantile kala-azar; tropical sore; rat bite fever, 
106 1 ; verruca peruana; oroya fever, 1062; hill diarrhea; sprue, 1063; 
trench fever, i065. 

Measles: etiology; contagiousness; symptoms; the rash, 1066; duration of 
stages; complications; the urine, 1067; diagnosis, 1068. 
Mumps: etiology; symptoms, 1068; complications, 1069. 

Scarlet fever: etiology; incubation period, 1069; mortality; symptoms; the 
blood; complications; suppurative otitis media; diagnosis, 1071; spurious rashes, 
1072. 

Rubella, 1072; differential diagnosis, 1073. 
Fourth disease: incubtion; onset; fifth disease, 1073. 
Escherich's infectious erythema, 1073. 

Diphtheria: dissemination and distribution; morbid anatomy; symptoms, 
1074; complications; differential diagnosis, 1076; Vincent's angina, 1077. 
Meningeal infections, 1077; morbid anatomy, 1078. 

Epidemic cerebro-spinal fever {Petechial fever, Spotted fever, Malignant 
Purpuric fever, Brain fever) : symptoms, 1079; intermittent form; abortive form; 
Kernig's sign; Brudzinski's phenomena, 1081; lumbar puncture; globulin 
content, 1082. 

Acute tuberculous meningitis; stages, duration, 1083; differential diagnosis; 
suppurative meningitis; syphilitic meningitis, 1084; alcoholic meningitis; sec- 
ondary meningitis; "circumscribed serous meningitis, 1085;" infantile meningitis; 
chronic remittent meningitis, 1086; Lethargic encephalitis, 1086; etiology; 
pathology; symptomology, 1087; diagnosis; prognosis, 1088; 
Acute infectious poliomyelitis (Acute Anterior Poliomyelitis, Infantile 
Paralysis): 1089; morbid anatomy, 1090; symptomatology; prognosis; chief 
clinical types of the disease, 1092; misleading factors in diagnosis, 1093. 
Smallpox (Variola): historic note, 1093; etiology, 1094; varieties of smallpox; 
characteristic symptoms, 1095; the typical eruption, 1096; confluent smallpox; 
hemorrhagic form; malignant smallpox; varioloid, 1097; diagnosis; vaccination; 
extent and duration of the protective influence, 1099; preparation of vaccine; 
sequence of events in vaccination, 1101. 

Varicella (Chickenpox): 1102; symptoms; differential points, n 03. 
Whooping cough (Pertussis): 1103; symptoms, 1104; diagnosis; comment, 
1105. 

Syphilis if 1 Lues Venerea" "Pox"): smear preparations, 1105; mode of convey- 
ance, 1 106: the three stages; the initial lesion or chancre and the bullet bubo, 
1 107; syphilitic exanthemata, 1108; indurative edema; the hair; the buccal 
cavity; tertiary syphilis, 1109; syphilis of the respiratory tract, 11 10; the lymph 
glands; hereditary syphilis; syphilis hereditaria tarda; prognosis, 11 n. 
Ulcerating venereal granuloma; yaws (frambcesia) : 1112; differential 
diagnosis, 11 15; gangosa (Muffled Voice): 11 16. 

Eryslpelas: symptoms; differential diagnosis, 1118; Pyemia and septicemia, 
1119. 

Leprosy: the bacillus leprae; mode of conveyance, n 19; development of leprosy, 
1120; anesthetic leprosy, 1121. 



XV111 CONTENTS 

Page 
Anthrax {Malignant Pustule, Charbon. Wool Sorter's Disease) , 1122; malignant 
anthrax edema; diagnosis, 11 23. 

Hydrophobia (Rabies, Lyssa): rabies virus and the Negri bodies, n 24; lys- 
sophobia (Pseudo-hydrophobia); tetanus (Lockjaw), n 25; symptoms; progno- 
sis. Glanders; acute glanders, n 26; acute farcy; the mycoses; aspergilloses; 
mucor-mycosis; systemic blastomycosis, 1127; coccidioidal granuloma; 
sporotrichosis; the nocardoses; madura foot, 1129; actinomycosis, 1 130; 
lupinosis; meat poisoning; lacquer poisoning, ii32. 
THE CHIEF ANIMAL PARASITES— RHIZOPOD A 1132 

FLAGELLATA, II32; TREMATODA (Flukes), II33; CESTODES (Tapeworms) , II34 

tenia echinococcus, 1136; ascaris LUMBRicoiDES; oxyuris vermicularis, 1 137; 

TRICHINIASIS, 1 138; UNCINARIASIS, H30; FILARIASIS, II40; DRACONTIASIS, II43; 

trichuris trichiura (Whipworm); dicotophyme gigas or eustrongylus gigas; 
strongyloides intestinalis, 1144. 

TRYPANOSOME FEVER AND THE SLEEPING SICKNESS; BRAZILIAN TRYPANOSO- 
MIASIS, 1145; sarcoptes scABiEi (Acarus Scabiei), 1147; vagabond's disease, 
1148. 

The myiases and dermatophiliasis, cutaneous myiases: the screw-worm; 
timber fly disease; the creeping eruption, 1148. 

CERTAIN DISEASES OF THE JOINTS OF PROVEN OR PROBABLE 

INFECTIOUS ORIGIN 1149 

Acute rheumatism: probable portals and agents of infection, 1149; 
symptoms, 1150; fever; heart complications, 1151; blood, 1152; skin; gastroin- 
testinal and respiratory tracts; nervous system, 1153; differential diagnosis, 
1 1 54; prognosis, 1155. 

Arthritis deformans, 1155; general progressive arthritis deformans, 1156; 
chronic or recurrent infectious arthritis; still's disease; syphilitic 
arthritis; gonorrheal arthritis, 1 15 7; static ailments, i 158. 

ACUTE NON-SUPPURATIVE POLYMYOSITIS n 59 

Etiology, symptoms, and duration, 1159; primary suppurative myositis; hemor- 
rhagic polymyositis; acute primary suppurative myositis, 1 160; syphilitic 
myositis; tuberculous myositis; myositis fibrosis, 1161; myositis ossificans; 
muscular cramp; myalgia (Muscular Rheumatism), 1162. 

CERTAIN IMPORTANT CONDITIONS OF UNKNOWN CAUSATION OR 

LACKING A PROPER DESIGNATION 1163 

Diabetes mellitus, 11 63; clinical definition, n 64; symptoms; coma; precau- 
tionary measures, 1 1 66; the blood, 11 67; the urine; prognosis, 1168. 
Diabetes insipidus, 1168; symptoms; prognosis, 1169. 

Gout: etiology; inheritance, 1169; age, 1170; essential factors, 1171; clinical 
characteristics; symptoms, 11 72; onset; glycosuria; retrocedent gout, n 73; 
chronic gout; irregular gout, n 74. 
Rickets: symptoms, 1175. 

Neurasthenia ("Nervous Prostration," "Nervous Exhaustion"), 1176; symp- 
toms, 1 1 81; diverse localization of symptoms, 1182; diagnosis, n 83. 
Sea-sickness and car-sickness: 1184. 

DISEASES OF THE NERVOUS SYSTEM 1185 

The neuron theory, 1185; conduction in motor and sensory areas; the motor 
tracts, 1 1 86; direct sensory tract, 11 87; the indirect sensory tract; functions 
of the tracts of the spinal cord, n 88; causes of disease of the cerebro-spinal sys- 
tem, 1189; degeneration, 1190; regeneration; sequence of degenerative changes; 
general relation of pathologic changes to symptomatology, 1191; sensory areas; 
motor lesions; unilateral spinal cord lesions; complete transverse spinal cord 
lesions, 1192. 

Reflexes, 1193; the more important special reflexes; the patellar reflex (knee- 
jerk), 1 1 94; ankle clonus, 1195; Babinski's toe reflex; Oppenheim's reflex; organic 



CONTENTS XIX 

Page 
reflexes, 1196; synkenesias of diagnostic value, 1197; examination of the muscles; 
significance of electrical reactions, 1200. 

Certain psychic derangements : disorders of memory; illusions, hallucinations, 
delusions, 1201; delirium; disturbances of sleep and of speech, 1202; the lesions 
affecting speech, 1203; mind blindness and mind deafness; investigation of 
sensory functions, 1204; tactile sense; muscle sense, 1206; ataxia, 1207; signi- 
ficance of sensory disturbance, 1208; hyperesthesia and hyperalgesia; anesthesia 
dolorosa, 1209. 

Topical diagnosis: certain cerebral centers; motor centers; cortical center for 
sight, 1209; cortex; silent areas, 1210; centrum semiovale; optic thalamus, 1211 ; 
the crura, 121 2; lesions of the medulla oblongata; lesions of the cerebellum 
summary of segmental paralyses, 12 13; the tongue, 1214; the uvula and velum 
palati; the pharynx and larynx; the sternocleidomastoid; flexion and rotation of 
the head; deficient upper spine flexion, 121 5; inability to raise arm; impaired 
lateral trunk movement; deficient supination; atrophy of forearm, 1216; failure 
of abduction and adduction of fingers; atrophy of ball of thumb; spinal lordosis; 
thigh adduction and flexion; leg extension and rotation, 121 7; drop foot; toe 
adduction and flexion; brachial plexus paralysis; summary of lesions of certain 
spinal nerves, 121 8; the cranial nerves, 12 19. 

The eye, its reflexes, and the optic nerve, 1220; eye reflexes; the optic 
nerve, 1221; amblyopia, amaurosis; the visual field, 1225; color fields; optic 
neuritis; ophthalmoscopy, 1227; conjunctivitis; retinoscopy, 1228; the fundus 
oculi; methods of ophthalmoscopy, 1229. 

Motor nerves of the eye, 1230; tests for lesions of the third, fourth, and sixth 
nerves; paralytic symptoms; strabismus; diplopia, 1231; conjugate deviation; 
trifacial; taste; motor action, 1232; the seventh nerve; facial spasm and paralysis, 
1233; auditory nerve; deafness, 1234; Meniere's disease; glosso-pharyngeal 
nerve; the vagus, 1235; the laryngeal nerves;, cardiac plexus; spinal accessory, 
1236; the sympathetic nervous system 1237. 

DISEASES OF THE BRAIN AND SPINAL CORD 1237 

Hemorrhagic pachymeningitis, 1237; external pachymeningitis; intrameningeal 
hemorrhage, 1238; hematomyelia; caisson disease; "miliary," "diffuse,'' and 
"tuberculous" sclerosis; multiple sclerosis, 1239; sinus thrombosis, 1240; cerebral 
congestion; cerebral anemia; cerebral edema; congenital hydrocephalus, 1241; 
hydrocephalus in adults; tumors of the brain, 1242; tumor identification, 1243; 
summary of focal symptoms, 1244. 

Cerebral hemorrhage, embolism and thrombosis, 1245; premonitory symp- 
toms, 1246; symptoms of attack; second stage, 1247; residual and localizing 
symptoms, 1248; differential diagnosis; intracranial aneurysm; embolism, 
1249; thrombosis; cerebral abscess, 1250. 

Dementia paralytica ("General paralysis of the insane"), ("General Paresis"), 
1251; symptoms, 1252; variation in type; differential diagnosis, 1252; anemia of 
the cord; thrombosis, embolism, endarteritis of the cord, 1253. 
Locomotor ataxia (Tabes Dorsalis), (Syphilitic Posterior S phial Sclerosis); 
symptoms, 1254; ataxic paraplegia ("Gower's disease," Posterolateral sclerosis"); 
primary combined sclerosis; hereditary ataxia (Friedreich's ataxia), 1256; cere- 
bellar hereditary ataxia (Marie); primary lateral sclerosis (Erb-Charcot disease), 
("Spastic Paralysis of the Adult"), 1257; hereditary spastic spinal paralysis 
(Hereditary spastic paraplegia), (Family form of spastic spinal paralysis); the 
spastic paralysis of infants (Birth palsy, Spastic cerebral paraplegia, Little's dis- 
ease, Spastic diplegia); 1258; hysterical spastic paraplegia; amaurotic family 
idiocy; syringomyelia, 1259; myelitis; compression myelitis, 1260; acute myelitis, 
1261; differential diagnosis, 1262; course; Landry's paralysis, 1263. 
Progressive muscular atrophy, 1263; Aran-Duchenne type; amyotrophic 
lateral sclerosis; the bulbar type, 1264; the peroneal type; muscular dystrophies; 



XX CONTENTS 

Page 
pseudo-muscular hypertrophy, 1265; myotonia (Thomsen's disease), 1266; 
myasthenia gravis, 1267. 

Neuritis, 1267; acute febrile polyneuritis; pressure paralysis, 1268; Von Reck- 
linghausen's disease; neuralgia; herpes zoster (Zona), {Shingles) ; periodic trans- 
ient paralysis; facial hemiatrophy, 1269; paralytic vertigo (Gerlier's disease); 
Raynaud's disease {Symmetrical gangrene, Local asphyxia); erythromelalgia; 
acroparesthesia; angio-neurotic edema, 1270; intermittent joint effusions; 
epilepsy; grand mal, 1271; petit mal; Jacksonian epilepsy; epileptic equivalents, 
psychoses, 1272. 

Chorea (St. Vitus' s Dance, Sydenham's Chorea), 1273; symptoms, 1274; differ- 
ential diagnosis; convulsive tic (Habit spasm); generalized impulsive tic (Gilles de 
la Tourette disease), 1275; pandemic chorea; saltatory spasm; paralysis agitans 
(Shaking palsy, Parkinson's disease); hysteria, 1276; symptoms, 1279; diagno- 
sis and prognosis; traumatic hysteria, 1280; symptoms commonly presented, 
1 281; mountain sickness; aviator's syndrome, 1282. 

THE INTOXICATIONS 1283 

Sunstroke (Thermic Fever, Insolation, Siriasis); etiology; symptoms, 1283; 
warning signals; sun traumatism; heat exhaustion, 1284. 

Alcoholism: acute and chronic alcoholism, 1284; Korsakoff's psychosis; 
delirium tremens (Mania a potu), 1285; morphine and cocaine habits, 1286. 
Chronic lead poisoning, 1286; chronic arsenical poisoning, 1287; ptomain 
poisoning and pood poisoning; botulism, 1 288; ergotism; pellagra, 1 289; 
beri-beri; the vitamine doctrine, 1291. 

MALINGERING 1291 

Simulated injury, 1292; some of the commoner feigned states; angina pectoris; 
blindness, 1293; contractures, 1295; fictitious wounds, 1297; insanity, 1298: pain 
and tenderness; paralysis, 1299. 

CONDITIONS SIMULATING DEATH 1301 

Asphyxia; catalepsy; syncope, 1301; signs of life in persons apparently dead, 
1302. 
A BRIEF SUMMARY OF THE SYMPTOMS AND TREATMENT OF ACUTE 

POISONING 1302 

Acids, mineral; treatment, 1302; aconite; arsenic; atropin; cantharides, 1303; 
carbolic acid; caustic alkalies; chloral hydrate; cocaine; colchicum; croton oil; 
castor oil; corrosive sublimate, 1304; formaldehyde; gelsemium; hydrocyanic 
acid; lead acetate; lobelia; mushroom poisoning, 1305; oxalic acid; opium; 
phosphorus; potassium nitrate, 1306; potassium chlorate; stramonium and 
hyoscyamus; strychnine; tartar emetic; tartaric acid, 1307. 

TABLE OF (APPROXIMATE) METRIC EQUIVALENTS 1308 

CENTIGRADE AND FAHRENHEIT SCALES 1308 

INDEX OF SYMPTOMS 1309 

GENERAL INDEX 1317 



MEDICAL DIAGNOSIS 



CERTAIN FUNDAMENTAL PRINCIPLES 
AND SPECIAL PROBLEMS 

Scope of the Term Diagnosis. — Diagnosis means more than merely nam- 
ing a disease. It demands such accurate subclassincation and intelligent, 
painstaking individualization, as necessitates a knowledge of etiologic factors, 
the nature and sequence of pathologic changes, the effect of age, occupation, 
residence, habits, heredity, past ailments, and even of the constitutional 
peculiarities and personal characteristics of the individual. 

Text-book vs. Bedside. — Accurate diagnosis is prerequisite to accurate 
prognosis and effective treatment. From text-books and lectures the student 
learns the known types; at the bedside he studies variation from the type and 
the "personal equation." 

Pedagogic Spoon-feeding. — The older teaching of medicine represented, 
of necessity, an extreme and remarkably effective application of the dogmatic 
method combined with a sort of pedagogic forced feeding of the student with 
enormous conglomerates of predigested pap. This resulted in a tremendous 
overload for the memory, slight opportunity for thoughtful consideration 
and an exaggerated respect for ex cathedra statement. 

Modern Methods. — The necessity for this system has passed in large 
measure and, with the lengthening of the courses in medicine, these have taken 
on the seminar form, and the objective type, to whatever degree the amount 
of available clinical material of the individual school permits. 

With respect to the student, this change has resulted in the replacement 
of mere feats of memory and unquestioning acceptance of authority, by 
intelligent individualized study, personal observation and a well-developed 
critical faculty. Even during his college years or his period of internship 
he may commence the sifting, sorting, and necessary forgetting, which was 
formerly postponed until the graduate dealt with his own patients in actual 
practice, a form of post-graduate study too often fraught with initial damage 
and discomforture to both parties. 

Honesty and an Open Mind. — In medicine, even more than in surgery, 
diagnosis demands a sufficiency of facts, truthfully recorded, intelligently sifted, 
and viewed without bias or prejudgment. 

Self-deception, a narrowed mental vision which disregards new facts of 
later development in the individual case and resists blindly the introduction 
of new methods in practice, no less than cowardly adherence to an erroneous 
preconception, are deplorable. 



Subclassifica- 
tion and indi- 
vidualization. 



Types and 
variants. 



Mental 
indigestion. 



A boon to the 
student. 



The critical 
faculty. 



Bias and 
cowardice. 



MEDICAL DIAGNOSIS 



Proper balance 
important. 



Many tests 
proposed. 



Few are 
chosen. 



Dangers of 
hasty accept- 
ance. 



Sanguine 
promises. 



Over-confi- 
dence and 
over-reaction. 



Scientific Optimism and Scientific Skepticism. — We of the medical pro- 
fession have not attained, as yet, that proper balance of scientific optimism 
and corrective scientific skepticism, no less necessary to the best interest of 
patient and physician than to medical progress itself. 

The civilized world is thronged with eager altruists seeking new medical 
truths; the result being a vast continuous outflow of honest, but more or less 
imperfectly established and unproven assertions, together with a small but 
persistent trickle of valuable facts, which tends constantly to raise the level 
of scientific fitness and practical achievement. To separate the wholesome 
grain of truth from the great volume of chaff is a never ending task of no 
small magnitude. 

Bricks without Straw. — Within the past few years, for example, many 
tests have been advocated as of more or less specific value in the differential 
diagnosis of gastric carcinoma; yet up to the present time not one of these 
has demonstrated its right to any place higher than that of a member of the 
symptom group and some have fallen short of that. 

To have accepted any of these tests as specific would have worked untold 
evil through errors of commission and omission alike; to have tried them out 
without bias would be most creditable to any student or practising physician 
possessing the necessary facilities and requisite technic* 

The Magic of a Name. — The glamor of a great name is well illustrated 
by the history of the rise and decline of tuberculin. 

Tuberculin. — It required years of disastrous experience to demonstrate 
the decided limitations with respect both to the diagnostic and therapeutic 
use of tuberculin, originally announced as a cure for tuberculosis, even in its 
advanced stages, under a most excessive dosage. J 

The use of huge test doses for diagnostic purposes excited violent local 
and constitutional reactions even in the slumbering and innocuous foci 
carried by a large proportion of humanity and in many instances lesions, 
apparently obsolete, awoke to renewed activity. 

No one who lived and practised medicine during that period can forget 
the furor which followed the first announcement of Koch; the wild rush of 
patients and physicians alike, to Berlin; the astounding self-deception of 
public and profession; the absurd statistics of incredibly rapid cures; and 
finally, the inevitable over-reaction, embodied in the dictum of Nicholas 
Senn, "away with tuberculin!" 

Every medical man knows now that harm resulted from a wholly natural 
overconfidence in the honest, but mistaken, oversanguine and premature, 
announcement of a genuine discovery by one of the greatest and most sincere 

* Sneyer: Absence of digestive leucocytosis. Watson: Increased alkalinity of the 
blood. Lang: Increased resistance of the red blood cells to hypo-isotonic salt solution. 
Brieger and Triebing: Heightened antitryptic index. Xeubauer and Fisher: Glycyl- 
tryptophan test. Salkowski and Kojo: Estimation of colloidal urinary nitrogen. Grafe 
andRohmer: Specific hemolysis. Salomon and Saxl: Urinary test, etc., etc., etc. 

t The initial therapeutic dose, one thousand times that employed by users of tuberculin 
today, was carried rapidly upward, despite the stormy local and general reactions excited. 



FUNDAMENTAL PRINCIPLES 



of medical investigators, who, despite this one error has placed the entire 
civilized world under a debt of gratitude. 

" The magic of a great name" is too often only magic in the end and there 
is no quality more valuable to or in the student, than a decent and respectful 
attitude of interrogation, inquiry, and independent reasoning. 

Conflicting Evidence. — Extraordinary differences between the results of 
laboratory experiment and those attending their clinical application are of 
relatively frequent occurrence. What is true in relation to the guinea pig, 
dog or rabbit is not true always and necessarily for mankind and, furthermore, 
the reaction of the diseased human body may be wholly different from that 
of the sound one. 

It follows that, despite the fact that through the laboratory and the experi- 
mental work there done, we have obtained the truths fundamental in the greater 
part of that new knowledge which is the glory of modern medicine, we cannot 
achieve results always by mere hasty translation of laboratory experiment into 
clinical usage. 

The best of the many modern illustrations of this fact is found in the 
relationship of acidosis to periods of starvation. 

In the case of the normal body, starvation means inexorably an increase 
of ketone bodies in the blood and urine. Resting upon this proven fact, the 
clinician has carefully avoided starving his diabetic patients. 

Now we learn through the brilliant work of Allen that what is true of 
the normal body may be wholly untrue of the patient suffering from severe 
true diabetes mellitus and that oftentimes the best way to remove diabetic 
acidosis is to starve the patient for a limited period. 

Similarly until within the past few years the diabetic diet was made 
rigidly one of proteins and hydrocarbons because of the well established 
laboratory proof of the inability of the diabetic to burn and store carbo- 
hydrates in a normal manner. 

By this method of feeding the output of sugar was reduced, but we actu- 
ally invited the far greater threat of acidosis. 

Now, one seeks to combine rationally all of the known facts with relation 
to protein, fat and carbohydrate metabolism in health and in diabetes alike 
and patients have a mixed dietary fitted to their caloric necessities and toler- 
ance for a minimal carbohydrate intake. 

Limitations Imposed by Extreme Delicacy. — Many genuine discoveries 
are unpractical or demand such delicacy of technic as renders them of limited 
use and sources of real danger in unskilled hands. 

The determination of the u opsonic index" affords an example of a pro- 
cedure so complex and delicate as to place it quite beyond the realm of the 
practical, yet its introduction was accompanied by an assumption of practical 
utility which the lapse of time and the test of experience have almost wholly 
destroyed. 

The Wassermann test is now undergoing its trial by ordeal and we are al- 
ready learning its limitations and better estimating its very genuine value 
in its proper field; yet so many and so subtle are the sources of technical error, 



Valuable 
qualities. 



A source of 
error. 



Acidosis. 



The opsonic 
index. 



The Wasser- 
mann test. 



MEDICAL DIAGNOSIS 



Fragmentary 
complexes. 



as to make the test unsafe in the hands of anyone who is not a trained and 
up-to-date serologist. 

The Desirable Attitude. — It behooves the student, physician and teacher 
alike to be alert and open in mind, prompt to try out new methods, yet slow 
to accept that which is merely new or to replace by it the older methods of 
known value and potency, until it shall have been thoroughly tested and 
proven. 

The name of tlie originator may stand for capacity, past achievement, and 
honesty of purpose, but is not to be considered the hallmark of impeccability. 

The Reactionary. — On the other hand lies that most abominable of all 
abominations, the stubborn mind-blindness represented by an extreme 
skepticism which denies even a hearing to anything representing a radical 
departure from established theory and practice. 

The extent to which this was carried in an age which tolerated the most 
fantastic theories and lacked even the fundamentals of rational medicine 
is well illustrated by the antagonism which Harvey encountered, despite 
his beautiful demonstrations proving the circulation of the blood. 

A Modern Instance. — Even the epoch-making discovery of Lister failed to 
secure general acceptance and application for years after that great investi- 
gator himself and many followers had practically eliminated both " damn- 
able" and "laudable" pus from their surgical wards. 

To achieve a proper balance between these two extremes is the duty of every 
student and practitioner of medicine and to the greatest possible extent he should 
seek to add his mite to the great and ever increasing treasure of scientific truth. 

A Common Source of Diagnostic Error.; — To any one who has taught and 
practised medicine for many years it becomes clearly apparent that a certain 
incompleteness of conception with relation to pathologic sequence and its 
resultant symptomatic expressions is accountable for many of our diagnostic 
shortcomings. 

We forget that the usual descriptions of chronic disease apply chiefly 
to its classical symptomatic expression as an established and far-advanced 
pathologic process, which has been steadily extending and progressing for 
years prior to its detection. 

Early Diagnosis the Desideratum. — The true end and aim of modern 
of scientific diagnosis must be the earliest possible recognition of any disease, 
acute or chronic, and the promptest feasible institution of an effective therapy, 
whether this consists merely in wise instruction, in a conservative and retard- 
ant regimen, adequate supervision and control, or, the immediate and direct 
use of drugs. 

Complete Clinical Picture Often Lacking. — The text-book description 
of a disease embodies necessarily an enumeration of all of the many symptoms 
which may be encountered in a large group of such diseases. The ailment 
as encountered in individuals may only in small part fulfill these apparent 
requirements. 

In chronic interstitial nephritis or chronic myocardial degeneration the 
frank symptoms presented by the far-advanced lesion in a state of gross and 



FUNDAMENTAL PRINCIPLES 



often terminal functional insufficiency are those that chiefly strike the eye and im- 
press the mind of the reader, yet it is not at that stage but in the earlier and lesser 
decompensatory periods, such as may precede by years the fatal issiie or -the 
obvious breakdown, that the physician must find ultimately his greatest usefulness. 

Though we cannot detect often their actual beginnings, we can measur- 
ably succeed in the diagnosis of relatively early stages of many chronic dis- 
eases, if we avail ourselves of the many direct tests now applicable under 
modern methods of examination and realize the value of imperfect diagnostic 
mosaics composed of fragmentary but sufficiently significant symptom 
complexes, subjective and objective, combined with an accurate and detailed 
case history, a thorough knowledge of etiologic factors and a proper under- 
standing and appreciation of the known variants of disease. 

The Distinctive Value of a Knowledge of Etiologic Factors. — A study of 
the causes of disease is valuable in relation to chronic, no less than acute ail- 
ments and certain constitutional peculiarities of structure and temperament, 
no less than actual antecedent illness are oftentimes of the utmost signifi- 
cance in relation to symptoms otherwise obscure. 

"Chronic congenital asthenia" is of the utmost value, as a constitutional 
defect known to underlie many conditions of great importance. The history 
of certain past acute ailments is of extraordinary suggestiveness in many 
instances. 

Example. — Knowing that at least 50 per cent, of even single attacks of 
acute rheumatism in childhood result in permanent damage to the heart, 
a history of such an attack becomes peculiarly suggestive in the presence 
of any suspicious but indeterminate cardiac symptoms or signs, and, in 
little children, may represent in such instances nothing more than a mother's 
account of "sore throats" and "growing pains," the peculiar significance 
of which must be known and appreciated.* 

A knowledge of past luetic infection, the most protean and potent of 
common etiologic factors, at once throws special emphasis upon certain lines 
of investigation or offers a probable explanation of the presence of obscure 
and ill-coordinated nervous symptoms, a mysterious recurrent headache, or 
vague and indeterminate indications of pressure at the base of the brain. 

Poll Parrotry. — The student should not memorize symptoms without proper 
consideration of their relation to the known specific and peculiar pathologic 
changes of the individual disease: rather let him learn primarily the general 
symptom groups, common to the many forms of u fever" "anemia," and the 
like, and then associate with the individual disease that which is "peculiar^ and 
specific in its symptomatology and, above everything, the distinctive pathologic 
changes which underlie it. 

A multitude of diseases are u febrile" and there are hosts of u anemic" 
patients of various types, but all fevers and anemias have a basic general 
symptomatology. This last he should learn thoroughly as of broad appli- 

* The younger children are peculiarly likely to show nothing save a little tenderness 
about one or more joints, following, after several days, "a sore throat." A vast number of 
such cases are wholly overlooked. 



Clinical 
mosaics. 



Affect diag- 
nosis, progno- 
sis, and 
treatment. 



Masked 
rheumatism. 



Syphilis. 



Useless 
overload. 



Learn basic 
symptoms. 



MEDICAL DIAGNOSIS 



Value of 
picture. 



Diagnosis by 
exclusion. 



Usual 
method. 



Of great 
value. 



Sources of 
humiliation. 



Differentiating cation, but stamp especially upon his memory the peculiarities or definite 

symptoms. . . . ._.."., 

symptomatic variations that any specinc ailment of that group presents. 

Mental Photography. — Furthermore, every student should try to get a clear 
mental photograph of any ailment he is studying, and of the pathologic changes 
that underlie and explain its symptoms. 

In his mind's eye as he reads he should see the man with typhoid, the fever 
chart, his physiognomy, decubitus, rose spots, and more than that, the intes- 
tinal ulcers that underlie them. Such a method makes for quickness of per- 
ception and thoroughness alike. 

Direct vs. Indirect Methods.— Diagnosis by exclusion is a useful and val- 
uable though roundabout method of arriving at conclusions by a process of 
negation; the object being to find in the signs or symptoms presented by a 
given case, one or more inconsistent with the diagnostic symptom group of 
all diseases save one. [Modern advance has greatly reduced the necessity 
for the method and added enormously to its difficulty and laboriousness. 

Diagnosis by deduction based upon our knowledge of the pathologic 
processes and sequences of disease together with the fullest obtainable symp- 
tomatic and contributory data, is the method in common use, and exclusion 
becomes merely a factor, not a formal procedure. 

Therapeutic Diagnosis. — A therapeutic diagnosis is sometimes necessary 
and valuable, as, for example, in obscure syphilitic infection when the effect 
of mercury, the iodides, or salvarsan may go far to banish doubt. 

In the recognition of the damaging, earlier, and lesser, cardiovascular insuf- 
ficiencies, digitalis is invaluable. 

"Snap" Diagnoses. — Certain single symptoms may name a disease and 
such are termed pathognomonic, but woe to the man who is betrayed into 
the habit of making "snap" diagnoses based upon some obvious or striking 
signs of apparent conclusive significance. His opportunity passed when 
pathology came to her estate and subjected brilliant but superficial opinions 
to the acid test of the autopsy. 

Precipitate Decisions. — Many complex cases are encountered in which 
several ailments are concurrent and the obvious diagnosis may not represent 
the lesion of chief importance in the given case. Hasty conclusions are 
damaging in most instances and their frequency lends emphasis to the rule 
that all examinations must be thorough and complete and that the discovery 
of one important condition must not close the mind to other possibilities.* 



* Finding the malarial organism had led to a hasty conclusive diagnosis of malaria in a 
case seen recently and, as an antecedent diagnosis, tuberculosis had been affirmed quite 
properly because of positive sputum findings. A blood culture revealed streptococcus 
viridans and the domina?it and progressively fatal ailment proved to be chronic recurrent 
bacterial endocarditis. 

Like instances are by no means infrequent and failures in diagnosis are extremely com- 
mon in decompensated heart lesions of the silent murmurless type, because of the assump- 
tion that some obvious secondary morbid change is primary. 

Dyspepsia, albuminuria, hepatic enlargement, congestion of the lungs, chronic bron- 
chitis and paroxysmal dyspnea are some of the common secondary conditions leading to 
hasty and erroneous conclusions and midway diagnoses. 



FUNDAMENTAL PRINCIPLES 



The Fundamental Source of Diagnostic Error in Chronic Ailments. — 

This may be briefly expressed by the statement that we do not take or are not 
granted the time indispensable to good work. 

There is evident still, that same tendency to seize upon that which is obvious 
and guess at that which is obscure, which, in times past, found its sole justifica- 
tion in lack of available knowledge and instruments of diagnostic precision. 

If one is to do good work he must be thorough, painstaking, and delib- 
erate, and the patient must be taught that a look, or even a "look-over," 
a few questions, and a prescription, do not constitute a modern 
examination. 

On the contrary an intelligent opinion, the unravelling of the tangled 
skein of symptoms in an obscure case, means more than the work of any one 
day and may demand a more or less prolonged period of direct observation 
and complete control. 

Exactly the same statement holds good with respect to failures in treatment. 

A tendency to patch rather than to repair is the cardinal sin in therapy 
today, as it was a hundred years ago. 

We cannot cure inveterate " nervous dyspepsia" with digestants or 
intestinal antiseptics, nor greatly prolong the life expectancy of a decom- 
pensating cardiopath with occasional doses of digitalis and a half-hearted 
attempt to restrict activity. 

We can do both in surprising measure, if opportunity, cooperation and 
time are given us to make possible genuine repair and relative rehabilitation. 

With respect to tuberculosis the lesson has been learned. With respect 
to cardiovascular disease and other ailments quite as important and responsive, 
we have yet to realize the possibilities both of diagnosis and treatment. 

Taking the Long Odds. — Many students and some practitioners habitu- 
ally diagnose medical curiosities, failing to thresh out the variations of the 
prosaic and simple before assuming the long odds. On the other hand, it 
falls to the lot of every physician to encounter rarities, and their recognition 
means added credit and reputation. 

The physician often encounters some unusual case, only to have it dupli- 
cated within a short time, and one hears often of the triplication of such cases. 

Such occurrences are less mysterious than they seem for the detection of 
the primary case intensities our interest and alertness. Diagnosis is easy, 
usually, if the given disease of great rarity occurs to us as a possibility, and we 
at once proceed to analyze and clarify the hitherto obscure history. 

We also magnify the fact of accidental concurrence of like ailments, for- 
getting the many individual instances which lack the apparently mystic 
duplication. 

Prognosis. — Accurate diagnosis is indispensable to an intelligent prog- 
nosis and, unless the patient is actually in articulo mortis, the uncertainty of 
mere time forecasts makes them veritable traps for the unwary. 

W T e often see patients at the point of death rally and live for months or 
years even when suffering from chronic disease, and to an even greater degree 



Two basic 
factors. 



Futile 
methods. 



Important 
field. 



Consider the 
prosaic first. 



Duplication of 
rare cases. 



A fallacy. 



Traps for the 
unwary. 



s 



MEDICAL DIAGNOSIS 



Rash 
prophecies. 



The man, not 
the disease 
alone. 



Common 
variants. 



the statement applies to those apparently overwhelmed by the toxemia of 
acute infections. 

The physician who rashly sets exact time limits to chronic diseases in 
response to the natural and inevitable interrogation of the relatives of a 
patient seldom gains much credit from his few successful guesses. 

Indeed prognosis has little to do with specific forecasts as to life expectancy, 
which must usually prove futile, but in its broader sense it is the field in 
medicine which best exercises the knowledge, judgment and ripened experi- 
ence of its master minds. 

Prognosis embraces almos: :!or that can enter into an accurate, broad 

and highly individualized diagnosis and peculiarly exalts and emphasizes the 
value of a study of the "personal equation" the setting apart of the particular 
man, woman or child afflicted with this or that disease* from the mc 

We must neither treat, nor forecast the result of, pneumonia of itself, but 
study the individual who is suffering from it. We know that the flabby 
fat man is quite inferior to his lean wiry brother in resisting power, and that 
the total abstainer is a better "risk" in disease, as in health, than the tippler. 
The vigorous young adult with sound heart and blood vessels stands quite 
apart from the man whose heart muscle and arteries alike have surfered from 
the storms and stress of four score years of life. The man of unimpeachable 
family history, sound physique, good habits and moral courage offers a far 
better prognosis than his fellow who comes from tainted or short-lived stock, 
is defectively constructed, the victim of bad habits or possessed of little or 
no courage and determination to fight for his life. 

Previous illnesses and their erfects, the particular virulence of the indi- 
vidual infection, the condition of the heart, the extent of pulmonary involve- 
ment, and the degree to which the circumstances and environment of the 
patient permit the use of the full resources of modern medicine to be exercised 
in his behalf, are some of the factors which would enter into the prognosis. 
In other diseases, acute and chronic, the last consideration is extremely 
important. 

Optimism vs. Pessimism. — The confirmed optimist in prognosis, 
when an extremist, does far less damage to any. save himself, than does the 
pessimist, for the latter not only frightens many a patient into an untimely 
: .::-.-. but. by his willingness to stop lighting the apparently victorious d:: 
loses a host of golden opportunities to wrest victory from seemingly irreparable 
disaster. 

Pessimistic forecasts in relation to chronic disease, especially when bluntly 
and tactlessly communicated to the patient himself, are oftentimes fraught 
with disastrous results, and in acute disease the physician is seldom justified 
in exercising a brutal frankness which may serve no good purpose, but remove 
one of the strongest of the fighting reserves of the sick man. 

In certain ir. U is wholly proper and necessary to convey to the patient 

the advice that he take precautionary steps with relation to his afairs; but this 
may be so delicately imparted, and so guarded by hopeful and comforting assur- 
ances, as to cause little shock in most cases. 



Vital factors. 



Lost opportu- 
nities. 



Damaging 
revelations. 



FUND AMK MAT. PRINCIPLES 



A Difficult Problem. — On many occasions the doctor is urged by family 
members to tell the failing but hopeful or unsuspecting patient flatly that 
he must die or is actually dying. Instances occur which make it necessary 
for the physician to assume this delegated function and of its legitimacy in 
the individual instance he must be the judge. The only deathbeds the author 
has attended in which peace was lacking at the end, have been those in which 
weak, high-strong patients were told that death was inevitable. On the 
other hand, he has witnessed the most beautiful resignation in the face of 
such knowledge. 

The wonderful euthanasic calm which so generally precedes dissolution 
robs death of much of its pang and is not lightly to be broken, but, if it must 
be, the same mysterious, kindly influence of ttimes softens the blow. Never- 
theless, the demands of religious belief, the known character and tempera- 
ment or expressed wish of the patient, certain legal formalities, such as the 
"dying declaration," which demands that the statement be made under the 
firm conviction that death is impending, justify such a disclosure, but only in 
rare instances need it be absolute, luiqualified and unattended by some expression 
of hope. In any event, bald disclosure is but seldom the duty of the physi- 
cian and its damaging effect, as long as any atom of fighting hope remains, 
must be remembered. 

Truthfulness Desirable. — All this does not mean that a patient cannot be 
told the nature of his ailment even though the full and detailed knowledge of its 
gravity or severity be withheld. 

This statement applies with peculiar force to cases of tuberculosis in that 
not only is the patient's cooperation absolutely essential to arrest or cure, but 
uuiispensable to the protection of others. 

The questions of frankness, evasion or actual temporary deception, are deter- 
mined by ordinary common sense which takes into consideration primarily, the 
fundamental fact that the physician's function is that of securing for the patient 
the maximum of benefit. If the patient may know the truth without added 
danger to himself, that truth should be told and, in chronic cases especially, it is 
rarely wise to keep the patient in ignorance of his condition. 

Tactful Disclosure. — Heart disease, Bright's disease, pernicious anemia 
and many other conditions can be dealt with effectively only when the full 
cooperation of the patient is secured, for absolute control, full opportunity 
for supervision and abundance of time, are absolutely necessary to his welfare. 

In the minds of the laity the terms "heart disease" and "Bright's disease" 
have a meaning but little less dreadful than cancer and this is the inevitable 
result and reflection of the traditional general attitude of hopelessness and neglect 
held by the medical profession toward these conditions. 

Knowing as we do the wide differences existing in the subdivisions of these 
ailments, the extraordinary frequency of over accentuation and over estimation of 
the gravity of the individual case, the astonishingly long duration and slow prog- 
ress often manifested, the curious and conservative transformations in type which 
are possible and the wholly insuperable obstacles to diagnostic and prog- 
nostic impeccancy, we serve our patients best, usually, by avoiding the sinister 



Euthanasia. 



Obligatory 
revelations. 



Securing 

intelligent 

cooperation. 



The funda- 
mental factor. 



Dread terms 



Fallibility of 
forecasts. 



IO 



MEDICAL DIAGNOSIS 



Tactful 
honesty. 



Revelation 

with 

reassurance. 



Usual 
response. 



Firmness and 
decision. 



concrete terms and telling them roughly and sketchily the pathologic causes or the 
general underlying basis of their symptoms. 

The patient who would translate into the terms of a rapidly fatal disease 
the words "Bright's disease," may be disturbed relatively little by the 
knowledge that his kidneys "are inadequate" to their daily task whether as 
to excretion, filtration or secretion, by reason of some changes in the filtra- 
tion apparatus and the secreting cells. Thence, he is told, comes the tend- 
ency to retain at times body poisons, raise blood pressure and overtax the 
circulation and the necessity for his faithful and conscientious cooperation 
is manifest. 

The revelation of the fact that "the circulation is deficient," that the Jieart 
muscle "is deteriorated," "is a bit short on horsepower" or "lacking in tone," 
or even that one of the valves is not wholly competent," oddly enough, may be 
told a patient with far less in the way of resulting shock than might be supposed. 
Furthermore, even though a fuller knowledge of a genuinely serious condition 
must be imparted, there is a world of comfort to the patient in the citation of actual 
instances of the same sort where the happiest results were obtained. 

The intelligent patient at once sees that a logical reason underlies the 
demand for his cooperation and is the more likely to prove genuinely help- 
ful and responsive, while retaining that hopefulness and undamaged morale 
which may bring added years of useful life. 

In general, the physician whose only thought is the welfare of his patient and 
who is possessed of humanity, tact, and sound common sense will not go far 
astray. 

The fool oftentimes must be frightened into obedience and some fools 
must be abandoned to their folly. 

Practitioner and Consultant. — The physician must work methodically, 
deliberately, and with open mind, but once his opinion is formed it should 
find tactful, clear and emphatic expression and every subsequent order and 
act must be characterized by firmness and decision. If to these qualities 
he adds that modest self-confidence, born of fulness of knowledge and re- 
source, he will go far. 

Consultation. — Such a man can deal with intelligent patients frankly and 
freely, will not be afraid to call counsel nor feel always that his after-confer- 
ence with his consultant must be held in private, according to a custom more 
honored in the breach than in the observance. 

Few physicians will use a visit of courtesy as a means of self-advantage 
or the humiliation of a fellow-practitioner, and one who cannot deal fairly 
with all parties concerned is out of place in this day and generation. 

Lay Co-workers. — There are few intelligent families, moreover, in which 
the attending physician cannot find a confidant with whom he can talk freely 
and honestly, thereby increasing his usefulness and gaining cooperation and 
support. 

Attitude in Sickroom. — Doubts, fears, and arguments, however, are not 
for the sickroom, where a confident, cheery bearing and helpful suggestion 
may mean far more than drugs. 



CASE-TAKING 



II 



Unworked 
mines. 



Essentials of 
case-taking. 



Quack vs. Physician. — Ihe quack never hesitates to make a diagnosis, Honesty vs. 

. . . . , , , , r i ignorance and 

but the physician ot parts, knowledge, and honesty must often make none or dishonesty. 
at best a provisional one, and wait for more light. 

The charlatan never acknowledges an error; the honest man, whatever 
his ability, must occasionally confess one. 

The more superficial, ignorant or dishonest the man, the more dogmatic and 
hasty are his diagnoses, for with breadth and depth of knowledge comes its highest 
gift, a conception of its limitations. 

CASE-TAKING 
Significance and Importance of the Components of the Case History 

The Value of the Case Book. — 77 should be stated most emphatically that 
case-taking, recording, and reporting should be carried into every man's practice. 

Old case books well kept are mines of knowledge, and the science of medi- 
cine would be greatly enriched were the workers in city and hamlet alike to 
give to it reports of the unusual cases now for the most part allowed to pass 
without record. 

Tyro vs. Expert. — Ability to make a case history full, accurate, yet con- 
cise; to elicit the salient facts, and to each assign its proper value and per- 
spective, demands that the observer be full of usable knowledge, quick of 
perception, and capable of avoiding both omission and verbosity. 

Certain routine inquiries are indispensable and the student should be 
consistently painstaking and systematic in the days of his apprenticeship, 
though later, when a skilled clinician, he can elicit the cardinal points of a 
case and arrive at correct conclusions with less ink and fewer words. 

The Subjective vs. the Objective. — Our knowledge of clinical symptoms 
in a given case depends upon either (a) what we are told or (b) what we see or 
determine for ourselves; i.e., they are either (a) subjective or (b) objective, the 
latter group including bacteriologic and chemic tests as well as physical 
signs. 

"Hearsay Evidence.' ' — In the patient we may encounter garrulity, stu- 
pidity, concealment, deceit or hypochrondriacal exaggeration. If he is coma- 
tose or possesses no common language, we are left dependent upon the testi- 
mony of outsiders. In any event we must exercise sound judgment, keen 
discrimination and facility in cross-examination or we cannot weigh properly 
the fallible, yet extremely valuable subjective data. 

THE OUTWARD SIGNS OF DISEASE 

The First Impression. — The first glance or even the handshake may 
influence diagnosis and prognosis, and, while shunning the habit of making V ak 
hasty physiognomonic diagnoses, the physician should train his observation fnspectfon. 
and emulate the example of his predecessors of a darker medical era, who 
became adepts by force of necessity. 

Diagnosis in disease of the nose, throat, eye, ear, and skin is essentially 
that of inspection, which throughout the whole range of medicine and 
surgery plays an important part. 



Obstacles to 
case-taking. 



12 



MEDICAL DIAGNOSIS 



Malingerers. 



Melancholia. 



Facies, pupils, 
and speech, _ 



Luetic bahes. 



Character and temperament, bad habits, disease past or present, may 
stand revealed at a glance. 

Diathesis.* — "Temperament/ 1 which relates to the physical type and 
mental cast of the individual and was born of the old humoral pathology, is 
closely related to " diathesis," which applies to the group, but the latter implies 
a tendency to some special type of disease or diseases and the former has 
lost the prominent place it held in earlier times. One need give little thought 
to the elaborate older classification, though the " nervous," "bilious," 
" phlegmatic, " "lymphatic," and " melancholic " temperaments are often 
clearly defined and aid in diagnosis and prognosis alike. Who, for example, 
has not encountered the "lymphatic" (congenitally asthenic) individual with 
a ''prairie-fire tuberculosis" before which the physician stands helpless? 

FACIAL EXPRESSION.— The expression helps us with those forgers 
of symptoms who seek ease, food and shelter under the hospital roof or 
wish to saddle damages for some spurious hurt upon the rich individual or 
corporation. 

If melancholy has marked the patient for her own, "he carries on his 
face the impress of her signet," and incipient or established insanity of other 
types may manifest itself in a peculiar expression of the eyes, an ''intensifi- 
cation of emotional expression" and oftentimes a deceptively merry one. 

The stolid or even morose appearance of the immobile "mask-like" face of 
paralysis agitans or the fixed expression of surprise or fright which it may bear, 
and even the slighter facial palsies are often overlooked by the unobservant. 

General paresis even in its early stages often yields outward evidence. 
Lips, tongue, fingers and facial muscles may be tremulous; the pupils unequal 
and reacting to accommodation, but not to light, or wholly rigid. The 
speech may be slow, hesitant or explosive, consonantal words being difficult 
for the victim. In the "expansive" type excessive irritability, outbursts 
of causeless anger or delusions of grandeur accompanied by rapid- changes 
of facial expression may be evident; everything of his being superlatively 
beautiful, his schemes grandiose yet obviously fallible, and he incomparable. 
The " depressive" form is characterized by a marked but somewhat unstable 
mental depression often associated with delusions of the hypochondriacal 
or even persecutory type. 

Carcinoma of the stomach in its advanced stages is frequently associated 
with a curiously morose or saturnine expression well shown in a famous 
statue of Napoleon in his last days.f This, when associated with marked 
emaciation and a peculiar muddy pallor, is most suggestive. 

Syphilis. — The syndrome formed by a peculiar eruption, coryza ("snuf- 
fles"), a hoarse cry, a weazened monkeyish face, fissured lips and raw nostrils 
and buttocks, if seen in a babe, is pathognomonic of congenital syphilis. 

* Modern research has robbed the term of much of its meaning and ancient importance 
through the discovery of specific etiologic factors in relation to its manifestations. 

It would be absurd, for example, to refer to the "furuncular" or "aneurysmal" diathesis 
in the light of our present knowledge of the infections underlying these conditions. 

t In the Corcoran Gallery, Washington. 



THE OUTWARD SIGNS OF DISEASE 



13 




Fig. 1. — Classical fades 
of untreated or inveterate 
lues. Areas of gray hair 
representing past alopecia. 
"Saddle nose." Patient 
and his father both showed 
perforated palate. 



The permanent upper central incisors of the older children are often 
peg-shaped, notched at their cutting edges, irregular and separated. 

Fine linear scars may radiate from the angles of the mouth, keratitis and 
chronic otitis media often co-exist, and at any age a frog-face may result from 
syphilitic necrosis of the nasal arch. Syphilitic alopecia may be present 
also, or may have left its mark in a patchy grayness of the hair. 

Many cases of past syphilitic infection give no evidence, the examiner 
being forced to put the direct or indirect question. The former may often- 
times be definitely and clearly put in the case of 
men, but it is usually wiser to ask casually first as 
to antecedent "venereal" or "private" disease, or, 
in certain instances of especial delicacy, to quietly 
submit a blood specimen to the pathologist and 
await the report on a Wassermann test.* 

The therapeutic test is often invaluable though 
fallible and no mere negation on the part of the 
patient should outweigh a significant symptom group 
so far as the physician's attitude is concerned. 

Outward acceptance, inward doubt, and appropriate 
action make a good tripod. 

One of the most easily recognized and pathogno- 
monic {but in our day rare) syphilitic types combines 
alopecia or scattered areas of gray hair with saddle-nose and perforated palate. 

A deeply fissured tongue suggests this disease, and many cases present 
themselves with significant body scars, an active and unmistakable eruption, 
or the "primary lesion itself." 

Dress. — The quality of the clothing and its condition may suggest 
social station and occupation.. Carelessly worn and disarranged garments, 
stained by food droppings, if noted in a person formerly neat, suggest mental 
deterioration. An ammoniac al odor suggests advanced prostatic disease with 
urinary incontinence or cystitis, and in such cases white stains upon the shoes 
might sometimes give a hint of coexisting saccharine diabetes. 

Recent Weight-Loss or Gain. — In public services especially, needy 
patients, formerly obese or dropsical, who have recently lost greatly in weight, 
may wear their old clothes, which may be suggestively loose and, on the other 
hand, a recently developed anasarca may make the patient appear to be 
bursting through his trousers. 

Edema of the ankles is frequently suggested by loose lacing of the shoes, 
which may be cut and slashed for the same reason or the better to accommo- 
date corns, bunions, or gouty toes. 

Paralysis. — In the various forms of pathologic gait, and especially in 
spastic conditions, the wearing away of the shoe in a particular part may be 
suggestive. 

* The student must realize that no individual, whatever his or her rank or calling can 
safely be held exempt from suspicion, yet tact and delicacy are essential. The therapeutic 
test and the Wassermann show how often a negative response must be discounted. 



Hutchinsonian 
teeth. 



Keratitis and 
frog-face. 



Putting the 
question. 



A pathogno- 
monic syn- 
drome. 



Social station 

and 

occupation. 



Ill-fitting 
clothing. 



Loose lacings. 



14 



MEDICAL DIAGONSIS 



Phthisis. 



Prostitutes. 



Larynx. 



Essentials of 
.speech. 



True aphasia 
vs. anarthria. 



Aphemia, 
agraphia, 
amimia. 



VOICE AND SPEECH.— One should carefully note departures from the 
normal tone and enunciation. Even the layman recognizes the soft, high- 
pitched tones of the phthisical patient, and one notes oftentimes the peculiar 
harshness in the voice of the prostitute and the thick muffled speech of the victim 
of tonsillitis or adenoid disease. 

Hoarseness and aphonia are at times symptoms of great importance, as 
pointing to acute or chronic laryngeal diseases, and the " whispering voice" 
may arise from tuberculosis or malignant laryngitis, extreme exhaustion, 
hysteric aphonia or a paralysis of the abductors, the last being due oftentimes 
to the pressure of an aneurysm or mediastinal growth upon a recurrent 
laryngeal nerve. 

Slow, scanning, syllabic speech, combined with an intention tremor, 
suggests disseminated sclerosis or, very rarely, Friedreich's ataxia. 

In advanced paralysis agitans the crescendo speech may sometimes be 
encountered, the sentence being begun slowly and with hesitation, but increasing 
in rapidity and ending in a storm of words. Monotony of tone is the commoner 
vocal characteristic of this disease. 

In glosso-labio-pharyngeal paralysis, 
pseudo-bulbar paralysis, one encounters 



amyotrophic lateral sclerosis and 
a mumbling speech, associated 



with tremor and atrophy of the tongue and a curious immobility of 
the lips. 

Aphasia and Anarthria. — Normal speech demands that the centers and 
mechanism for the perception and recollection of spoken and written or 
printed w T ords, of articulation, and of association, should be normal and 
harmoniously interacting. 

It is evident that various disturbances may exist according to the charac- 
ter and location of the lesion; furthermore, that we must discriminate between 
" aphasia" and the cases of paralysis of the muscles of articulation ("anarth- 
ria"). True aphasia is usually of central origin, the peripheral mechanism 
being unaffected. 

Motor Aphasia. — This must be recognized as distinct from sensory 
aphasia. It is characterized by inability to voluntarily express by speech 
("aphemia"), by writing ("agraphia") or by gestures ("amimia") what may 
be a perfectly clear mental image. 

Sensory aphasia, on the other hand, indicates a failure to understand 
or recognize spoken words (auditory aphasia, word deafness) or written words 
(visual aphasia, word blindness). A large number of subdivisions occur 
under both types, such as the loss of power to carry a tune or write music, 
or a failure to interpret or recognize musical sounds. Still another variety 
("paraphasia") occurs in w T hich wrong words or characters are spoken 
or written, or the same word repeated. 

Apraxia. — By this is meant a loss of the faculty of recognizing or appre- 
ciating the identity, nature, and uses of objects or sensations, and here again 
one has various subdivisions, such as mind blindness (visual amnesia), mind 
deafness (auditory amnesia), as well as terms indicating an inability to 
recognize and interpret odors, tastes, etc. 



THE OUTWARD SIGNS OF DISEASE 



is 



THE COLOR OF THE SKIN.— The two conditions chiefly to be noted 
are pallor and cyanosis. The pale face may or may not mean true anemia, 
for a high color may co-exist with a low hemoglobin percentage. The color 
of the mucous membranes is more reliable and even u rosy chlorotics" usually 
show a pale conjunctiva. Ordinarily, pallor of the cheeks, lips, tongue, throat, 
ears, conjunctivae and finger-nails indicate a reduced hemoglobin percentage 
with or without a reduction in cells, though it may only mean a reduced 
amount of normal blood at the surface due to contracted vessels or a weak 
circulation. 

Anemic Types. — The color varies markedly in different types of severe 
anemia, being greenish yellow in typical cases of chlorosis, almost waxy white 
in many simple anemias, a peculiar lemon yellow in most cases of Addisonian 
anemia, and a curious earthy tint in the profound secondary anemia of 
advanced malignant disease of the stomach. 

Mode of Onset. — Sudden pallor, as in minor shock, syncope, nausea or 
certain neuroses, is usually unimportant and fleeting, but, in tubal pregnancy, 
cardiac disease, concealed hemorrhage, perforation of the stomach or bowel, 
and similar conditions, sudden pallor is a valuable and important sign. The 
pallor of the anemias, aside from those due to rapid blood loss, is slowly 
progressive and persistent. 

Nephritis. — In acute Bright' 's disease the skin is white and associated 
edema may produce a peculiar and characteristic pasty pallor. In parenchy- 
matous nephritis we meet with pallor, or in its late stages a sallow or 
brownish hue. 

Many authors speak of the peculiar "fawn-colored" skin as related to 
interstitial nephritis, but the author has found it oftenest in the "mixed'' 
type of chronic kidney disease or in very late stages of the interstitial form 





Fig. 2. — Bright's Disease. Fades 
occasionally encountered in chronic 
nephritis. Morning fulness of eyelids. 



Fig. 3. — Appearance of lids in afternoon 
or evening. 



the earlier period being often associated with the ruddy or high-colored 
("clubman") countenance, and many of its victims appearing exuberantly 
healthy. In most instances interstitial nephritis exists for long periods 
without the slightest physio gnomonic sign. 

Baggy Eyelids. — A tendency to edema of the eyelids, especially of the 
lower, is often evident, and the pale, puffy and almost translucent lid of 
early morning may have become shrunken and wrinkled later in the day. 
The condition cannot be considered as pathognomonic, but should be 
regarded as suggestive. In chronic parenchymatous and "mixed" nephritis 
alike, the face may appear more or less puffy, sallow or even fawn colored. 



A misleading 
symptom. 



Chlorosis, 
pernicious 
anemia, and 
cancer. 



Sudden pallor. 



Acute vs. 

chronic 

nephritis. 



Mixed and 
interstitial 
nephritis. 



Diurnal 
variations. 



i6 



MEDICAL DIAGNOSIS 



False pallor. 
False color. 



Selective 
points for 
cyanosis. 



Venous 
obstruction 
and impaired 
oxidation. 



Acute 
diseases. 



Extreme 
cyanosis in 
ambulants. 



"Red 
cyanosis." 



Drug cyanosis. 



Cold skin. 



Heart Disease. — The color in certain forms of advanced heart disease is 
both interesting and important. 

Aortic regurgitation is usually associated with a pallor of the indoor- 
worker type, without true anemia, but in endocarditic regurgitant and obstruct- 
ive disease of the mitral valve, even if compensation is present, the color is often 
deceptively high, producing, in girls especially, what the laity may consider 
an exquisite complexion, though in older women the pink is duskier and 
more patchy.* 

The skilled eye detects the underlying cyanosis which shows still more 
plainly in the mucous membrane of the lips, the skin of the ears, nose and pa- 
tella, or in the nails whose pink is replaced by a darker hue or, in extreme 
cases, by a purplish or blackish gray. 

Cyanosis. — This, whether general or local, with or without true dyspnea, 
ordinarily indicates obstructed venous return, deficient oxidation, or com- 
monly both factors, such as may result from any of the following conditions: 
ordinary suffocation, congenital heart disease, asthma, emphysema, pul- 
monary fibrosis, obstructed glottis, trachea or bronchi, as from foreign 
bodies, croup, laryngeal diphtheria, capillary bronchitis or broncho-pneu- 
monia proper, mediastinal tumors, or other heart and lung lesions. 

It occurs also in acute diseases, such as pneumonia, pleurisy with either 
liquid or gaseous effusion, and, to a slight degree, in severe acute bronchitis. 
Paralysis and spasm, particularly of the diaphragm, may produce marked 
cyanosis, as may the inhibition of efficient respiration by severe pain. 

The chief and most important physical factor in both local and general 
cyanosis is the slowing -of the circulation, whether central, localized or due 
to increased viscosity and blood volume, as in erythremia, but the reduction 
of hemoglobin may result from the action of chemical poisons alone without 
any material slowing of the blood current. 

In lobar pneumonia, profound cyanosis of the finger-nails is usually the 
forerunner of death. 

No outward sign of disease exceeds cyanosis in importance, and in its 
extreme form it exists in but three classes of walking patients, viz., severe em- 
physema or erythremia in the adidt and congenital lie art disease in the child. 

It is often associated with mere chilling of the body surface, hysteria, 
neuritis, etc. Erythremia is associated with a peculiar red cyanosis and in all 
cases of erythrocytosis cyanosis is a prominent feature. 

Local vasomotor relaxation or paralysis is readily distinguished by the 
lack of turgidity of the venous trunks, and it should be remembered that cer- 
tain forms of drug poisoning, especially that of acetanilid and its congeners, 
nitro-benzol, etc., may account for an otherwise inexplicable and extreme 
cyanosis. 

Through excessive heat loss cyanotic areas are cold save in acutely in- 
flamed parts. The slighter degrees are often unnoticed by the student, but 
pronounced cyanosis cannot be overlooked. 

*Such deceptive color is frequently present in splenic leukemia, even when quite 
advanced. 



THE OUTWARD SIGNS OF DISEASE 



17 



Other Abnormal Color Variations. — Of the many other departures from 
the normal tint one may mention the yellowish brown, dark brown, or brown- 
ish black of Addison s disease, the peculiar bluish or blackish gray of argyria 
(chronic silver poisoning), the sallow tint of chronic malaria and the varying 
yellows produced by jaundice. 

Arsenical melanosis is quite common and may exactly simulate Addison's 
disease, but usually diminishes under drug discontinuance. Marked pig- 
mentation is occasionally encountered in exophthalmic goiter. The yellow- 
ish-brown patches of pregnancy (chloasma gravidarum) and pelvic disorders 
are common and easily recognized. Certain abdominal tumors and peri- 
toneal tuberculosis may cause extensive and misleading color changes. 

Streaky pigmentation usually indicates scratching as the result of skin 
parasites or pruritic lesions and is often seen in public clinics. One occasion- 
ally encounters a pigmentation of like causation so diffuse as to closely simu- 
late that of Addison's disease. 

Melano -sarcoma is associated with a grayish or blackish skin and the 
urine shows melanin. A brownish or dirty gray, spotted or patchy discolora- 
tion may occur in hepatic cirrhosis with or without jaundice, and bronzing 
may be associated with combined cirrhosis and diabetes (bronze diabetes) or, 
in rare instances, with extreme long-standing jaundice alone. Aside from 
its secondary color manifestation, syphilis in its tertiary and congenital form 
sometimes produces a peculiar sallow pallor not easily described, but readily 
observed. The author has encountered it chiefly in old cases of imperfectly 
treated syphilis, and it is likely to be associated with other luetic " reminders." 

Drug Habitues. — Peculiar but indefinable forms of pallor and sallowness 
may mark the cocain and opium habitue, and occasionally the author has ob- 
served in such cases a physiognomy remarkably like that of chronic nephritis; 
but more often the habit may exist for years without distinctive outward signs. 

Certain cases of deep pigmentation occur lacking demonstrable etiology and 
without impairment of the general health. 

As regards both marked color loss or its decided modification in chronic dis- 
eases, it should be borne in mind that the symptom is, as a rule, one indicative 
of the advanced stage of the disease. 

High Color. — A florid face is often present in gouty subjects or in many of 
those suffering from early interstitial nephritis or hepatic cirrhosis, but may 
be due to idiosyncrasy, acne rosacea or daily exposure to harsh weather con- 
ditions. It often indicates an overluxurious and self-indulgent life or the 
abuse of alcoholics. 

Unilateral flushing is frequently observed as a neurosis, in lobar pneu- 
monia, or as the result of mere pillow pressure, migraine, and, less commonly, 
of irritation of the fibers of the cervical sympathetic as in aneurysm of the 
aortic arch or mediastinal growths. 

"Morbid blushing" is a troublesome and not uncommon vasomotor 
idiosyncrasy. 

The flushed face of fever patients is too common to merit extended dis- 
cussion. 



Yellow, browD, 
and black 
skins. 



Chloasma 
gravidarum. 



Vagabond's 
pigmentation. 



Obscure 
pigmentation. 



Not always 
high living. 



i8 



MEDICAL DIAGNOSIS 



Hemolysis. 



Toxic 
jaundice. 



Blocked bile 
current. 



Icterus 
nervosa. 



General cutaneous hyperemia is seen in poisoning by belladonna, hyo- 
scyamus, or coal-tar products, is common in the trivial fevers of infancy 
and early childhood, and may precede the specific exanthem in fevers of the 
eruptive type. 

JAUNDICE. — {Icterus) Hepatogenous vs. Hematogenous. — Clinically, 
jaundice is either u obstructive ," as in inflammation of, or direct or indirect 
obstruction of, the common duct, or, "toxemic" the latter form often being 
wrongly termed hematogenous. Although hemolysis is the primary change,, 
both types are essentially hepatic as regards the direct source of bile pigment, 
and ''obstruction" and "diffusion" jaundice cover nearly every type. 

. There are toxins which act directly upon the blood itself (within the 
hepatic tissues) or affect the hepatic cells. Poisoning by phosphorus, potas- 
sium chlorate, ether, chloroform, toluylendiamin, snake venom and arsenic 
are examples of one form; yellow fever, pyemia and malaria of another; while 
certain infectious diseases are characterized by marked associated jaundice. 
Such are "WeiVs disease" and " acute yellow atrophy" 

It occasionally complicates pneumonia, ulcerative endocarditis, syphilis, 
relapsing fever, and even influenza. 

The typical mild jaundice is seen in simple obstructive catarrh of the 
bile ducts. In hepatic cirrhosis it is late and seldom extreme. 

Obstructive Jaundice. — The term "obstructive" as usually applied, covers 
a blocking of the passage of the bile from the liver to the intestines with 
resultant absorption into the general circulation. 

The causes are severe gastro-duodenitis, catarrhal conditions, gall-stone, 
or parasites, involving the common duct, pressure closure by tumor, or, very 
rarely, by fecal accumulation, the pregnant uterus, or abdominal aneurysm. 

Strictly speaking, all cases of jaundice are obstructive, as even in the toxic 
form there is a high viscidity which favors absorption.* 

Emotional Jaundice. — The remarkable jaundice associated with mental 
shock or profound emotion is probably obstructive and due to spasm and 
reversed peristalsis. In one such case coming under the author's notice pro- 
found jaundice followed a mere fleeting fit of anger. f 

Dardanelles Jaundice. — This curious form, very prevalent amongst the 
British soldiers of the Dardanelles expedition, was non-obstructive, and proved 
to be due to a paratyphoid bacillus. 

Hereditary Jaundice, of the Minkowski Type.— This interesting condition 
may affect succeeding generations and appears in several forms. 

First, hereditary icterus neonatorum, in which an angiocholitis and com- 
mon duct stenosis is commonly present and an extreme mortality ratio 
observed. 

Second, a peculiar form associated with hepatic and splenic enlargement, 
anemia and infantilism. 

f Carcinoma of the liver is accompanied by jaundice in more than one half the 
cases, but the cause is found to be pressure from the adjacent involved glands. In 
abscess of the liver, single or multiple, it may be absent or only slight. 

* Jaundice is observed occasionally in cases of brain concussion. 



THE OUTWARD SIGNS OF DISEASE 



19 



"Diabete 
bronze." 



Clay-colored 
stools. 



Third, a congenital acholuric form with splenic enlargement, no bile in 
the urine, and little disturbance of the general health. 

Symptoms of Jaundice. — The skin, ocular conjunctiva, and the oral and 
pharyngeal mucous membrane yield the best evidence, especially if the latter importance oi 
are blanched by the pressure of the ringer or better by a microscope slide, 
but even a marked discoloration is invisible by artificial light. 

By daylight the color of the skin varies from a faint or brilliant yellow to 
a deep greenish brown or bronze (melas-icterus), sometimes simulating Addi- 
son's disease, and not infrequently present in the last stages of ordinary 
cirrhosis of the liver as well as in that extremely rare form of combined inter- 
stitial hepatitis and pancreatitis known as bronzed diabetes. 

Obstructive Type. — The sweat and urine are discolored* in clinically 
obstructive jaundice, the latter often yielding the first evidence of the 
condition: the pulse and respiration are usually slow; the stools are pale 
gray, pasty and fetid; either constipation or diarrhea may be present; trouble- 
some pruritus is common and urticaria or purpura occur in occasional 
instances. 

A marked hemorrhagic tendency is shown in severe cases and is of special 
interest with relation to surgical procedure. 

There may be marked mental depression or extreme irritability and, in 
certain grave cases, muscle cramps, convulsions, active delirium or a typhoid 
state may end in coma. The urine often contains albumin and hyaline 
casts. 

Acute Yellow Atrophy. — True malignant jaundice is a rare disease of 
unknown causationf chiefly affecting women, often related to pregnancy, 
sometimes to violent emotion or shock, but is probably invariably associated 
with some antecedent or concurrent infection. 

Icterus Neonatorum. — There is a mild type, benign and trivial, extremely 
common in new-born children, occurring during the first twenty-four or 
forty-eight hours and lasting for a week or two. 

The grave form of icterus of the new-born , when not hereditary, may be due 
to sepsis, usually of umbilical origin, to syphilitic disease of the liver, or to 
congenital absence of the ducts. It is frequently associated with hemorrhage 
from the navel and is a fatal disease. 

Toxemic Jaundice. — In this condition jaundice is usually less intense, the 
stools are colored, the urine contains little or no bile, and the disease termi- 
nates promptly in recovery or death. It is associated with severe acute infec- 
tions of varying character, certain forms of mineral or snake-venom poisoning, 
or the pernicious forms of anemia and malaria, and the constitutional symp- 
toms may be profound. 

In certain fatal cases observed by the writer actual obstructive jaundice of the Jaundice may 

/ y J J be extreme. 

ordinary clinical type has been closely or even exactly simulated but disproven by 
operation or autopsy. 

Urobilin Icterus. — Urobilin cannot cause icterus, but may be associated 

* The milk of nursing women and even the sputum may be discolored. 

t But 250 cases are on record since the first observation by Ballonius in 1616 (Osier). 



"Icterus 
gravis." 



The mild form , 



A fatal 
ailment. 



20 



MEDICAL DIAGNOSIS 



Malnutrition 
and fluid loss. 



General terms. 



Obstruction 
and hydremia. 



Salt retention. 



with bilirubin in a jaundice due to partial biliary obstruction, and in slight 
degrees of obstruction may appear alone in the urine.* 

DRY AND MOIST SKIN.— Hyperidrosis.— Sweating of the hands or feet 
may indicate idiosyncrasy, debility, congenital asthenia, or sexual neuroses. 

Unilateral sweating, especially of the head or face, like pallor or cyanosis, 
occurs in pressure involvement of the sympathetic and in certain migraines 
and neuralgias. Sweating of the head is especially common in rickets and, of 
half the body, in rare instances of hemiplegia. 

General sweating occurs as a critical phenomenon in certain acute dis- 
eases, as an associated symptom in malarial fever or phthisis and persistently 
in acute rheumatism, collapse, and severe pain. 

Anidrosis. — A dry skin is associated with profound malnutrition and with 
most diseases causing extreme loss of fluid by the bowels or kidneys. It is 
a pronounced symptom in certain ailments such as myxedema, in which the 
skin may be both dry and harsh, and diabetes, chronic interstitial nephritis 
and carcinoma also furnish good examples. 

Sudden checking of perspiration in those working under conditions of 
extreme high temperature is a well-known warning of impending heat stroke. 

Qualitative Changes in the Perspiration. — The yellow sweat of jaundice, 
the extraordinary and rare, blue, brown, yellow, red, or even hemorrhagic per- 
spiration of hysteria, the sour-smelling sweat of acute rheumatism, the dis- 
gusting odors of bromidrosis or the urinous taint of the sweat in diseases 
associated with impaired renal function may be encountered. 

EDEMA. — Three terms are used in this connection: (i) edema proper, 
i. e., fluid confined to the actual connective tissues and usually localized; 
(2) dropsy, the accumulation of fluid in the serous cavities combined with 
edema; (3) 'anasarca (general edema). The last term, however, is often 
used synonymously with the one preceding. 

Obstructive vs. Hydremic Edema. — Edema represents a capillary transu- 
dation exceeding the absorptive capacity of the lymphatics and may be ob- 
structive (passive congestions), or hydremic (toxemias, infections, cachexias) 
and in many if not most instances represents a combination of both. Re- 
tained toxic substances and increased permeability of the systemic capillary 
walls are doubtless prominent factors in the latter, if not in both groups, and 
experiment fails to prove the older theory of pure hydremic plethora, i. e., 
increased blood volume and water retention, while nevertheless indicating 
that the latter may play some part. 

In both the so-called static and hydremic forms, and especially in that asso- 
ciated with chronic parenchymatous nephritis, sodium chloride retention has 
been shown to assist in maintaining the edema. 

Milroy's Edema. — This is a curious hereditary, permanent edema of the 
legs usually asymmetrical in its early stages. 

Inflammatory Edema. — The clinical distinction between inflammatory 
edema and ordinary edema is largely dependent upon the physical constituents 

* Such is the case in the two latter forms of congenital jaundice mentioned on the 
preceding page. 



THE OUTWARD SIGNS OF DISEASE 



21 



of the inflammatory exudate as compared with the simpler transudate, but, 
inasmuch as pronounced evidences of local inflammation and usually 
of acute infection accompany the former, no difficulty can often arise in 
differentiation. 

Vagaries of Edema. — A thorough knowledge of the favorite locations and 
the vagaries of this condition is essential, inasmuch as it may shift its seat, 
obey or disobey the law of gravitation, and vary from swelling of the lids, 
slight purfiness of the ankles, or a localized angioneurotic edema, to general 
dropsy, in which the patient is drowning in his own transudate. 

Angioneurotic edema is a localized* but transient, firm swelling, closely 
allied to urticaria and erythema nodosum, not ordinarily pitting readily on 
pressure, found in various regions of the body in certain ill-defined conditions 
and serious only when, as rarely happens, it involves the glottis. 

Slight and Transient Edema of the Lower Extremities. — Aside from the 
lesser degrees and earlier stages of many of the recognized causes of edema 
this is found in cases of simple anemia, or after prolonged and exhausting 
tramps in those unaccustomed to physical exercise. 

In the earlier stages of gradually induced cardiac decompensation edema may 
appear late in the day, only to vanish during the night's rest, and its absence 
during the greater part of the waking hours causes many errors of observation. 

Of certain cases of Bright' s disease the reverse is true, slight ptiffiness of 
the eyelids being present in the early morning, but vanishing during the forenoon. 

Cardinal Signs of Edema. — The characteristic feature of all simple edemas 
is the appearance of a non-inflammatory swelling, often very slight, but usually 
tending to obscure the normal outline of the affected portion, readily receiving, and 
for a variable period retaining, indentations produced by the pressure of the 
examiner's finger or by the constriction due to clothing. 

Cavity Exudates and General Dropsy. — In its extreme grades the same 
process tends to produce liquid transudates in such serous cavities (lymph 
spaces) as the pleura, pericardium, and peritoneum, producing what are known 
respectively as u hydrothorax," u hydro pericardium" and "ascites." 

Such conditions accompanying general edema constitute u general dropsy," 
which in practice is limited to Bright' s disease, a failing heart, from whatever 
cause, or, both combined. 

In Bright' s disease, especially, an hydrothorax or hydro pericardium may 
occur suddenly and unexpectedly and escape observation until serious pres- 
sure symptoms are manifested even though no localized or general edema 
exists elsewhere in the body. 

Cardiac Edema. — As between renal and cardiac conditions the attendant 
edema at times presents some distinguishing features. 

In heart disease, edema (predominantly obstructive), even without general 
anasarca, is associated usually with cyanosis, often very slight, and in its 
original seat and progress usually follows the law of gravity, commencing in 
the feet (or over the sacrum in recumbent patients) and extending upward. 

In all forms of non-inflammatory edema the slighter primary manifestations 
occur in loosely bound connective-tissue areas of maximum distensibility. 

* Very rarely the condition is universal in distribution. 



Usually 
transient and 
trivial. 



An important 
and elusive 
sign. 



Lymph-space 
transudates. 



Unheralded 
complications. 



Seeks the 
dependent 
part. 



Primarily in 
looser tissues 



22 



MEDICAL DIAGNOSIS 



Primarily dis- 
regards law of 
gravity. 



Marble edema. 



Cardiac type of 
edema. 



Diurnal vs. 

nocturnal 

edema. 



Misleading or 

elusive 

edemas. 



Urticaria and 
angioneurotic 
edemas. 



Unilateral vs. 

bilateral 

edemas. 



Renal Edema. — In acute and chronic parenchymatous nephritis any 
marked edema (hydremic) usually appears first in the face and eyelids and 
extends downward, being associated with marked pallor, unmixed with any 
considerable degree of cyanosis, unless there be obstructive effusion in the peri- 
toneal cavity or thorax, or, as frequently happens in the established cases, 
there exists a complicating decompensation on the cardiac side. 

Furthermore, the edema of acute Blight's disease as it appears on the body 
generally, or the extremities, is distinctly firmer than a recent cardiac edema, and 
in persons with a delicate skin and more especially in children, the blue super- 
ficial venules contrast sharply with the dead white of the tense overstretched 
skin (marble edema). 

Interstitial Nephritis. — In typical cases edema of any severity is absent 
until the terminal stages are reached and then appears as a result of cardiac 
insufficiency and is of the cardiac type. 

Effect of Posture. — Edema of the cardiac or renal type, when established, 
is markedly affected by changes in the position of the patient; that of heart 
disease or parenchymatous nephritis, especially so, the attitude assumed by 
such a case during any night being often indicated in the morning by an in- 
creased swelling of the side upon which he has lain. As before stated, cardiac 
edema usually appears first in the most dependent portion of the body, as in 
the feet and ankles after a day's activity, or over the sacrum in the bedfast. * 

Leathery Edema. — In those curious, partially compensated heart cases 
with chronic gravity edema, in which the ambulant patient mistakenly or 
from necessity keeps on his feet for weeks, months, or years, one may see 
a peculiarly hard edema of the legs and lower thighs. 

The shin becomes leathery and pigmented in such instances and in conse- 
quence can be indented only by sustained firm pressure. 

One should not be misled by certain edemas of the lower extremities 
due to varicose veins, usually, but not always, unilateral, though seldom equal 
in degree if bilateral. 

Edema of the calves without edema of the ankle or other regions has been 
observed by the author in several victims of heart disease possessed of un- 
usually tight, trim ankles. Such an edema might easily be overlooked if, 
as is usually the case, only the ankles or lower tibial shaft are tested. 

Collateral Localized Edema. — Over purulent exudates, areas of suppurative 
inflammation and severe neuritis, such edema may, but does not always, occur; 
as, for example, in empyema, mastoiditis, parotitis, pericarditis, hepatic 
abscess, perinephritic abscess, superficial lymphangitis and multiple neuritis. 

Non-inflammatory circumscribed edemas are either angioneurotic, pur- 
puric, giant urticarial, or, of the ordinary obstructive type due to the mechan- 
ical blocking of veins or lymphatics. 

Edemas are almost invariably bilateral, if of the cardiac or renal type; uni- 
lateral, if due to the blocking of the local circulation; but bilateral edema may also 
result from blocking of a main venous trunk. 

* Tenderness' over the tibia, if bilateral, should always suggest persistently recurring 
edema even if none is detected at the time of examination. 



THE OUTWARD SIGNS OF DISEASE 



23 



Edema of the arm may be due to the pressure of tumors or enlarged 
glands upon the venous drainage channel, to thrombosis, and even to massive 
pleuritic effusion or mediastinal tumors, including aneurysm. 

Obstructed flow in the femoral veins causes edema of one leg or unequal 
involvement of both.* The whole lower half of the body may be affected if 
the inferior vena cava be blocked. The head, neck, arms and thorax are 
edematous if the superior vena cava is obstructed below the azygos veins; 
the head and neck alone, if the obstruction be above these veins. 

Other specific causes of edema are trichinosis, beri-beri, and ordinary multiple 
neuritis. The blue edema of hysteria is a rare condition allied to or identical 
with the angioneurotic form. 

The cachectic edemas, as seen in leukemia, scurvy and pernicious anemia, 
are usually of the mild cardiac type and, as previously stated, in terminal 
chronic Bright's disease of the interstitial type the edema is distinctly or 
predominatingly cardiac. 

LYMPHANGITIS AND PHLEBITIS.— Acute Septic Forms.— Both 
acute lymphangitis and acute phlebitis, if severe, may be associated with 
edema and occasionally great difficulty arises in the differentiation of the 
two conditions. 

For that matter the two ailments may, and often do, co-exist and both 
depend upon the same etiologic factors in the form of pyogenic organisms. 

Acute Septic Lymphangitis. — This is extremely common as compared 
with phlebitis and especially so in relation to infected wounds of the upper 
extremities. 

Its cardinal features are : first, red streaks running proximally in the direc- 
tion of the tributary glands, associated with tenderness on pressure over these 
lines and tenderness and swelling of the glands draining the infected area. 

In severe cases the edema is progressive, the swollen lymphatics may be 
felt as thin raised cords and irregular areas of redness occur at intervals over 
the lymphatic lines. 

Acute Phlebitis. — In acute phlebitis the glandular tenderness and swelling 
are usually absent or much less marked. The redness is less decided or altogether 
lacking, the vein if palpable is much larger than the lymphatic cords and the 
superficial venules are markedly dilated. 

If the resulting thrombus undergoes purulent transformation, embolic 
phenomena initiate a pyemic state. 

The red areas of a lymphangitis may suggest erysipelas but lack the well- 
defined, sharply circumscribed, advancing, raised margin of that disease. 

A migratory form of septic phlebitis is occasionally encountered which 
may be most baffling. 

ASCITES. — Fluid in the peritoneal cavity may be part of a general dropsy 
as in heart disease, Bright's disease, or obstructive pulmonary conditions such 

* Such edema may coexist with that of the cardiac or renal type and persist after the 
heart or kidneys cease to be factors in its production. 

In walking patients especially the unequal involvement of the two sides always suggest 
it. 



Venous block. 



Secondary 
cardiac edema. 



Confusion 
possible. 



The red lines. 



Palpable 
lymphatics. 



Migratory 
phlebitis. 



Common 
causes. 



24 



MEDICAL DIAGNOSIS 



Massive 
effusions. 



Shifting 
dulness and 
tympany. 



Ascitic wave. 



False wave. 



Effect of 
adhesions. 



Technic 
important. 



Small 
exudates. 



as emphysema and fibroid lung, which have produced right heart insufficiency, 
or it may result from any form of chronic peritonitis, whether simple, tuber- 
culous, or malignant. Furthermore, it may be caused by portal obstruction, 
whether due to disease of the liver itself, to thrombosis of, or to pressure 
upon, the vein. 

Small and Large Effusions. — In tuberculosis, malignant disease and most 
of the cases associated with new growths, the effusion though always con- 
siderable is relatively small. 

Occurring as a part of general cardiac or renal dropsy, or of portal obstruc- 
tion, the exudate is ultimately large and produces a tense and markedly pro- 
tuberant abdomen. 

This tends to broaden in the flanks if the patient assumes a dorsal recumbent 
position. The umbilicus is prominent and percussion reveals a dulness obeying 
the law of gravity, and hence, in the absence of limiting adhesions, shifting its 
seat as the position of the patient is changed. 

Whenever and from whatever cause the peritoneal cavity contains any con- 
siderable free exudate, the fluid seeks the most dependent portion, the intestines 
float upward, and yield a tympanitic note which shifts posturally exactly as does 
the dulness, but to diametrically opposite locations. 

The patient being in a sitting or standing posture, a fluctuation wave may 
usually be felt as a shock to the receiving finger if the abdomen is sharply 
tapped upon one side just below the line of percussion dulness, while the 
finger-tips of the other hand are placed opposite. The ulnar surface of the 
hand of an assistant should be lightly applied in the median line between the 
percussing and receiving fingers to interrupt a false vibration in the wall 
otherwise indistinguishable from the true ascitic wave. 

Sources of Error. — Shifting dulness may be interfered with by adhesions 
which prevent the flow of exudate or hold intestinal coils in a fixed relation to 
the wall; moreover, some time may be required in certain cases for the fluid 
to change its site, and several moments should be allowed to elapse before 
negative findings are reported. 

Dipping. — Such effusion makes palpation of the spleen, liver or underlying 
tumors difficult and often demands that the palpating finger shall be suddenly 
and sharply depressed, preferably both during forced inspiration and at the 
end of forced expiration, the temporary displacement of the fluid often mak- 
ing the underlying structure palpable. 

The knee-elbow position is necessary for the detection of small exudates, the 
dulness then appearing in the very region most resonant in the recumbent 
patient. 

In massive effusions with excessive tension the ascitic thrill or wave may be, 
but rarely is, absent. It may be difficult to obtain in small effusions, in the 
presence of adhesions or through an excessively fat or edematous abdominal wall. 

Differentiation. — Elaborate tables of differential diagnosis in relation to 
ascites seem to the author almost futile. 

Movable percussion dulness in the flanks and bilateral dulness with central 
resonance at once rules out pregnancy and cysts, whether pancreatic, massive 



THE OUTWARD SIGNS OF DISEASE 



25 



ovarian or hydatid, the signs being diametrically opposite. Encysted ascites 
may give rise to insuperable pre-exploratory diagnostic difficulties. Meteor- 
ism, i.e., excessive tympanites yields a universally tympanitic note. 

Hepatic Cirrhosis. — The ascites of portal obstruction, usually due to 
hepatic cirrhosis, lacks the associated edema of the face usually encountered 
in acute and chronic parenchymatous nephritis, though a variable degree of 
edema of the cardiac type may be present in the lower extremities in long- 
standing cases. Ascites without general edema often co-exists with emacia- 
tion, giving rise to the " poached-egg belly" which in the adult is usually asso- 
ciated with cirrhosis of the liver, portal thrombosis or a tuberculous or malig- 
nant peritonitis. 

A big belly in a thin man invariably indicates a pathologic condition. 

Character of Ascitic Fluid. — In hepatic cirrhosis, cardiac or renal disease, 
it is usually clear, straw colored, and of low specific gravity (1010 to 1015). 
It is but moderately albuminous (2 per cent, or less) and may spontaneously 
coagulate on standing. The color is slightly darker in cirrhosis than in the 
ordinary secondary forms. In tuberculosis and malignant disease it is 
of higher specific gravity, contains 4 per cent, or more of albumin, may be 
hemorrhagic and, rarely, is milky or turbid from fat or true chyle. 

Chylous vs. Fatty Ascites. — The two latter conditions may oftentimes be 
readily distinguished by the size of the fat globules which in chyle resemble 
a closely packed field of cocci as shown on microscopic examination. Mere 
blocking of the thoracic duct may or may not cause chylous ascites. Rup- 
ture of the duct or of a chyle-bearing lymphatic may occur, or filaria sanguinis 
hominis, or malignant or tuberculous ulceration be present. 

Chyliform Ascites. — In malignant or tuberculous disease especially, a 
milky ascitic fluid may be present which is not a true chylous ascites but 
rather an exudate attending a chronic inflammatory process and containing 
fat as a product of cell degeneration and disintegration. In such cases 
the exudate contains large numbers of such degenerating cells. 

Lactescent Ascites. — A curious milky, but not fatty, ascites is occasionally 
met with, under the same conditions as accompany chyliform ascites. 

In such cases there is no separation into layers and the peculiar appear- 
ance is due supposedly to lecithin or some protein. 

Occasionally an exudate occurs which cannot be distinguished from that 
of a true chylous ascites save by its relatively very slow reaccumulation 
after tapping and emptying the peritoneal cavity. 

LYMPHEDEMA, — The chronic forms of edema due primarily or chiefly 
to lymph stasis involve also a persistent and more or less progressive prolifera- 
tion of the skin and subcutaneous connective tissue of the affected members. 

Its best known form is that known as "elephantiasis." This ailment is 
endemic and due to the presence of the filaria sanguinis hominis, and indeed 
is frequently encountered in countries infested with this organism (filaria 
Bancrofti). 

On the other hand, sporadic cases are not infrequently encountered which 
present the same clinical appearance but lack any specific etiologic factors. 



Edema slight. 



"Poached-egg 
belly." 



Characteristic 
of transudate 



Exudate. 



Milky fluid. 



The false and 

commoner 

form. 



Endemic form. 



Sporadic type. 



26 



MEDICAL DIAGNOSIS 



Prominent 
symptoms. 



Onset and ex- 
acerbations. 



Palpatory 
crackling. 



In each variety the persistent and slowly progressive enlargement of the leg, the 
leathery, furrowed, uneven, varicose surface and the slowly increasing difficulty 
in locomotion are unattended by the cardinal sign of cardiac or renal edema, viz. — 
pitting on pressure. 





Fig. 4. — Sporadic lymphedema. 
{Courtesy of the late Dr. Burnside Foster.) 



Fig. 5. — Sporadic lymphedema. 
{Courtesy of the late Dr. Burnside Foster.) 



One or both legs may be affected and in the endemic form a similar enlarge- 
ment of the scrotum, penis, labia, or clitoris may occur or the same process 
may attack the arm, lip, or ear. (See under c: Elephantiasis"). 

Only slight pain or discomfort is experienced in the non-filarial cases, but 
in those of the endemic type a considerable amount of suffering may arise. 

The endemic (filarial) form may come on suddenly with fever, redness, and 
swelling and such patients may be subject to recurrent attacks of the same 
type, each resulting in greater residual permanent enlargement of the affected 
part. 

SUBCUTANEOUS EMPHYSEMA.— Save in malignant edema and 
glanders, this condition indicates the entrance of air into the subcutaneous 
tissue through a wound or rupture of an air-containing viscus, as in trach- 
eotomy, cough, rupture of pulmonary alveoli, malignant ulceration of the 
esophagus, etc. It offers no difficulty in diagnosis because of the pathogno- 
monic tissue-paper-like crepitation of the distended tissue under finger 
pressure. 

SUBCUTANEOUS HEMORRHAGES.— These will be fully considered 
under purpura, and it need only be said that the discoloration of the effused 



THE OUTWARD SIGNS OF DISEASE 



2 7 



blood is persistent under pressure, that the spots undergo the same changes 
in color as an ordinary bruise, are not elevated usually, and vary greatly in 
size. 

Petechiae and Ecchymoses. — The term ecchymosis is applied to the 
subcutaneous hemorrhage one-half inch or more in size as in the ordinary 
bruise and, like the petechia, it may be regular or irregular in outline. 

The petechia is less than one-half inch in area and often is pin-point or 
pin-head sized. This term is often incorrectly used to describe a point of incorrect 
redness which blanches under pressure such as the "rose spots" of typhoid term, 
fever. When complicating an exanthem, as in measles or smallpox, true 
petechiae invariably indicate a severe type of disease. In chronic diseases 
they are ordinarily associated with a definite cachexia or a hemorrhagic 
tendency (see "purpura"), and in certain obscure infections they indicate 
sepsis and, especially, malignant or "chronic infective endocarditis, 
should not be confused with the nodular swelling of erythema nodosum 

In ulcerative endocarditis the occurrence of petechiae may be of great diag- 
nostic value and in the u recurrent infective endocarditis" the presence of cutaneous 
ephemeral, red, raised, tender cutaneous nodules appearing upon the extremities 
is of interest and of almost pathognomonic value. 



They In acute and 
chronic 
disease. 





Fig. 6. — Collateral veins in a typical case 
of portal obstruction {After Krause.) 



Fig. 7. — Collateral veins in a typical case 
of obstruction of the inferior vena cava. 
(After Krause.) 



COLLATERAL VENOUS CIRCULATION.— Portal vs. Caval Obstruc- 
tion. — Hepatic cirrhosis or thrombosis of the portal veins may produce a 
marked and evident enlargement of the superficial abdominal veins, and a 
similar condition occurs in thrombosis of the inferior vena cava. The former 
chiefly affects the median region of the abdomen; the relation of its veins to 
the navel suggesting the term " caput medusce," and though the lower thoracic 
veins are involved, the group lies chiefly within lines dropped from the 
middle of the clavicle to the groin. 



"Caput 
medusae.' 



28 



MEDICAL DIAGNOSIS 



Visible 
dilatation. 



Visible 
arterial 
pulsation. 



Clinical rela- 
tionships. 



Simulate many 
diseases. 



Idiosyncrasy. 



Important 
inferences. 



Wet cupping 
and the 
electric belt. 



In the latter (obstruction of the inferior vena cava) the enlargement 
is predominantly lateral and usually less complicated in pattern. Unfor- 
tunately, admixture of the two may occur as in the case of a massive ascites 
of cirrhosis producing caval obstruction leading to enlargement of both groups 
of superficial veins, and furthermore the distinctions laid down above do not 
always hold true in other instances. 

Visible Internal Mammary and Intercostal Veins. — In any form of 
intrathoracic tumor, especially of the mediastinum, visible enlargement 
of the internal mammary and intercostal veins may be evident when the 
main venous trunks are blocked. If the superior vena cava is obstructed the 
blood flows downward to reach the ascending current in the inferior vena 
cava through the azygos veins. 

Congenital Obliteration of the Aorta. — Obliteration of the descending 
thoracic aorta below the ductus arteriosus Botalli is a clinical curiosity, the 
patient usually, but not always showing a visible, pulsating, arterial, collateral 
circulation between the subclavian above and the vessels of the lower 
extremity below. 

The pulse in the lower extremities is small and delayed, the aorta dilated 
proximally to the point of obstruction, and a diastolic aortic bruit and left 
ventricular enlargement, are usually manifest. 

Lower Thoracic Veining. — The arborescent branchings, indicating more 
or less closely the peripheral diaphragmatic attachment and frequently ob- 
served on the walls of the chest, seem to be without definite clinical signifi- 
cance. The author has seen them most often in cases showing pleural 
adhesions, right ventricular dilatation or overstrain, cirrhosis of the liver, 
obstructed pulmonary circulation of the chronic type, chronic cough, and, 
not infrequently general arterial or myocardial degeneration. 

DRUG ERUPTIONS.— The iodides may produce acne-like or even 
varioliform or erythematous rashes; the bromides, an acne-like eruption; 
whereas phenacetin and its congeners, the balsams (such as copaiba), sodium 
salicylate, diphtheria antitoxin and various other sera, are capable of pro- 
ducing urticaria, or, other rashes, the more misleadingly simulating scarlatina 
or measles, in that a febrile ailment may be coincident. Many drugs produce 
rashes in certain individuals only, and these efflorescences are so varied as to 
preclude description. 

DESQUAMATIONS.— The chief diseases followed by desquamation 
are: scarlet fever (lamella), measles (bran-like scales), smallpox (crusts), 
erysipelas (flakes), dermatitis (exfoliation). 

SCARS. — Study the history of scars. The pits of previous smallpox may 
exclude that disease in some doubtful exanthem in a comatose patient. The 
scar of a carbuncle at the back of the neck may suggest glycosuria, . and 
multiple linear scars at the angles of the mouth often follow congenital 
syphilis. Linear knife-cut scars on the left hand usually indicate right- 
handedness and vice versa. Small, bright, shining, slightly depressed scars 
on the chest may indicate the past use of croton oil, and grouped, finely linear, 
parallel scars over the lungs, heart, liver, or spleen, suggest wet cupping for 



THE OUTWARD SIGNS OF DISEASE 



20 



the relief of some pain or acute inflammation in the past, the nature of which 
may prove an important link in the case history. Scars at the waist line are 
common in those who have worn electric belts, and in the supraorbital region 
or intercostal zones may suggest respectively supraorbital or pectoral zoster. 

The tiny depressed scars of acne affect the chest, shoulders or face, and 
similar ones when generally distributed suggest syphilis, whereas cicatrices 
over the heel, sacrum and scapula suggest bed sores and hence past severe 
ailments such as typhoid. In elderly men an old time "seton" may have 
left its double scar at the back of the neck. 

Scars of Suicidal Attempts and Past Operations. — Bullet and stab wounds 
especially, may be suggestive in relation to past suicidal attempts, character, 
past associations, occupation and present disease.* 

Cervical scars, if anterior, long and linear, particularly if left-sided in origin 
and transverse in direction, suggest abortive suicidal attempts. Such are 
usually made by a razor and run obliquely downward from the angle of the 
jaw across the median line, or almost transversely across the throat, seldom 
following the line of operative incision of the anterior cervical gland chain or 
observing the limitations in extent and direction of the thyroidectomy in- 
cision, as would be the case with the somewhat similar scar of a past 
operation. 

Puckered, depressed irregular scars in the cervical triangles, especially the 
anterior, suggest the slow healing of once broken down, discharging, tuber- 
culous glands; while fine, long, linear cicatrices suggest radical operation 
for their removal, when they follow the known direction of the glandular 
chain. 

Irregular depressed scars in the groin do not suggest past syphilis but rather 
chancroid. 

The scars of operations for appendicitis, ovariotomy, gall-stones, gastric 
ulcer, and the like are but too common nowadays and too characteristic to 
merit special description. All abdominal scars, however, demand an exami- 
nation of that part of the abdominal wall incised in order that any hernial 
tendency may be detected. 

Luetic Scars. — There is not much of positive differential or diagnostic 
value in syphilitic scars save in certain situations or in certain forms of 
eruption, but when present and sufficiently characteristic they are of great 
assistance. 

In general, one may say that syphilitic scars may be round, reniform, oval 
or horseshoe-shaped, and are smooth and seldom traversed by fibrous bands 
except at joints. 

Lupus scarring may closely simulate syphilis, but is not multiform. Fre- 
quently there are multiple punctate depressions, and some old luetic scars are 
pliable and have a brownish-red areola (see also " Syphilis"). Of special 

* In a person of a misleadingly clerical appearance and pretensions, such a wound proved 
to have been the result of a drunken brawl in a bawdy house of which he was the proprietor, 
and led to an investigation of past and present habits that proved illuminating with relation 
to his obscure ailment. 



Zoster, acne, 
and syphilis. 



Bed sores. 



Neck scars. 



Glandular 
tuberculosis. 



Groin scars. 



Common 
operative sites. 



Valuable when 
distinctive. 



3Q 



MEDICAL DIAGNOSIS 



Drug habit. 



Tumors and 
nodes. 



Caput 
quadratum. 



The rickety 
rosary. 

Cranio-tabes. 



significance are the scars indicating a primary lesion (usually, of course, upon 
the genitals), and those of a destructive ulceration of the soft palate. 

Epithelioma and Hypodermic Marks. — The scar of operation for epi- 
thelioma of the lips or nose is especially suggestive, and bluish marks from an 
old needle coated with oxide of iron, or similar marks together with evidences 
of repeated superficial infection, may suggest confirmed morphinism or 
cocainism. Many victims of drug addiction use a dirty needle and in its 
introduction disregard clothing when circumstances render its removal 
inconvenient. In right-handed persons of this type the opposite arm and 
the right thigh are often characteristically scarred. 

THE HEAD. — Sutures and Fontanelles. — Open sutures persisting after 
the ninth month suggest hydrocephalus, cretinism or rickets. The posterior 
fontanelle should be closed at the end of the second month; the anterior at the 
end of the second year. 

Delayed closure with a gap of unusual size suggests hereditary syphilis, 
rickets or cretinism. Bulging fontanelles occur in chronic hydrocephalus and 
in meningeal hemorrhage or inflammation, but slight prominence and pulsation 
may occur in any child suffering from febrile ailments and is negligible. A 
sunken fontanelle is present in wasting diseases and spurious hydrocephalus. 

Cranio-tabes, indicated by a soft "egg-shell" crackle on pressure over 
circumscribed occipital areas or over the posterior portion of the parietal 
bones may occur in rickets, congenital syphilis or hydrocephalus.* 

The pulsating congenital tumors of variable size bulging from the sutures 
are classified as hydrencephalocele, meningocele or encephalocele. 

Wens or cysts are common in the scalp and should not be confused with 
the deeper seated immovable syphilitic nodes representing a gummatous 
periostitis. In the latter case any co-existing brain symptoms suggest 
similar growths on the inner surface, their consistence being soft and doughy 
and nocturnal exacerbations of any attendant pain a prominent feature. 

Rickets. — A square or oblong head with flattened elongated vertex; a 
high, square forehead, often with frontal and parietal protuberances, when 
it surmounts a small face, indicates severe, classical rickets. It is usually 
associated with delayed closure but no bulging of the fontanelles, together 
with a sweating forehead, muscular weakness, mental retardation, delayed 
growth and beading of the costo-chondral articulations especially the fifth 
and sixth ('rickety rosary"). Epiphyseal swelling and thinning and 
palpable crackling of the postero-inferior aspect of the parietal and occipital 
bones {cranio-tabes) are often demonstrable. 

Deformities of the chest, legs and spine are common and the restless 
little sleeper may have rubbed away the hair at the occiput. 

Hydrocephalus. — If the child's head be large but globular or pyramidal 
rather than square, the face relatively small, the space between the eyebrows 
prominent, the fontanelle large and bulging, the sutures separated and the 
external veins visibly distended, a history of excessive cranial growth or 
congenital deformity will be obtained and hydrocephalus is evident. 

* The same "egg-shell" crackling is encountered in osteosarcoma of the long bones. 



THE OUTWARD SIGNS OF DISEASE 



31 



Typical 
syndrome. 



Deformity of 
long bones. 



A curious 
contrast. 



Oxycephaly. (Tower Head). — The head of excessive height above the 
ears and running to a narrow or pointed vertex is occasionally encountered. 
The supra-orbital ridges are poorly developed and exophthalmos and optic 
neuritis may result from increased intracerebral pressure. 

The ailment is due to premature closure of certain of the sutures. 

Congenital Syphilis. — Cranial asymmetry, exaggerated frontal emi- 
nences, keratitis, a saddle-nose, or a perforated palate may co-exist with 
"sore bottom" in the luetic child, and, with the exception of the last, even 
as isolated symptoms are of great diagnostic significance. 

Osteitis Deformans (Paget' s Disease). — A marked increase of the head 
circumference without facial involvement may be associated wdth the 
curvature of the enlarged shafts of the long bones characterizing the 
disease. 

Leontiasis Ossea. — This frequently produces marked deformity of the Leonine brow, 
skull by osteophytic deposit particularly in the frontal regions and is asso- 
ciated with massive orbital rims and exaggerated malar prominences. 

Facial Hemiatrophy. — Slight unilateral differences may be merely 
degenerative stigmata, but in true hemiatrophy the face is mesially divided 
into distinctly different halves, the extreme and apparent emaciation of 
the one side contrasting sharply w T ith its better-nourished fellow. 

In microcephalic idiocy the skull is extremely small and narrow. 

THE EYELIDS. — Dark circles or duskiness under the eyes most marked 
in brunettes are commonly but often mistakenly construed as indicating 
pelvic disease. Though frequently an indication of such conditions, and 
often present as a transient condition in young women during or at the onset 
of a menstrual period, they may be constantly present in certain normal 
women and especially in olive-skinned brunettes. In both sexes and at any 
age they may accompany extreme prolonged pain, insomnia, overexertion, 
weak heart, or exhausting diseases. 

Puflaness or edema of the lids may indicate mere recent weeping, trichino- 
sis, disease of the accessory nasal sinuses, Bright's disease, arsenical overdose 
or chronic poisoning, anemia, or pertussis. Unilateral swelling may be due 
to angioneurotic edema or to actual inflammations, such as boils, insect 
bites, erysipelas or glanders. Associated with exophthalmos, it may indicate 
cavernous sinus thrombosis or tumor pressure upon the ophthalmic veins. 

Inflammation of the lids may be due to conjunctivitis, simple or specific, 
and is a common manifestation in measles, coryza, iodism, hay fever and eye 
strain. Styes, chalazion, warts, epitheliomatous or syphilitic ulcers, gouty 
tophi, lachrymal cyst, or obstruction with tear overflow, and blepharitis 
marginalis need no extended description. The injected conjunctiva of 
measles is an early and suggestive symptom. 

THE EYES. — Many valuable inferences may be drawm from careful 
inspection of the eyes, and the expression may indicate bad habits con- 
cealed, or give a valuable clue to the temperament and mental status of 
the patient. Study of the background is of course a matter for special 
investigation. 



Trivial or 
important. 



Seek simple 
causes first. 



Red eyes of 
measles. 



32 



MEDICAL DIAGNOSIS 



Sign of slight 
value. 



Bilateral vs. 
Unilateral. 



Wasting 
diseases or 
atrophy. 



Important 
associations. 




—Exophthalmic 
Typical facies. 



Ocular Palsies. — Paralysis of the ocular muscles alone as indicated by 
ptosis or strabismus at once suggests syphilis, brain tumor, locomotor ataxia, 
meningitis or profound toxemia. 

Nystagmus is an involuntary lateral, rotary or vertical movement of the 
eyeball, and in the absence of hysteria, extreme 
refractive errors, albinism, cataract or corneal opaci- 
ties, suggests disseminated sclerosis, Friedreich's 
ataxia, tumors of the cerebellum or pons, terminal 
locomotor ataxia, basal meningitis, chronic hydro- 
cephalus, or epilepsy. 

The Arcus Senilis. — This is indicated by a white 
line surrounding wholly or in part the corneal 
margin and is a symptom of slight specific signifi- 
cance when seen in persons beyond middle age, as it 
is merely a local indication of a general senile degen- 
erative process. In younger persons it is of much 
more significance and may be associated with 
definite cardiovascular symptoms. 
Exophthalmos. — In most cases this is bilateral and associated with 
exophthalmic goiter, both eyes being unduly prominent and producing a 
peculiar staring expression, striking and easily recognized. 

Unilateral exophthalmos usually indicates a new growth, abscess, or 
tumor of some kind in close relation to the affected eye, thrombosis of the 
cavernous sinus or hemorrhage into the orbital tissue. 

Enophthalmos. — This is the oppo- 
site of exophthalmos and ordinarily 
accompanies collapse, wasting diseases, 
severe hemorrhage or persistent pro- 
fuse diarrheas. Unilaterally it is found 
in hemiatrophy or lesions of the sym- 
pathetic nerve. 

Corneal Opacities. — These indicate, 
as a rule, syphilis or tuberculosis, but 
they may result from direct corneal 
injuries of any nature. 

Cataract. — In many cases this dis- 
ease of the crystalline lens is associated 
with diabetic manifestations or seems 
to reflect a general degenerative process 
and should suggest a painstaking in- 
vestigation of the heart, blood vessels, 
and urine. Juvenile cataract is fre- 
quently associated with struma or congenital syphilis. 

The Dry and the Moist Eye. — If the eye be permanently or for long 
periods uncovered by the lids, as in profound collapse, it becomes glazed and 
dry, or even seriously inflamed as in rare cases of exophthalmic goiter with 




Fig. 9. — Thrombosis of right cavernous 
sinus. Edema of right side of face and 
right unilateral exophthalmos. {Gordon.) 



THE OUTWARD SIGNS OF DISEASE 



33 



Epiphora. 



Misleading 
redness 



extreme protrusion of the eyeballs. On the other hand, profuse lachryma- 
tion may accompany irritation of the conjunctiva or result from a mere 
photophobia. Actual persisting overflow (epiphora) may be present if the 
lachrymal duct is blocked or markedly displaced from any cause. 

THE NOSE. — Saddle-nose is discussed elsewhere. A coarse, broad organ 
is seen in certain strumous types and in pituitary disorders, myxedema and 
cretinism, or may be purely racial or familial. Its base may be broad and 
shapeless in adenoid disease and nasal polypi, and it may be the seat of dis- 
tressing and humiliating vascularity even in the temperate individual. Such 
innocent redness is most frequently due to exposure to the elements, gastric 
and pelvic derangements, cardiovascular disturbances, or chronic obstructive 
nasal catarrh. The alas may carry a tuberculous or epitheliomatous ulcer and 
are frequently involved in the herpetic manifestations of certain acute diseases. 

False Saddle-nose. — In achondroplasic dwarfs (see under " hands") 
the broad-based pug nose often suggests the true saddle-nose of syphilis. 

No confusion should arise and the condition as seen in achondroplasia is 
due to precocious calcification. 

Offensive nasal discharge suggests atrophic rhinitis, syphilis, necrosis or 
impacted foreign bodies. 

Sneezing needs no special discussion though occasionally a troublesome 
phenomenon.* 

Working Alae. — In neurotic individuals this is commonly observed and it 
also constitutes one of the signs of marked dyspnea. 

THE EAR. — Earache. — Iri infants the condition may be indicated only 
by crying, restless movement of the head or rubbing of the ear, and in them, 
as in the case of the profoundly toxemic adult, who may give no evidence of 
pain, an acute suppurative otitis media may be entirely overlooked until 
the discharge appears. 

The condition is a common one in acute infections, such as in tonsillitis, 
pharyngitis, scarlet fever, 'influenza, typhoid, diphtheria and measles, and 
its complications are so serious (mastoiditis, meningitis, brain abscess, etc.) 
as to demand careful watching in such cases. 

Earache and deafness may also be due to impacted cerumen, abscess or 
ordinary furuncle of the meatus externus, simple catarrhal inflammation and 
blocking of the Eustachian tube, decayed teeth and alveolar abscess, foreign 
bodies, neuralgia, and rarely cancer of the tongue. 

Hematoma Auris. — Bruising and swelling of the pinna is frequently 
encountered in the insane. 

Cyanosis and anemia may be reflected in the color of the external ear. 
It is the most frequent situation for frost-bite and may be the seat of 
ochronosis (blue-black cartilages), persistent localized gangrenef and gouty ochronosis, 
tophi (gritty sodium urate nodules near the margin of the pinna). • tophi. 

* In one instance known to the author violent and persistent sneezing was excited by 
normal sexual stimuli. 

t In a case of drug habituation a recurrent superficial gangrene of years' duration affected 
the ear alone and ceased permanently only when the victim, who refused all treatment 
directed to a cure, stopped the use of the hypodermic and took his morphin by the mouth. 



Otitis often 
overlooked. 



34 



MEDICAL DIAGNOSIS 



Significance of 
discharge. 



Herpes and 

mucous 

patches. 



Sordes. 



The "fruity* 
breath. 



Cadaveric 
emanation. 



Discharges of various kinds may be noted, slight and serous if due to 
meatal eczema; purulent if from suppurative otitis media or meatal abscess; 
clear and serous or primarily bloody in fractures at the base of the skull. 
Hemorrhage from the lobe is not uncommon in hemophilia even without 
wound or demonstrable abrasion. 

Edema over the mastoid process and pressure tenderness are important 
signs of mastoid disease though occasionally due to local periostitis. 

THE LIPS. — The grouped vesicles of herpes common in coryza, pneu- 
monia and malarial fever, the mucous patches or even the initial lesion of 
syphilis, epithelioma, fissures, and, in badly nursed profoundly prostrated 
patients, crusts and sordes, are some of the important conditions to be noted. 
The color of the lips is a valuable sign of cyanosis and a less constant and 
specific one of anemia. 

Epithelioma usually occurs at or beyond middle age, ordinarily affects 
the lower Up, grows indolently and exists for a long time without marked 
involvement of the neighboring glands. 

Syphilis. — A labial lesion of syphilis is promptly followed by glandular 
swelling. Mucous patches and syphilitic fissures tend to involve the angles 
of the mouth and leave linear radiating scars, but ordinary "cold cracks "or 
fissures are of no significance. 

Acute swelling of the lips commonly indicates trauma, insect bite, angio- 
neurotic edema, simple abscess, or, more rarely, corrosive poison, cancrum 
oris, erysipelas or phlegmon. 

The Open Mouth. — Aside from paralysis or primary mental defects, the 
dry lips and open mouth are seen in coma, chronic hypertrophy of the 
tonsils, or nasal obstruction (usually due to adenoids), inflammation of 
the buccal cavity, the profound exhaustion of certain acute adynamic 
febrile conditions and the terminal stages of chronic disease. 

The Odor of the Breath. — In acute poisoning this may yield information 
of the first importance and the odor of carbolic acid, the aromatic, bitter- 
almond aroma of hydrocyanic acid and the peculiar smell of ether, chloro- 
form, laudanum and alcohol are readily detected. In the terminal stages of 
diabetes mellitus the fragrant fruity breath is most suggestive of an excess of 
acetone and diacetic and oxybutyric acids in the blood and hence of im- 
pending coma. Phosphorus yields an unmistakable odor. 

Foul breath in itself most often indicates improper care of the teeth, consti- 
pation, chronic naso-pharyngeal catarrh or local disease of the buccal cavity 
and pharynx, or, more often, the naso-pharynx. The bad breath of chronic 
drinkers is usually associated with a furred tongue and chronic gastritis. 

Uremia. — A peculiar heavy, aromatic odor is noticeable in the so-called 
"uremia" of acute and chronic nephritis or in the terminal stages of failing 
heart, and a peculiar cadaveric emanation is sometimes noticeable at the time 
of death from exhausting disease. 

THE BUCCAL CAVITY.— Pigmentation.— The pigmented areas of 
Addison's disease appear here and upon the lips and tongue, as do the tints 
of jaundice and cyanosis. 



THE OUTWARD SIGNS OF DISEASE 



35 



Exanthems. — In acute exanthematous diseases the buccal cavity may 
be the site of the earliest eruption, as in measles where small red spots with 
a tiny bluish-white center appear before the development of the cutaneous 
rash (Koplik's spots). 

The papules and vesicles of varicella and variola may often be seen and the 
vivid redness of scarlet fever is somewhat characteristic. 

Petechiae. — In scurvy (scorbutus), purpura, terminal leukemia, hemo- 
philia and other ailments associated with hemorrhage, both submucous and 
superficial bleeding may occur and the latter may assume a most intractable 
and even fatal form. 

Moisture and Dryness. — As regards secretion, there may be either dry- 
ness, such as occurs in the administration of atropin, in mumps, or as the 
result of mouth-breathing from whatever cause, or, the opposite condition, 
salivation, such as accompanies certain of the acute inflammations of the 
buccal cavity or results from the overuse of mercury. Either secretory 
abnormality may be associated with hysteria. "Drooling," such as occurs in 
bulbar palsy, facial paralysis, diphtheritic paralysis, and idiocy, is not 
necessarily attended by actual increase of secretion. 

STOMATITIS. — Inflammation of the buccal mucous membrane may be 
encountered in any one of six chief forms: 

i . Simple catarrh, as seen in teething children, acute infections, gastro- 
intestinal disturbances or direct irritation. 

This condition is characterized by redness, dryness and heat of the mucous 
surface with subsequent increase of mucous secretion, local discomfort upon 
taking food, and moderate fever. True salivary flow is diminished. 

2. Follicular or Aphthous Stomatitis. — This indicates impaired general 
health and digestion, is common in children and not infrequent in adults, 
and is characterized by small vesicles soon transformed into superficial small 
ulcers with an inflamed areola, often appearing in crops and involving chiefly 
the edges and the tip of the tongue, the deeper folds, or the inner aspect of the 
cheeks. Constitutional symptoms are identical with those of the catarrhal form 
but the process may be persistent or spreading and painful. 

3. Parasitic Stomatitis ("thrush," "muguet," "soor," "mycotic stoma- 
titis") is due to the didium albicans seen readily under the microscope 
and indicates usually poor nutrition and uncleanly artificial feeding in 
infants. 

It is characterized by small curd-like deposits appearing first upon the 
tongue, but tending to coalesce, spread, and, in extreme cases, cover the whole 
aural and pharyngeal surface. The patches are readily removed and leave no 
ulcerated or excoriated stir face. 

4. Mercurial Stomatitis (Salivation). — Either through occupational 
poisoning, idiosyncrasy or overdosing, mercury may cause profuse salivation 
associated with spongy swelling and even ulceration of the gums, loosening 
or loss of the teeth, or even necrosis of the jaw. 

A metallic taste and fetid breath with tenderness of the teeth are usually 
the first symptoms, and patients under mercurial treatment should be care- 



Salivation and 
drooling. 



A useful 
procedure. 



36 



MEDICAL DIAGNOSIS 



A deadly 

disease. 



fully watched for increased flow of saliva and made to bring the teeth sharply 
together at each visit in order that tenderness may be detected. 

5. Gangrenous Stomatitis {Noma). — This fatal ailment is rare, being 
seldom encountered save in the badly nourished and environed children of 
the slums, in whom it follows convalescence from acute fevers, chiefly 
measles. 

It is characterized by the appearance of a sloughing, spreading ulcer usually 
on the cheeky rarely on the gum. The breath is fetid, there is high fever, pro- 
found prostration, delirium and diarrhea. Gangrene rapidly develops in the 
cheek and may involve adjacent structures to a frightful degree or appear in other 
portions of the body. 

6. Ulcerative or Fetid Stomatitis. — This condition stands midway 
between the aphthous form and cancrum oris, occurring chiefly in children 
during dentition, rarely in adults, and at times seeming to be epidemic. 

The gums are swollen and spongy, bleed readily and show linear sloughing 
ulceration. The process occasionally involves the tongue and inner surface of 
the cheeks and lips; the submaxillary glands enlarge and the constitutional 
symptoms are often severe and associated with extreme prostration and marked 
febrile reaction. . A recurrent form and a membranous form occur. 

Rarely, and chiefly in marasmic or scorbutic children; the process assumes 
a type suggesting noma, but ordinarily recovery occurs in a week or ten 
days. 

The interesting stomatitis of "sprue" and "Trench Mouth" is fully 
described under the proper headings. 

THE TONGUE.— The Coated and the Clean Tongue.— In many diseases, 
acute or chronic, whether affecting proximate or remote structures, the 
condition of the tongue may assist, slightly, diagnosis, prognosis and 
treatment. 

A lightly coated tongue may be found in health or may indicate fever, 
disease of the naso-pharynx, gastrointestinal disturbances, mere smoking, 
drinking, or the possession of bad teeth. 

A heavy, pasty, yellow coating is usually indicative of naso-pharyngea] 
catarrh, catarrhal gastritis, or other disturbances of the digestive tract and is 
encountered in rheumatism, influenza, and certain other acute infections. 

Abnormally clean tongue may be, and often is, associated with gastric hyper- 
acidity or even ulcer. 

In chronic dyspepsias of the asthenic type the tongue is flabby, often enlarged 
and laterally indented by the teeth. 

In the typhoid state the heavily coated tongue is sometimes bright red along 
its margin and at its tip, which oftentimes shows a triangular red area. 

The Brown Tongue and the Beefy Tongue. — In all conditions of profound 
The tongue of toxemia and exhaustion such as septic conditions, severe typhoid fever and the 
typhoid state in general, the tongue tends to become brown, dry and fissured, 
is tremulous and is protruded or retracted slowly or only on command. Such a 
tongue or its congener, the red, shiny, dry, "beefy" tongue indicates a bad 
prognosis. 



Helpful but not 
dependable. 



The indented 
tongue. 



THE OUTWARD SIGNS OF DISEASE 



37 



The "Strawberry Tongue" with its bright red swollen papillae empha- 
sized by a white pasty background is often an early sign of scarlet fever. A 
unilateral coating is sometimes present in hemiplegia, but may be due to bad 
teeth on the affected side. 

Ulceration and Fissures. — These may be a part of the buccal inflammations 
elsewhere described and always suggests a careful examination for syphilis, 
gastrointestinal disturbances and disease of the teeth and gums. 

Tuberculous ulcers are surrounded usually by a zone of pallor and are | 
themselves relatively pale, shallow and sharply defined. Like syphilitic 
ulcers they are rarely primary. 

The luetic ulcers are usually like serpiginous fissures if secondary, but in 
the gummatous tertiary form may be deep and rapidly progressive. Sus- 
pected malignant ulceration always demands the preliminary therapeutic 
test for the exclusion of syphilis as, otherwise, differentiation may be 
extremely difficult. 

Deep fissures along the edge or deep scarring of the surface suggest past 
syphilis as does a smooth atrophy of the posterior surface. 

The tongue reflects more or less definitely the general pallor of anemia and 
the cyanosis of cardiac or pulmonary disease, and one may detect sometimes 
scars suggestive of the tongue-biting accompanying multiple past epileptic 
seizures. Such scars may also result from an existing glosso-labio-laryngeal 
paralysis. In general, tongue scars are especially suggestive-of syphilis. 

Unilateral atrophy, the tremor and jerky protrusion of marked alcoholism 
or actual delirium tremens, and the intermittent fibrillary muscle spasm 
associated with paresis, must not be forgotten. 

Marked enlargement may be due to acute glossitis or to acromegaly and 
myxedema. Tumors must be thought of as well as the various acute condi- 
tions affecting the mucous membrane of the mouth. 

Various pigment deposits may occur here as in other portions of the oral 
mucous membrane, the most marked being the deep brown, purple, or black 
deposits of Addison's disease, and the yellow tint of the inferior lingual surface 
in jaundice. 

Miscellaneous Discolorations. — A black tongue usually indicates the use 
of iron, bismuth, or charcoal, and brown discolorations axe most commonly due 
to the use of tobacco, licorice or chocolate, less often to laudanum and 
rhubarb. 

The term Nigrities linguce is applied to a peculiar form of black tongue 
due to the development of a yeast-like fungus Cryptococcus- lingua pilosce 
upon its dorsum. 

The pigmentation of the prominent elongated, filiform papillae has given 
it also the name "hairy tongue." 

The corrosive acids either whiten the surface (oxalic, carbolic, sulphuric 
acids as well as ammonia and corrosive sublimate) or yellow it (chromic, 
hydrochloric and nitric acids). Caustic soda or potash and the nitrate of 
mercury redden it. The tongue may be the source of persistent hemorrhage 
in purpura or hemophilia. 



Scarlatina 
tongue. 



Tuberculosis 
and syphilis. 



Important 
indications. 



"Black" or 
"hairy" tongue. 



Mineral acids 
and caustic 
alkalies. 



3& 



MEDICAL DIAGNOSIS 



Geographic 
tongue. 



Etiologic 

importance 

great. 



Lead 
poisoning. 



Sordes. 



Mucous 
patches. 



Early vs. Late 
dentition. 



Wot 

negligible. 



The term "geographic tongue" is derived from the annular red patches 
on the dorsum and edges, due to a painless desquamative process. These 
spread peripherally and, by coalescence, form eccentric areas with prominent 
margins. 

Leukoplakia buccalis ("buccal psoriasis," "leucoma," "ichthyosis") is 
characterized by non-ulcerative, smooth, white, firm, raised patches. The 
smoker's patch occupies the dorsal surface of the tip as a pearly yellow, or 
perhaps reddish plaque. 

Movements. — : Slow, hesitant protrusion and withdrawal are observed in 
the typhoid state. Tremor may be marked in the same condition as well as 
in paralysis agitans and, combined with fibrillary twitchings, in bulbar palsy, 
general paralysis of the insane and disseminated sclerosis. 

THE GUMS. — Relation of Diseases of the Teeth and Gums to General 
Ailments. — The relation of diseases of the teeth, jaws, gums, and of mouth 
infections in general, to other ailments both local and constitutional, is of 
late receiving deserved attention and it would appear that these tissues 
are second only to the tonsils and accessory nasal sinuses in etiologic 
importance. 

Certain cases of heart infection, chronic arthritis, nephritis, dyspepsia, 
general malnutrition and the like have been repeatedly traced back to mouth 
and jaw infections in the author's clinic and private practice. 

Marginal redness is usually of little significance, being attributable to 
uncleanliness in most instances, or to dental caries. It is of some impor- 
tance in young persons as an indication of tuberculosis and is present in some 
cachectic states. 

A grayish or bluish-gray line, composed actually of a series of dots and 
lines, about i mm. from the actual margin may indicate lead poisoning. 
Rarely a similar greenish-blue line is present in copper poisoning. 

Swollen, spongy or bleeding gums commonly indicate mercurial stoma- 
titis or conditions of great debility and exhaustion as in scurvy and various 
cachexias. In neglected cases of the typhoid type accumulation of oral 
debris form the so-called sordes. Dental abscesses, pyorrhea, and various 
growths such as the malignant epulis also occur. 

Around the base of the gums as well as in the more readily visible portions 
of the buccal mucous membrane may be seen the sharply defined, flattened, 
moist, grayish, "mucous patches" in cases of syphilis. 

THE TEETH. — As regards the period of eruption of the first and second 
sets of teeth, a wide margin must be allowed in both directions, an unusually 
early or distinctly delayed appearance being of no significance. 

A greatly delayed dentition is usually indicative ofmalnutrition and often 
associated with distinct developmental defects. 

The disturbances of "teething," while doubtless greatly exaggerated 
and usually negligible in well-nourished, breast-fed children, are nevertheless 
important and are accountable, directly or indirectly, for many "upsets" of 
infancy. Any doubting physician would be convinced of this fact if he him- 
self should for a time suffer from similar inflammations from whatever cause. 



THE OUTWARD SIGNS OF DISEASE 



39 




.Ttffliffinr 



»*II»»«i* 



Fig. io. — First dentition. Illus- 
trating the sequence of eruption of 
the temporary teeth. A, sixth to 
ninth month; B, eighth to twelfth 
month; C, twelfth to fifteenth 
month; D, sixteenth to twenty- 
fourth month; E, twenty-fourth 
month to end of third year. 



On the other hand, we should not adopt 
dentition as a blanket term to cover obscure 
ailments lest we overlook more concrete and 
A serious conditions.*! 

As in the case of the finger-nails, transverse 
grooves or furrows on the teeth indicate past 
severe illness; dentated cutting margins are 
common in malnutrition; and pitted teeth 
may be due to past stomatitis. 
B Early decay is common in pregnancy, 
phosphorus poisoning, rickets, diabetes and 
other forms of severe malnutrition and the 
importance of good teeth and especially, sound 
roots, in connection with chronic dyspepsia 
and many other conditions is too little ap- 
C predated. Many obstinate and persistent 
gastric ailments are promptly cured by proper 
attention to the remaining teeth. 

In " status lymphaticus" the two central 
upper incisors may unduly exceed their 
lateral neighbors which are actually sub- 
normal in size. 

Pyorrhea alveolaris, associated with the 
presence of entameba buccalis, and such blind 
abscesses and peridental infections as are re- 
vealed only by the X-ray, are extremely im- 
portant as hidden sources of chronic infection. 

Hutchinsonian Teeth. — If the upper 
central incisors of the second dentition are 
peg-like, short, narrow, separated, with a 
single notch at the cutting edge and rounded 
corners, they constitute an almost pathog- 
nomonic sign of congenital syphilis. 

Mere serration of the cutting edge, or even 
notching, is in itself insufficient for diagnosis, 
being encountered frequently in badly nour- 
ished, non-syphilitic children. 



D 



* The normal periods are, in months: First dentition: two lower central incisors 6 to 9. 
Four upper incisors 8 to 12. Four anterior molars and lower lateral incisors 12 to 15. 
Canines 1 6 to 24. Posterior molars 24 to 36. Permanent set {in year s) -.Molars, 
first set 6; second set 12 to 15; third set 17 to 25; Incisors 7 to 8. Bicuspids 9 to 
10. Canines 12 to 14. It follows that at the end of the first year there are 6 teeth; at the 
end of the second 16, and that the first dentition should be completed in two ancl one- 
half years. 

t The late Frederic Forchheimer taught that "teething produces teeth and nothing more," 
and such statements, though exaggerated, have gone far to correct the tendency to 
ascribe specific, serious ailments to this common and usually trivial condition. 



Often 
important. 



Foci of 
infection. 



True type. 



4° 



MEDICAL DIAGNOSIS 



Caution 



Commonly 
misinterpreted. 



Arched palate. 



Pain 
inhibition. 



Lack of vigor. 




Fig. ii. — Hutchinsonian teeth. 
Congenital syphilis. 



A false diagnosis of syphilis is a very serious matter and every case should 
be fully proven before any opinion is expressed to family members. 

One may base tentative treatment upon his own assumption and the 
therapeutic test is still invaluable but extreme reticence is wise and necessary. 

Progressive Separation of the Teeth. — This is encountered in cases of 
acromegaly associated with enlargement of the 
upper or lower jaw and constitutes an important 
sign of this disease. 

Teeth grinding is a common symptom of 
adenoids, reflex irritation or gastric disturbance 
in children and is rarely due to the commonly 
accepted cause, worms. 

THE JAWS.— The high-arched palate, due 
usually to neglected chronic naso-pharyngeal 
obstruction, and so often associated, with the 
neurotic temperament in the adult, is readily 
noted, as is the massive lower, or less often, 
upper, jaw of an acromegaly. The prominent 
square jaw and the receding chin are universally associated in the lay 
mind with firmness or the lack of it respectively, but such assumptions are 
subject to many exceptions. 

Jaw spasm suggests tetanus, spasmophilia, hysteria, strychnin poisoning 
or irritation of cerebral origin. . Paralysis may be noted in pontine hemor- 
rhage, neuritis, brain tumor, or meningitis, and the jaw movement may be 
more or less mechanicallyimpeded or pain-inhibited in such diseases as quinsy 
mumps, and trichiniasis. 

THE SOFT PALATE. — Perforations have been referred to previously as 
essentially pathognomonic of syphilis. Paralysis is usually due to diphtheria, 
less commonly to cerebral tumor, meningitis, caries and bulbar palsy. 

The condition of the fauces and tonsillar areas is of great importance in 
relation to the exanthemata, but will be considered under diphtheria, ton- 
sillitis and other headings. 

Anesthesia of the soft palate and its uvula is a common and valuable 
indication of hysteria. 

THE HANDS.— The Handshake.— Aside from the stigmata of occupa- 
tion, the hands afford much suggestive information. The flabby handshake 
itself often indicates a congenital lack of vigor or acquired weakness. 

Tremor may often be felt as well as seen, and thus what seems like a mere 
formality may contribute to diagnosis and prognosis. 

Persons of the asthenic or tubercular type often have hands of a peculiarly 
delicate texture, easily compressed and weak in grasp and the flexible slender 
hand of many such individuals sharply contrasts with the clumsier resistant 
one of the person of phlegmatic type and lacking such congenital stigmata. 

The broad spade-like hand of myxedema, the bulbous terminal phalanges 
and incurved nails of chronic pulmonary disease (pulmonary osteoarthro- 
pathy), the clumsy hand of acromegaly with its bony hypertrophy, great 



THE OUTWARD SIGNS OF DISEASE 



41 




size and myxedema-like outline, as well as hands showing Heberden's nodes, 
gouty tophi, the deformities of arthritis deformans, or those of so-called 
chronic rheumatism may be readily recognized. 

The atrophy of neuritis and deforming arthritis is 
associated with a peculiar glossiness of the skin especially 
marked in the fingers. In Raynaud's disease the so- 
called "cold" or "dead" fingers are encountered and 
actual gangrene of the skin may result from that ail- 
ment, or from direct injury, severe frost-bite, neuritis, 
leprosy or senile endarteritis. 

In achondroplasic dwarfs one may encounter 
excellent examples of the " trident hand" (see "Achon- 
droplasia"). 

Wasting of the Hand. — Aside from neuritis, arthritis 
deformans, and mere disuse, a most significant and im- 
portant wasting occurs in progressive muscular atrophy, 
syringomyelia, poliomyelitis, amyotrophic lateral sclero- 
sis, and the cervical forms of chronic pachymeningitis. 
Tender, Superficial, Transient Nodules. — As stated 
previously superficial, small, tender nodules constitute 
one of the most important signs of "chronic recurrent 
infective endocarditis" and appear both upon the hands 
and feet, affecting especially the dorsal, but occasionally 
both surfaces. 

These transient tender nodules should not be confused 
with the relatively or absolutely insensitive ones so com- 
monly seen after an attack of acute rheumatism, especially 
in children. These persist for weeks or months. 
Wrist-drop. — This common symptom is due to paralysis of the 
musculospiral nerve as the result of direct injury or poisoning by lead or 
alcohol. 

THE FINGER-NAILS. — Chronic indolent ulceration (onychia) surround- 
ing the nail suggests syphilis or marked malnutrition but occurs also in 
tuberculosis, leprosy, syringomyelia, 
neuritis and chloral habit. 

Brittle, striated, or split nails, with 
or without marked deformity, most fre- 
quently occur in connection with gout, 
peripheral neuritis, syringomyelia, and 
prolonged repeated exposures to the 
X-ray. 

Most important to the case-taker at 
times are the transverse ridges indicating 
a past severe illness. These are easily 

noted, last for a period of six or eight months, and by the proximity to the 
matrix indicate approximately the date of the causative ailment. 



Fig. 12. — 1. Heber- 
den's nodes. 2. Syph- 
ilitic dactylitis. 3. 
Clubbed fingers. 4. 
Arthritis deformans. 
5. Spade hand of 
myxedema. 




Fig. 



13. — Clubbed ringers. Chronic 
pulmonary disease. 



Myxedema 

and 

acromegaly. 



"Dead 
fingers." 



" Trident 
hand." 



Rheumatic 
nodules. 



Register past 
illnesses. 



42 



MEDICAL DIAGNOSIS 



Color 
indicators 



Rachitis and 
scorbutus. 



Barlow's dis 
ease. 



The nails are also color indicators for cyanosis and anemia and will show 
the ebb and flow of the capillary pulse in aortic regurgitation. 

Nail-shedding occurs after injury to the matrix or may be the result of 
neuritis, locomotor ataxia, or syphilis. 

THE ARM AND LEG. — Many of the conditions affecting these extremi- 
ties, such as edema, pain and tenderness, are discussed under their appro- 
priate headings. 

Hard, circumscribed, immovable, bilateral, non-mflammatory swellings, 
Luetic nodes, upon either the ulna or tibia, are usually syphilitic nodes, and the more diffuse, 
bilateral, painful enlargements of the tibia often associated with nocturnal 
increase of pain usually prove to be luetic when the modern tests are applied 
or antisyphilitic treatment is instituted. The smaller rheumatic nodules 
are described fully elsewhere. 

Localized edema, heat, redness, and severe deep-seated pain over long 
bones and especially the tibia, suggests acute periostitis or osteomyelitis 
which, if neglected, may lead to death from acute sepsis or to chronic fistulous 
openings indicating secondary necrosis. 

Enlargement of the lower end of the radius suggests rachitis, and an 
exquisitely tender, non-inflammatory, branny induration over the shaft of 
the femur or leg bones in infants or young children is an almost pathognomonic 
sign of infantile scurvy, an ailment often obscure in its other manifestations 
(see '•Scorbutus 5 '). 

Varicose veins are common in the lower extremities and may be bilateral 
or unilateral. They are often associated in middle-aged or elderly persons 
with chronic indolent ulcers and may produce a misleading edema like that 
of cardiac weakness. Such swelling, however, is, as stated previously, usually 
either wholly or predominantly unilateral. 

Unilateral edema with congestion or pallor, pain and localized tenderness, 
suggests phlebitis. .4 perforating ulcer, usually under the ball of the great 
toe. may be present in advanced locomotor ataxia or, more rarely, in 
diabetes. 

Deep cyanosis or cold whiteness of the foot or toes suggests Raynaud's 
disease, frost-bite or the early stage of an actual gangrene which may be 
associated with injury, arteriosclerosis, massive embolism, diabetes, frost- 
bite, ergotism, Raynaud's disease and rarely, it is claimed, with exoph- 
thalmic goiter. Mottled, dusky redness and pain over the sole of the foot 
may indicate erythromelalgia. 

The presence or absence of normal pulsation in the accessible peripheral 
arteries, such as the dorsalis pedis and posterior tibial, should be carefully 
noted, in connection with painful diseases of the lower extremities especially, 
as indicating the dysbasia arteriosclerotica of Erb [inter mittier end e Hinken ,* 
obliterative endarteritis or incipient gangrene. 

This condition, much more common than is generally believed, is fre- 

* This interesting ailment is also known as "intermittent claudication" and "crural 
angina" and is associated with an arteriosclerotic process localized or predominant in the 
affected extremities. 



Intermittent 
lameness. 



THE OUTWARD SIGNS OF DISEASE 



43 



quently overlooked in its earlier stages and the patient is treated for chronic 
sciatica or rheumatism without avail and to the neglect of the cardio- 
vascular system. 

It may never lead to gangrene but always suggests the presence of 
degeneration of the myocardium and thus demands that special attention 
be paid to the heart itself. 

Enlarged glands in the groin or femoral triangle suggestive of syphilis, 
chancroid, Hodgkin's disease, leukemia, malignant disease, etc., should 
be noted, as well as the enlarged epitrochlear gland above the inner condyle 
of the humerus which may indicate a past or present syphilis.* 

Transient nodular swellings usually painless and subsiding with bruise- 
like color changes are common in erythema nodosum and as stated previously, 
small, painful, tender areas occur in chronic recurrent septic endocarditis. 

The BACK. — The chief deformities of the spine are essentially four in 
number: 

i. Lateral Curvature ("Scoliosis"). — This is most frequent in young girls 
of asthenic structure and habitus who suffer from faulty position in standing 
and sitting, and from general muscular weakness. It also results from 
rickets, chronic diseases of the lung and pleura, paralyses affecting posture, 
and mollities ossium. In its ordinary form this deformity is seldom extreme 
and is usually remediable. 

2. Lordosis or exaggerated normal curve is ' exemplified by the later 
stages of pregnancy and suggests that condition, abdominal tumors, ascites 
and pseudo-muscular hypertrophy. 

3. Kyphosis. — If the sharply angled posterior projection of the spine is 
present, Pott's disease (spinal caries) or mollities ossium are suggested, though 
a simple dorsal curve occurs in rickets, debility and chronic emphysema. 

4. Immobility of the Spine. — Temporary stiffness may be due to muscular 
strain or rheumatism, and chronic rigidity indicates arthritis deformans, 
paralysis agitans or Pott's disease. 

The curious spondylitis deformans is a rare ailment chiefly affecting 
middle-aged men and is a peculiarly localized rheumatoid arthritis. One 
form affects the spine alone; another commences in the hip-joints and ex- 
tends upward to the spine and shoulder, the result being a rigid kyphotic 
spine alone or with ankylosis of other affected joints. Certain cases are 
associated with marked muscular atrophy and nerve root pains. 

Tumors and Swellings. — A great variety are discussed in surgical and 
orthopedic works, and congenital spina bifida, abscesses due to caries, fatty 
tumors, bed sores and sacral edema are more or less frequently encountered. 

THE JOINTS.— The following points should be determined: (a) 
Presence, extent and character of any redness, swelling and deformity, (b) 
The position assumed, (c) Heat, (d) Tenderness, (e) Fluctuation or 
edema. (J) Degree of mobility in relation to pain excitation, (g) Presence of 
crepitus, (h) Outline of bony structures, (i) Ankylosis, (j) Atrophy, 
(k) Contractures. (I) Associated or antecedent injury, (m) Acute or chronic 

*A most inconstant sign in old syphilitic cases. 



Often 
overlooked. 



Asthenic girls. 



"Poker 
spine." 



44 



MEDICAL DIAGNOSIS 



Sign of 
effusion. 



Exudate is 

purulent. 



infection, local or remote (tonsils, accessory sinuses, teeth., etc.). (n) 
Excessive exhaustion, exposure, fatigue or other recognized causative or pre- 
disposing factors. 

General Comment. — It should be remembered that in acute rheumatism 
the larger joints are chiefly and primarily affected, usually bilaterally, suc- 
cessively, and in a definite order, and that the skin is moist, the sweat acid, and 
fever and anemia marked. 

In acute gout a single joint, usually the great toe, is primarily affected, 
a preference is shown for the small joints, the actual pain and throbbing 
are greater and more definitely paroxysmal than in rheumatism in which 
they are chiefly excited by movement even of the slightest degree. 

In chronic rheumatism deformity is, as a rule, not extreme, fever absent, 
changes of the weather markedly affect it and exacerbation and subsidence 
are the rule. 

In arthritis deformans an acute primary attack cannot at first be dis- 
tinguished from acute rheumatism, but it is more persistent, yields less readily 
to specific treatment (salicylates, etc.) and tends ultimately to become 
chronic, the joints grating on movement, deforming and finally becoming 
fixed. Both large and small joints are involved and the disease may be- 
come almost universal.* Many cases of arthritis deformans develop in- 
sidiously and exhibit no acute or subacute stage. 

The Floating Patella. — In the knee-joint, fluid is most readily detected by 
fully extending and supporting the extremity and making downward pressure 
upon the patella which may be felt to tap against the articular surfaces. 
Ordinarily the outline of the distended synovial membrane in such a case is 
characteristic. 

Septic Arthritis. — This occurs chiefly in the course of, or immediately 
following, acute infectious diseases, especially scarlet fever and dengue, and 
is common in pyemia and gonorrhea. The infantile form of septic arthritis 
may occur without an assignable cause and progress rapidly to suppuration. 
This term is specifically applied to such cases as show a purulent joint exudate. 
The various tuberculous lesions are too numerous to permit of discussion in 
this volume. 

Common Errors.— One of the most regrettable of diagnostic errors is 
involved in the failure to recognize osteomyelitis which all too frequently is 
treated primarily as rheumatism. Radical surgery is urgently needed in 
Fatal mistakes, these cases and one should remember that the epiphyses are chiefly involved 
rather than the joint itself and that the disease is distinctly septic in type, 
I the pain extreme, deep-seated and boring, and, further, that in osteomyelitis 
as in acute rheumatism several points may be involved, and furthermore, 
that a secondary pyemic arthritis may occur. 

* In all cases of chronic affections of the joints, of a rheumatic or rheumatoid nature, one 
must consider the probability of their etiologic unity as now clearly indicated by recent 
investigations relative to the causative effect of chronic infections of the tonsils, accessory 
nasal sinuses, the teeth and gums and the prostate. Acute rheumatism itself is really a 
streptococcic arthritis, though the joint exudate is usually sterile, the peculiar strepto- 
cocci being found in the subserous connective tissue, as first shown by Poynton of London. 



THE OUTWARD SIGNS OF DISEASE 



45 



//; hemophilia, scurvy or purpura, both hemorrhagic and pseudo-rheumatic 
joint affections may occur. 

In locomotor ataxia and in syringomyelia, one of the large joints, most 
frequently the knee, ankle, or hip, may become suddenly swollen, with or 
without pain, and go on to rapid disintegration (Charcot joints). 

In any chronic joint affection, and as a result of prolonged disuse, there may 
be marked muscular atrophy simulating that of certain diseases of the spinal 
cord, but the electrical reactions are preserved. 

Hysterical joints may create much confusion, being excessively tender and 
frequently contractured. Chorea is often associated with what is probably 
a true rheumatic arthritis. 

Pain Referred to Joints. — Examples of misleading pain of this character 
are found in the reference of the pain of hip-joint disease to the corresponding 
knee; the shoulder- joint pain of angina pectoris or a circumflex neuritis; the 
misleading radiating pains of spinal caries, of aneurysms and of locomotor 
ataxia. Diaphysitis, caries of the ends of the long bones and especially 
osteomyelitis are most misleading. 

TREMOR. — Modes of Testing Tremor. — To distinguish between passive 
tremor and intention tremor the patient is asked to make some movement such 
as is involved in taking up and fastening a collar button, buttoning the vest, 
or lifting a glass of water to the lips. In the latter variety a tremor is in- 
creased, or indeed initiated, by the coordinate movements, and may be wholly 
absent when the patient is at rest. 

All tremors of the extremities are increased by extension; therefore the 
patient should stretch the arm or leg in front of him, keeping the fingers or 
toes separated as widely as possible in hyperextension. Again if the tips of 
the fingers are allowed to rest upon the physician's palm a vibration other- 
wise imperceptible may be readily detected. 

Facial Tremor. — Any latent or existent tremors of the muscles of the face 
may be emphasized by the firm closure of the eyes, elevation of the eyebrows, 
or by drawing the corners of the mouth down or outward, and tremor of the 
tongue is markedly increased by full protrusion. 

In the case of individual muscles or muscle groups in various portions of 
the body, putting these in action or under continued strain usually increases 
the tremor. 

One should note whether the tremor in question is localized or general, passive 
or intention, coarse or fine, jerky, rapid or slow, regular or irregular, temporary 
or persistent. 

Conditions with Which Tremor is Associated. — The tremor of advancing 
age and the extremely rare condition of congenital or inherited tremor are 
unimportant, as are those due to temporary nervousness, muscular or mental 
overstrain and the excessive use of tea, coffee or tobacco. 

Tremor in acute disease usually indicates a profound toxemia, being one 
of the unfavorable symptoms, for example, in typhoid-fever, and it is often 
encountered in the typhoid state whatever be the underlying original 
disease. 



Hemorrhagic 
diathesis. 



Charcot joints. 



Atrophy of 
disuse. 



A confusing 
type. 



Misleading 
localization. 



Effect of 

coordinated 

movement. 



Extension 
increases 
tremor. 



Action vs. 
Repose. 



Trivial tremor. 



4 6 



MEDICAL DIAGNOSIS 



Rapid, fine 
tremor. 



"Pill-rolling' 
and "bread- 
crumbling." 



Disseminated 
sclerosis. 



Tongue and lip 
tremor. 



Scrivener's 
palsy. 



In alcoholism it is not only a prominent feature of delirium tremens, but 
may often enable the physician to detect a recent debauch or persistent 
excessive potations, and, if marke'd, it suggests the possible imminence of an 
acute attack. Such a tremor is ordinarily fine, regular and persistent, and 
very similar to that of drug habituation. 

Exophthalmic Goiter. — In this disease the tremor is fine and rapid, and 
if associated with a large thyroid and rapid pulse with or without exoph- 
thalmos, the diagnosis is made. Every suspected case should be tested for 
tremor. 

Coarse jerky tremor may be associated with cerebral lesions or dis- 
seminated sclerosis. 

Paralysis Agitans. — This is ordinarily a relatively slow tremor, first 
affecting the thumb and forefinger and causing a rolling movement of the 
thumb over the forefinger known as the " pill-rolling " or "bread-crumbling" 
tremor. It disappears during sleep and unlike intention tremor is checked by 
volitional movement. In its more advanced form it may involve the arms, 
legs, and head. 

Mineral Poisoning. — Any case of otherwise unexplained tremor should sug- 
gest the possibility of chronic poisoning by some metal or drug, such as cocain, 
opium, arsenic, lead or mercury. 

Intention Tremor. — This condition suggests always disseminated sclerosis, 
but may be met with in a marked form as a senile tremor, occasionally in 
hysteria, and rarely in cerebral lesions, or even lead poisoning. 

Tremor of Muscles of the Face. — Fibrillary twitching or flickering of the 
facial muscles strongly suggests profound asthenia, general paresis or chronic 
alcoholism. In progressive muscular atrophy, juvenile or spinal, it may be 
observed in other regions as well. 

Tremor limited to the tongue and lips occurs in some cases of profoundly 
asthenic fevers and in general paresis. 

SPASMS, CRAMPS, AND CONVULSIVE SEIZURES.— The term 
cramp should be reserved for a painful, spasmodic, muscular contraction, 
temporary or intermittent and localized. In the skeletal muscles it may be 
associated with alcoholism, gout, diabetes, Bright's disease, pyelitis, pyelo- 
nephritis, hysteria, or excessive muscular fatigue and most commonly involves 
the calf of the leg. 

Occupational Cramps. — The constant overuse of one set of muscles such 
as is met with chiefly in the occupational neurosis, is typified by the "scrivener's 
palsy" and may take the form of cramp, though more frequently it is a simple 
spasm, mere weakness or an actual paralysis. 

Cramp Colic. — The term is quite correctly applied to painful muscular 
spasm of the viscera such as is involved in renal, intestinal, or biliary colic. 

Wry Neck. — This may be congenital, traumatic or purely spasmodic 
and save for cases associated with actual traumatism at or subsequent 
to birth, represents a disturbance affecting the spinal accessory nerve. 
In true congenital wry neck there is atrophy of the sterno-mastoid (usually 
the right) and facial asymmetry, as opposed to mere muscle callus due to 



THE OUTWARD SIGNS OF DISEASE 



47 



rupture at the time of delivery. Spasmodic wry neck may be tonic, clonic, 
or more rarely combined, and may follow injury or exposure or be a true 
neurosis. In any event the muscle group of spinal accessory innervation is 
chiefly involved and the spasm of the rotators elevates the chin and swings it 
toward the unaffected side. The shoulder may be raised and the head drawn 
decidedly backward if the trapezius be much involved. Bilateral spasm 
drawing the head back and the face upward is rare. The clonic spasms are 
particularly distressing, and unfortunately the disease usually tends to be- 
come fixed. 

One must remember the possibility that wry neck of the acquired type 
may be the result of an associated cervical caries, or a part of the phenomena 
of "spasmophilia." 

Nodding Spasm. — {Spasmus nutans). — This condition is usually a neu- 
rosis, particularly, as seen in the adult. In children it may be mimetic, 
reflex (teething), or associated with rickets and, probably, with spasmophilia. 

Ocular spasm, especially nystagmus and, less often, strabismus, may be 
associated with this condition. The oscillations cease during sleep, are in- 
creased by excitement or when under observation and associated mental 
defects or an epilepsy are occasionally noted. The reflex cases may be purely 
transient. 

Tetany. — This condition is probably one expression of the spasmophilic 
diathesis and is entirely distinct from tetanus * 

It is merely a painful bilateral and symmetrical tonic spasm of the 
extremities, of variable duration, tending to exhibit periods of exacerbation 
and occasionally intermit. It usually involves the feet and hands, less 
often the face, neck and jaw (trismus) and rarely affects the muscles of the 
trunk. 

The disease is most frequent in infancy and the tendency diminishes with 
added years save for a disposition to intensification occurring at puberty. 

Excessive muscular irritability is evidenced by the active contraction 
not only of the one, but sometimes of all, the extremities following pressure 
upon the main nerve trunks (Trousseau's sign), and even the lightest tap 
over the facial nerve causes contraction of the facial muscles (Chvostek's 
sign). The spasms may be intermittent, rhythmically recurrent, or persist- 
ent over considerable periods. 

The attacks vary greatly in severity and duration and in infants and 
young children may last but a few hours or even minutes. 

Paresthesia may follow the lightest pressure upon a sensory nerve and the 
response to the galvanic current is greatly intensified, both cathodal and anodal 
closure contractions being induced by 5 milliamperes of current. Fever is some- 
times present, and the disease is usually paroxysmal in type and associated 
with poor nutrition, deficient calcium salts, rickets, and marked gastro- 
intestinal disturbances. 

Among the rare exciting causes of tetany are gastric lavage (in cases of 

* A deficiency of calcium has been noted in this condition and oral administration is 
said to relieve it. 



Varieties. 



Trapezius 
involvement. 



Important 
warning. 



Nocturnal 
intermissions. 



"Trousseau's" 
sign. 

Chvostek's 
sign. 



Duration of 
attacks. 



Electric 
reactions of 
spasmophilia. 



Calcium 
deficit. 



48 



MEDICAL DIAGNOSIS 



Epidemic 
tetany. 



Transitory 
cramp. 



Often familial. 



Vermicular 

muscular 

contraction. 



Of slight 
importance. 



Journalistic 
standbys. 



dilated stomach), pregnancy and lactation, and removal of the thyroid gland, 
or, more probably, as the result of coincident parathyroid resection. 

An epidemic, non-fatal, form of tetany in adults has been quite prevalent 
at times on the continent of Europe, but is extremely rare in America. 

Paramyoclonus Multiplex. — This syndrome covers those peculiar cases 
occurring almost always in males and of unknown causation, in which 
lightning-like clonic, with occasional tonic, spasms of the larger muscles recur 
either persistently or paroxysmally, unaccompanied by sensory disturbances. 

These are usually symmetrical and rhythmical and cease during sleep. 
It is often distinctly familial and in the type described by Unverricht either 
succeeds or accompanies epilepsy. 

Myokymia. — This condition is characterized by continuous fibrillary 
contractions chiefly affecting the extremities. The affected muscles show a 
diminished response to both faradic and galvanic currents. 

Myotonia (Thomsen's Disease). — This markedly but not exclusively 
familial disease is characterized by tonic muscle cramp induced by voluntary 
movement but passing off as these are repeated. 

The myotonic reaction observed in these cases is a characteristically slow 
contraction and relaxation upon stimulation by either the faradic or galvanic 
current; a deliberate vermicular muscle-contraction wave passing from 
cathode to anode. 

Athetoid Movements. — These curiously deliberate, writhing, twisting 
movements of the fingers and hands, more rarely of the feet and toes, may 
result from infantile palsy or follow hemiplegia in adults. They are slower 
and less jerky than the movements of chorea, with which they are sometimes 
confounded. 

Myoidema. — One frequently notes a marked fleeting, localized contrac- 
tion if a muscle be sharply tapped with the finger. This phenomenon is 
especially common in the muscles of the chest in connection with tubercu- 
losis but is not a sign of diagnostic importance. 

Catalepsy (Auto-hypnotism). — This extraordinary symptom usually 
indicates hysteria, but may be encountered, in melancholia, dementia, brain 
tumor, meningitis and tetanus, or be produced by hypnosis of which it con- 
stitutes the second stage. 

The patient appears asleep and the limbs show a peculiar plastic rigidity 
and will remain for minutes or hours in the position in which they are placed. 
It is often auto-hypnotism, the eyes are closed, rolled upward, the pupils 
contracted and sensibility to pain and special general sensation is abolished. 
The duration of such attacks varies from a few minutes to several hours, but 
may endure for months in dementia precox or melancholia. In such cases 
the patients are kept alive by gavage. 

Hysterical Seizures. — The actual study of cases is necessary to an under- 
standing of the physiognomy and external manifestations of this extraordinary 
condition, but once a large number have been carefully observed the 
difficulties, in great degree, are removed. The topic is dealt with entire in 
its proper section. 



THE OUTWARD SIGNS OF DISEASE 



49 



disease. 



Reflex type. 



INFANTILE CONVULSIONS— A tendency to easily induced convulsive | 
seizures like laryngismus stridulus and tetany seems to be one expression of the 
Spasmophilic diathesis at present believed to be largely dependent upon a deficit f^™* 1 " 1 ' 
of calcium salts. 

Attacks precisely similar to those of epilepsy or differing only in some Malnutrition 
particulars may be observed in both children and adults. In the former they 
may be associated with indigestion, general malnutrition (whether primary or 
secondary to disease), rickets, fever, as is so frequently seen at the onset of 
acute infectious diseases, rarely in congestion of the brain and quite commonly c 
as reflex phenomena due to peripheral causes. 

Disease or irritation, such as dentition with its associated digestive dis- 
turbances, phimosis, diseases of the eye and ear, or possibly intestinal worms 
may be exciting causes. Convulsions accompany the larger number of 
cases of cerebral disease in children, and one observes occasionally in young 
infants from the time of their birth a decided though gradually diminishing 
tendency to convulsive seizures. 

Symptoms. — Aside from the usually premonitory symptoms, such as 
slight twitching, teeth grinding, restlessness or irritability the attack is 
precisely similar to that of epilepsy. The diagnosis in repeated attacks 
may depend upon their subsidence or disappearance after a cause has been 
found and removed, but the spasmophilic electric reactions are clarifying 
diagnostic elements.* The infant mortality from this source is considerable, 
and, unfortunately, a large number of true epilepsies commence during the 
first three years of life. Over a third of those investigated by Osier occurred 
in the first year. 

Comment. — The onset of an acute infectious disease, simple overloading 
of the stomach, or indigestion, are accountable for the excitation of the greater 
number of such attacks in predisposed children. If the condition is persistent 
we have to think not only of epilepsy but of the various diseases affecting the 
brain and its covering, of renal disease and of adenoids. 

STATION, ATTITUDE, GAIT 

Test for Static Ataxia. — Static ataxia is tested by having a patient stand 
with heels and toes together. Marked swaying (more than an inch or two 
of excursion) increased upon closing the eyes strongly suggest locomotor 
ataxia and is, in fact, usually associated with other evidences of incoordina- 
tion, lost knee-jerks and a pupil reacting to accommodation but not to 
light.f 

In Meniere's disease or a lesion of the mid-cerebellar lobe the patient 
may sway violently and fall unless closely watched. 

In cerebellar lesions the ataxia of all types is extremely coarse but is ataxia?"" 
much lessened in recumbency, nor is Rombergism so greatly increased Rombergism. 

* See "Tetany." 

t One sufferer from locomotor ataxia aptly described his sensation as that of a "chicken 
on a clothes line." 



Cause usually 
simple. 



Locomotor 
ataxii. 



Meniere's 
disease. 



5o 



MEDICAL DIAGNOSIS 



Sthenic vs. 

asthenic 

ailments. 



Voluntary 
shifts. 



Abdominal 
lesions. 



Variable 
decubitus. 



Rigidneck. 



Fear of jarring 
or handling. 



High 
diaphragm. 



Acute form. 



A double risk. 



upon closing the eyes as is the case in locomotor ataxia. In ordinary vertigo 
and the pseudo-ataxia of hysteria, muscular incoordination usually disappears 
in recumbency. 

Decubitus {Active or Passive). — In the bedfast patient, its chief divisions 
are the active and passive, dorsal and lateral, and it varies with the condition 
of the patient and the nature and localization of his disease. 

Even a severe pneumonia does not always rob the patient of his active 
decubitus, but in severe typhoid fever the patient lies relaxed and helpless, 
must be moved from side to side, and occasionally lifted and straightened 
out to relieve a cramped posture or prevent his gravitating to the foot of 
the bed. 

The terms dorsal and lateral explain themselves, but it is important to note 
whether the patient changes voluntarily from one to the other decubitus 
or, through weakness or because of pain excitation or increase, maintains 
a fixed posture.* 

In appendicitis the patient usually lies on the back, often with the right 
knee drawn up, or, as in general peritonitis, with both knees so placed. In 
severe abdominal colics (intestinal, hepatic, renal, etc.) the knees are often 
drawn close to the belly and the lateral coiled position is common. 

In acute pleurisy the attitude is variable, the patient often lying on the 
affected side to limit movement and favor the vicarious respiration of the 
sound side. In others this attitude is primarily painful, but with the com- 
ing of an effusion and subsidence of inflammation it is the favored position. 

Acute meningitis, if established, is characterized by cervical rigidity, 
retraction of the head and neck giving a distinctive appearance. 

In severe rheumatic fever and in certain cases of infantile scurvy and 
rickets as well as in early acute peritonitis, the patient lies in a dorsal posi- 
tion, and his whole expression may evince the liveliest apprehension, when his 
bed is approached or any effort made to examine or move him. 

ORTHOPNEA.— In cases of heart disease in which the right heart has 
failed; in asthma whether spasmodic, cardiac or renal, and in severe emphy- 
sema, massive pericardial effusions, mediastinal tumors, or laryngeal obstruc- 
tion, one is likely to find that peculiar combination o f dys pnea and an obligatory 
partial or complete sitting posture which constitutes orthopnea. 

In cases where the diaphragm is pushed upward, as in massive ascites 
or severe meteorism, orthopnea may be present, though usually absent. 
Consciousness and a certain amount of physical strength are necessary to 
the voluntary maintenance of this position. 

An acute orthopnea is seen not only in asthmatic seizures, but with major 
angina pectoris, sudden cardiac weakness and infarction or edema of the lungs. 

Important Variant of Orthopnea. — In certain cardiovascular cases it 
may be impossible for the patient to resist the impulse to assume suddenly a 
sitting or even a standing posture, and, inasmuch as sudden death has 

* In acute self -limited ailments like pneumonia we may sometimes observe a profoundly 
toxic, apparently comatose, patient change his decubitus from passive to active and feel 
that the ebbing tide has turned. 



THE OUTWARD SIGNS OF DISEASE 



51 



frequently followed the natural attempt on the part of the attendant to re- 
strain the patient, both judgment and discrimination are required. 

This condition is most frequently encountered by the author in coronary 
sclerosis, anginas and advanced aortic lesions. In the terminal incompen- 
satory stage of mitral lesions there is often a peculiar listless rolling of the 
head from side to side, which, with the associated anasarca, blurred features, 
cyanosis and orthopnea, makes a characteristic picture. Modifications of 
this syndrome may persist for weeks and are ominous. 

In some cases of aneurysm, acute aortitis, asthma, extreme cardiac in- 
compensation, or a malignant growth involving the mediastinum, the patient 
not only sits up, but must lean forward so as to rest the head upon the knees or 
upon some special support. 

In several cases of Hodgkin's disease coming under the author's obser- 
vation, rapidly enlarging glands within the mediastinum made this attitude 
obligatory for weeks before the patient's death, a special bed-table or arrange- 
ment of pillows affording support for the head and arms. In diaphragmatic 
pleurisy the patient usually sits inclined toward the affected side. Rarely, in 
dyspnea or dysphagia, due to the pressure of aneurysm or mediastinal 
growths, and, in some cases of vertebral caries as well, the prone position 
is that of election. 

Most careful attention should be given to the attitude of the semi-un- 
conscious patient with particular reference to paralysis, for the appearance 
and passivity of an affected member or side is oftentimes characteristic. 

Common Conditions. — The curvatures of kyphosis, scoliosis, lordosis, 
and the compensatory spinal arching of emphysema are everyday matters. 
The wide " stance" of advanced locomotor ataxia and the similar attitude 
of osteitis deformans are also more or less characteristic. 

Emprosthotonus and Opisthotonus. — Spasmodic flexion of the body which 
makes its supports the forehead and feet (emprosthotonus) is less frequent 
than the backward flexion which makes the head and heels the sustaining 
points (opisthotonus). Either may occur in hystero-epilepsy, uremic con- 
vulsions, tetanus, cerebro-spinal meningitis and strychnin poisoning. 

GAIT. — Necessary Maneuvers. — When a special examination is necessary 
the legs should be uncovered from the hips down and in women the night- 
dress or chemise may be brought forward between the thighs and fastened 
above. 

The patient should walk briskly, then slowly, with the eyes open, then shut, 
stop abruptly, and also turn sharply at command and follow a rug border or 
crack at right angles to the previous line of vision. 

Due allowance must be made for nervousness and careful watch be kept 
lest a serious fall occur in some ataxic patient. 

The limping gait suggests acute or chronic joint ailments, flat-foot, corns, 
etc. 

A tilting forward of the body is noticeable in those merely "round 
shouldered," in paralysis agitans, extreme emphysema, kyphosis due to verte- 
bral caries, and certain painful abdominal affections both acute and chronic. 



Herald of 
death. 



Prone position. 



Spinal cuTva- 
ture and 
"stance." 



Associated 
conditions. 



Caution. 



52 



MEDICAL DIAGNOSIS 



Locomotor 
ataxia. 



Other 
associations. 



"Mowing 
gait.' 



Hysteric 
simulation. 



Foot-drop. 



A late 

symptom. 



Leaning backward or an actual lordosis may be due to spinal disease, 
advanced pregnancy, abdominal tumors, ascites or extreme obesity, and is 
a striking symptom of pseudo-hypertrophic paralysis and cretinism. 

Ataxic Gait. — The gait of the advanced ataxic stage of locomotor ataxia 
is striking, the feet being raised suddenly, jerked uncertainly forward beyond 
the ordinary limit and brought down heel first with a stamp. The patient 
keeps them well apart and must keep his eyes upon the ground, lest he sway 
or even fall. A sudden turning movement or an abrupt rise from the sitting 
posture is to him difficult or impossible. A 
patient may have the disease for years, how- 
ever, before this typical gait appears. 

An ataxic gait occurs in many conditions 
other than locomotor ataxia; and among these 
are Friedreich's ataxia, cerebellar tumor, 
syringomyelia, hereditary cerebellar ataxia, 
some cases of general paresis, and various 
intoxications affecting the cerebrospinal sys- 
tem, i.e., lead, arsenic, alcohol, etc. 

The Spastic Gait. — In this gait, character- 
istic of hemiplegia if unilateral, or some form of 
lateral sclerosis if bilateral, the rigid leg moves 
stiffly, the foot drags, necessitating a tilting of 
the pelvis at each step, and the toes describe 
an arc (" mowing gait"), thus wearing down 
the sole of the shoe on its inner side. 

In hysteria a simulated unilateral spastic 
condition may be observed but in most instances 
the foot is merely dragged and not swung inward. 
' Cross-legged Gait. — Spastic contraction of 
the adductors sometimes produces a cross-legged 
"progression" also occasionally simulated in 
hysteria. 

The Steppage or Prancing Gait. — This is 
most often seen in multiple neuritis or peroneal 
muscular atrophy as a result of foot-drop, because of which the patient must 
lif t the foot high with each step in order to raise the toe clear of the ground 
and avoid tripping. The result is a peculiar "high action," the patient 
appearing to step over constantly' recurring, though non-existent, obstacles. 

The Shuffling Gait of Senility. — This is a matter of daily observation and 
is associated with slowly progressive loss of strength and mentality. 

The Choreic Gait. — When present, it is sometimes peculiarly like that of 
the school boy, who in the schoolroom clownishly stumbles or trips over his 
heel to attract the attention of his fellows, and it is seldom or never unasso- 
ciated with other characteristic symptoms. Spasmodic adduction, extension, 
and outward rotation of the legs form a sequence which soon makes progres- 
sion impossible if unrelieved. 




Fig. 14. — Tabes. Station: 
legs widely separated, feet 
everted. 

May be evident even when 
the ataxic gait is not typical or 
even very marked. {Gordon.) 



THE OUTWARD SIGNS OF DISEASE 



53 



The Reeling Ataxic Gait. — This is especially characteristic of cerebellar 
(vermis) lesions, and differs in no essential respect from that of a drunken 
man. A similar gait may occur in any condition accompanied by vertigo. 

The Waddling Gait. — In this form lordosis is marked, the feet are widely 
separated, the pelvis and head of the femur are jerked forward at each step, 
the flexed knee is advanced, extended only after the foot is placed flat upon 
the ground, and the patient cannot stand on tiptoe. It indicates bilateral 
hip disease, congenital dislocation of the hip-joints or pseudo-hypertrophic 
paralysis. 

Dromedary Gait. — In the so-called "progressive torsion spasm" of chil- 
dren (Flatau-Sterling) the peculiar movements in walking have given rise 
to the terms " camel's walk" or "dromedary gait." 

The Festinant Gait. — When present this is pathognomonic of advanced 
paralysis agitans, and, in typical instances, the patient seems as if trying to 
recover from a thrust from behind. He goes slowly at first; then trots of 
shuffles at increasing speed with the body bent forward and finally pitches 
helplessly forward, if unsupported. Retropulsion and lateropulsion of the 
same type may be present also in such extreme cases. 

Intermittent Claudication. — ("Dysbasia angiosclerotica" u intermittierende 
Hinken"). This justifies further special reference, for though it is associated 
definitely with arteriosclerosis and deficient circulation in the lower limbs, 
it is frequently overlooked or misinterpreted.* 

77 is characterized by numbness, pain or muscle cramps on standing and 
walking, associated with a temporary rigidity, paresthesia or disability, all of 
which symptoms are often entirely absent when at rest. 

The condition is far more frequent than is generally believed and in several 
cases observed by the author is has been associated with serious myocardial 
degeneration and general circulatory embarrassment. 

The pulse is usually absent or extremely weak below the knee during the seizure 
and is usually deficient in one or both of the main arteries of the foot even when 
the patient is at rest.\ 

Thomsen's Disease. — This, a family disease, is characterized by recurrent, 
transient muscular stiffness or painless contraction on attempting any muscular 
action. 

This, in walking, at first checks or delays each step, but gradually wears 
away and permits normal progression, only to re-appear when any new muscle 
group is called into play or the same action repeated after a rest. 

Astasia-abasia. — This curious condition must be classed as a functional 
neurosis inasmuch as all other nervous functions are normal and the picture 

* The same condition may be present in the arm in rare instances. 

t This condition need not be confounded with the intermittent spinal claudication of 
Dejerine, which represents what, at first, is a mere sense of fatigue in one limb under exercise 
later in both and still later the development of a spastic paraplegia. Disturbances of the 
deep reflexes and the sphincters appear early, pain is absent, the pulse in the arteries of the 
foot is unaffected. The disease is, nevertheless, due to the same cause as intermittierende 
hinken, but the changes are localized in the arteries supplying the lumbo-sacral segments of 
the spinal cord. 



" Drunken' 
gait. 



Not rare if 
sought. 



A significant 
finding. 



A curious 
complex. 



Effect of 
posture. 



54 



MEDICAL DIAGNOSIS 



■Jumpers." 



Importance of 
weight. 



Its many 
causes. 



strongly suggests hysteria. Walking may be impossible yet all of its move- 
ments may be normally performed when the patient is lying in bed. The inability 
may be absolute or partial, giving rise to what simulates spastic paralysis on 
the one hand or flaccidity upon the other. 

Saltatory spasm is sometimes observed, the abrupt leaps being due to 
violent involuntary muscular contractions induced by the assumption on the 
erect posture. 

DESCRIPTION OF NYLIC STANDARD TABLE OF HEIGHTS AND WEIGHTS 

Dr. O. H. Rogers, of the New York Life, has constructed from the same 
figures, the graphic table shown on the opposite page. 

"The short vertical lines marked $'6", 5V, 5'8", and so on are the height lines. The 
diagonal curved lines, marked 20, 30, 40 and 55, are the age lines for men; the lines desig- 
nated by the sign o- are the age lines for women. The intermediate ages fall at proportion- 
ate distances between these curved lines. The intersections of the age lines with the verti- 
cal height lines fix the normal weight-points. The weights at intervals of 5 pounds are 
recorded on the horizontal lines to the right of the diagonal curved lines. 

"Thus, a man s'6" in height should weigh, at age twenty, 135H pounds; at age thirty, 
*43/^ pounds; at age forty, 149^ pounds; at age fifty-five, 153^6 pounds. The weights 
for intermediate ages are found at corresponding intermediate points. 

"A woman $'6" in height should weigh, at age twenty, 1363^ pounds; at age thirty, 
137K pounds; at age forty, 143^ pounds (the same as a man at age thirty). At fifty-five 
the weights of men and women are the same. In this way are found the normal weights for 
any height at any age. 

"Now, let us suppose that a man $'6" in height and twenty years of age weighs 225 
pounds; how much is he overweight? His normal weight is 135 H pounds. Passing from 
the normal weight-point horizontally to the right until we reach the vertical line marked 
225, we find ourselves just outside the 65 per cent, line; such a person is thus found to be 66 
per cent, overweight. Again, supposing the weight to be 100 pounds, we pass horizontally 
to the left to the 100 pounds vertical line; the intersection of our weight line with this ver- 
tical line shows him to be 26 per cent, underweight. In the same way the percentage of 
any given weight above or below the normal may be obtained. 

"The vertical weight lines are 25 pounds apart, but for greater accuracy the intervening 
spaces are divided by broken lines into 5-pound subdivisions. 

"Mistakes in the use of the chart will be avoided if the following steps are taken in their 
order : 

"1. Fix upon the height line. 

" 2. Locate the age-point on that line. The point thus found gives the normal weight for the 
height and age. 

"3. If the case is very much over- or underweight — pass horizontally to the right in case of 
overweight, and to the left in case of underweight, to the intersection with the vertical weight line. 
The position of the point thus found fixes the per cent, over- or underweight." 

WEIGHT AND HEIGHT.— Every doctor's office should contain a pair of 
accurate scales, and the past, recent, present, and best weights are oftentimes of 
great importance in diagnosis, prognosis and treatment. 

Obesity. — In general, one encounters a tendency to increase in weight 
after the age of forty and excessive corpulence is ordinarily associated with a 
weak musculature, poor resistance to acute disease and a decided tendency to 
degeneration of the heart, blood vessels and kidneys in middle age. 

Emaciation. — This may arise from exophthalmic goiter, hysteria, worry 
and loss of sleep, the anxieties and strain of a love affair, improper or insufn- 



THE OUTWARD SIGNS OF DISEASE 



55 





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56 



MEDICAL DIAGNOSIS 



Self-starva- 
tion. 



A cause of 

"nervous 

indigestion. 



Wasting. 



Misleading 
gains in 
weight. 



Weighing 
infants. 



cient food, diabetes, chronic vomiting, profuse diuresis, sweating, purging and 
many other exciting causes. 

It is pronounced in certain digestive disorders, in symptomatically active 
universal congenital asthenia, in all severe or prolonged fevers, true diabetes 
mellitus and the various wasting diseases of children. 

One of the commonest factors is unconscious self -starvation through whimsical 
or mistaken limitation of the diet as is so often seen in the asthenic forms of 
indigestion. 

Chronic starvation, unconscious, deliberate or imposed, is one of the com- 
monest and least recognized causes of persistent dyspepsia of the functional 
type as encountered in asthenic individuals and some very serious cases 
arise from the vicious, dangerous, and not infrequently fatal, fasting cures 
conducted by quacks, or self-imposed. 

Progressive Loss of Weight. — This is one of the most significant signs of 
incipient tuberculosis, carcinoma of the stomach and many other chronic 
ailments. 

A fair estimate of weight loss can be made by pinching tip a fold of skin over 
the triceps when the elbow is semiflexed and noting the degree of the misfit. 

In chronic exhausting diseases and in the emaciation of advanced age the 
skin is not only loose, but also relatively inelastic and relaxed. 

Increase of Weight. — Following illness, this ordinarily indicates an im- 
proved general condition and the arrest of any local disorder, but large tumors, 
myxedema, edema and exudates, also increase it, and in heart disease and Bright' s 
disease especially, the variation in body weight may reveal a transudate not 
shown by outward signs. Loss of weight in the renal and cardiac types of 
edema may at times, therefore, be a favorable symptom. 

Weight loss may mean little or no loss of strength and in those who have 
become obese from physical inaction and overeating and drinking, may ac- 
tually promote muscular activity, but progressive emaciation and increasing 
weakness are usually of serious import. 

Infants should be weighed weekly and should show an increase of from 200 
to 250 grams per week for the first four months, from 120 to 200 grams 
weekly for the five succeeding, and somewhat less for the remaining months 
of the first year of life. 

During the first days after birth they may show normally a considerable 
weight loss. 

. Accurate Weighing. — When accurate results are necessary in individual 
cases, weighing should be done at the same hour in relation to meals, on the 
same scales, and with the same amount of clothing, if possible, inasmuch as 
the estimate of 5 to 7 pounds usually made for the clothing of adults is subject 



Height and 
weight. 



Standard 
relationship. 



The relation of height to weight is important and is well shown in the in- 
genious and accurate " Nylic" table. (Page 55). 

The Attitude of Life Insurance Companies. — Insurance companies regard 
with suspicion men whose weight runs more than 20 to 25 per cent, above or 
below the standard as indicated by the table, and that this prejudice is well 



THE OUTWARD SIGNS OF DISEASE 



57 



founded has been shown by the results of the "combined actuarial investi- 
gation" which has proven an unduly high mortality in this class of lives. 

Light Weight. — In connection with underweight a family history of tuber- 
culosis or a personal history of doubtful environment, past infection, a 
narrow chest, small heart and the evidence of poor circulation are extremely Demands 
important. The many etiologic factors, acute and chronic, naturally re- j scrutiny. 
ceive close scrutiny. 

Overweight. — So also in overweight one must distinguish between those 
who have big bones, firm well-developed muscles and moderate abdominal 
girth and the flabby, big-bellied, sedentary livers and heavy eaters, par- 
ticularly if these latter have a family history indicating an hereditary tend- 
ency to apoplexy and diseases of the heart and kidneys. 

Comment. — Very tall slender men, giants, professional athletes, and big- 
bellied heavyweights are not as a rule long-lived. 



Necessary dis 
crimination. 



58 



MEDICAL DIAGNOSIS 



Stumbling 
blocks. 



Diseases of 
infancy and 
youth. 



AGE— RACE— SEX— HABITS— SOCIAL STATE AND RESIDENCE 

AGE. — Age Estimation. — By. practice and observation we can usually 
estimate closely the age of patients, but hair dye and modern beauty parlors 
may deceive the very elect among case- takers. On the other hand, manly 
chivalry may be a stumbling block and, in the case of women at least, like 
the tactful census enumerator, we may at times be obliged to accept state- 
ments with a mental reservation which should find a place in the case history.* 

Certain ages represent a special predisposition to certain diseases, acute 
and chronic. 

In infancy and childhood we meet especially with acute digestive dis- 
turbances, spasmophilia, rickets, the exanthemata, affections of the lymph 
glands, meningitis, infantile palsies, epilepsy, chorea, croup, cretinism and 
congenital heart disease. 




Fig. i 6. — Rapid aging. An active energetic man aged forty-nine. 
(Compare with Figure 17, page 59.) 

Tuberculosis attacks the young with an especial frequency and a re- 
sultant higher mortality, but in those under the age of puberty it is peculiarly 
liable to affect the lymph glands, particularly those of the cervical triangles, 
the bones, or the abdomen. 

During adolescence, chlorosis, various forms of hysteria, epilepsy, 
acute rheumatism, gastric ulcer and tuberculosis are extremely common. 

* In certain very rare instances the appearance of youth is maintained without the use 
of artificial beautifiers. The author recalls one woman, thirty-five years of age, who had the 
face of a girl of sixteen. 



AGE — RACE — SEX — HABITS — SOCIAL STATE AND RESIDENCE 



59 



As middle age approaches, the tendency to the exanthemata and to 
acute infections is diminished and a predisposition to degenerative diseases 
of a chronic type appears. Such are arteriosclerosis, myocarditis, prostatic 
disease, gout, gall-stones, diabetes, the insanities, various forms of paralysis, 
profound blood disturbances such as leukemia and pernicious anemia, 
carcinoma, and chronic Bright's disease. Cardiovascular syphilis tends to 
become clinically prominent in middle age, even though the primary infec- 
tion and insidious, initial degenerative changes may date back several 
decades. 

In old age the predisposition to cardiovascular and malignant disease is 
intensified, and, in addition, we find chronic bronchitis and emphysema, 
passive pulmonary congestion, and a return to the childish tendency to 
broncho-pneumonia. 




Fig, 17. — Rapid aging. Same man six years later. 

In some instances diseases are wholly limited to certain age periods, but 
usually, in weighing diagnostic probabilities, the question is one of relative 
frequency only. For example, cancer of the stomach does occur in young 
people, but is as rare in a person under twenty, as is mumps in one over 
seventy. 

Apparent vs. Actual Age. — Two very essential points are (a) apparent as 
compared with actual age; and (b) unduly rapid aging. 

Rapid aging may bring the man of thirty to the same status as the one of 
seventy, and on the other hand, the latter, by reason of inherited vigor of con- 
stitution and right living may be physically twenty years under his actual age. 
Every clinician repeatedly encounters cases of marked arteriosclerosis in men 
under thirty and the inheritance of poor structural material, lues and dissipa- 
tion or mental strain are the chief factors in early aging. 



The degenera- 
tive period. 



Rapid aging. 



Extended 
youth. 



6o 



MEDICAL DIAGNOSIS 



Woman's pre- 
disposition and 
immunity. 



Scope of 
inquiry. 



Specific 
inquiry. 



Age and Prognosis. — Finally, one must remember the effect of age upon 
prognosis. The acute exanthemata, though more readily acquired, are 
for the most part much more lightly borne by the child than by the adult 
and, on the other hand, resistance to tuberculosis is much more marked in 
persons above the age of thirty. Pneumonias are peculiarly fatal at the 
extremes of life, but "young old people" strongly resist the advance of 
chronic disease. 

SEX. — In general, men and women suffer about equally and resist in 
about the same measure the larger number of diseases: nevertheless, there 
are certain striking differences both as to incidence and severity. As 
compared with men, women, through the disabilities peculiar to their sex, 
appear to develop a superior philosophy and endurance particularly marked 
in chronic disease. 

The woman is especially liable to the multiform expressions of congenital 
asthenia, hysteria, myxedema, arthritis deformans, chlorosis and chronic 
secondary anemias, gall-stones, goiter, cancer of the breast or uterus, and 
gastric ulcer. 

On the other hand, she is relatively free from hemophilia, aneurysm 
and locomotor ataxia, and less liable to acute infections, gout, appen- 
dicitis, typhoid fever, certain diseases of the heart, progressive muscular 
atrophy, diabetes, carcinoma of the stomach and bowels, leukemia, per- 
nicious anemia and Addison's disease. 

With respect to aortic disease, her so-called "immunity," in the light 
of recent research, appears to represent a less degree of exposure to that 
syphilitic infection now justly held accountable for the larger proportion of 
such cases as first become manifest in middle age. 

RACE. — The special predisposition of the Hebrew to functional nervous 
ailments and diabetes mellitus; of the Irish to tuberculosis; of the English to 
gout; of the continental races to suicide, etc., etc., is well known. More- 
over, certain races show markedly greater resistance to disease and 
surgical procedure than do others. 

HABITS AND ENVIRONMENT.— The term "habits" should often 
cover a much larger Held than the patient's indulgence in tobacco, drugs, or 
alcoholics and include his environment and mode of life, his hours for meals 
and for sleep, his manner of eating and the nature of his meals, no less than 
the extent of his drinking. 

In dealing with dyspeptics, one should ask specifically what was taken for 
breakfast or lunch preceding the time of the examination, or just what is 
usually taken at such a time, how much water is drunk and when, how much 
time is taken for the meal, whether the food is properly masticated, and, 
indeed, ascertain the condition of the teeth and gums by direct inspection 
when examining the tongue and throat.* 

* As a matter of routine practice, the examination for infected tonsils, pyorrhea alveo- 
laris, peridental abscess, antrum disease and other foci of infection, has become a prime 
necessity, because of the important part played by cryptogenic infections in the causation 
of disease. 



HABITS 



6l 



Tea, Coffee and Tobacco. — Too much stress is laid upon the mere use of 
tea, coffee and tobacco, and too little upon the idiosyncrasy of the patient in 
regard to these articles. 

That which constitutes excess for one may be but moderation in another, 
and the slight amount representing the average consumption is usually of 
little consequence; hence it is a positive hardship to arbitrarily shut off, 
rather than to sensibly cut down, the tea, coffee or tobacco which for years 
has been the solace of some elderly patient. 

As regards tobacco, especially, one may say that the signs of overindulgence 
are found in unrefreshing sleep, furred tongue and bad taste in the mouth, 
nervousness which takes the form of mental irritation and perhaps tremor, 
and at times a distinct disturbance of digestion and irritability or palpita- 
tion of the heart. In the man under middle age these symptoms mean little; 
in the elderly man much, and for the latter, persistence in excess is fraught 
with danger. 

Snuff Habituation. — The very extensive and steadily increasing use of 
"Copenhagen" snuff now is known to be attended in many instances by 
distinctly toxic symptoms. 

It is used not only by "snuffing," but also, and perhaps more generally as 
a "quid" held persistently in the mouth in the gingival buccal angle. 

" Snuff- or Copenhagen-heart" often differs in no essential respect from 
the irritable, labile and arrhythmic "tobacco-heart." 

In addition one must consider snuff as a possible cause of obscure chronic 
indigestion, chronic headache, psychasthenic states, and actual exertion 
dyspnea due to cardiac insufficiency, usually of minor grades. 

The Use of Alcohol. — The common mistake of the novice is a failure to 
bring out tactfully yet fully the facts bearing upon a patient's alcoholic 
indulgence. 

He is too easily satisfied when the patient says he is u not a drinking man," 
or he "takes an occasional drink," or u not enough to hurt him," " a drop now 
and then," "just a social glass," etc., etc. An absolute denial of overindulgence 
is usually proudly made by the man who has been a hard drinker for years 
but has stopped, it may be only a few days before examination. The "now 
and then" kind, or those who say "often not for a year," frequently represent 
the worst type of periodic spree drinkers. 

One should, therefore, inquire tactfully about the present and the past, 
the extent, the hour, the kind, in what relation to meals and with what 
apparent effect upon the health. 

It is impossible to lay down an absolute rule as to what constitutes excess 
and it is probable that the man who takes a little liquor, even two or three 
times a day well diluted and on a full stomach, may suffer little or no bad 
effects, but the American style of drinking is peculiarly harmful as taking the 
form of "cocktails" before meals and of a multiplicity engendered by the 
pernicious custom of "treating." 

A Genuine Risk. — The danger in "moderate" drinking lies doubtless much 
more in the risk of forming a habit than in the physical damage wrought by the 



Individualiza- 
tion necessary. 



Excess a 
relative term. 



Tobacco 
poisoning. 



Its dangers. 



Snuff -heart. 



Misuse of 
terms. 



Euphemisms 
of the 
bibulous. 



Specific 
inquiries. 



What consti- 
tutes excess 



62 



MEDICAL DIAGNOSIS 



Relation to 
disease. 



Bastard 
complexes. 



Hypodermic 
marks. 



intoxicant itself, but the reality and insidious nature of this risk is but too well 
known to every practising physician. 

Relation to Disease. — The three diseases most often due to such over- 
indulgence are: delirium tremens, alcoholic neuritis, and cirrhosis of the liver, 
but it is a powerful contributory factor in an enormous number of chronic 
diseases. It depresses vitality, diminishes resistance and thus invites and 
promotes their development and accelerates their progress. In severe 
acute diseases, such as pneumonia, the confirmed drunkard stands little 
show. 

DRUG HABIT. — Opium and Cocain. — As regards the use of drugs, we 
have chiefly to deal with the various forms of opium and with cocain. Neither 
produces in every individual a clear and definite syndrome, but nervous insta- 
bility and a peculiarly baffling and bastard symptom-complex are suggestive. 
A markedly dilated pupil in cocain users or a markedly contracted one in the 
victim of the opium habit may attract attention, but in either at the time of 
examination the pupil may be normal. 

If one examines such patients thoroughly, he will often find recent hypo- 
dermic punctures, black dots representing old ones, or evidence of recent or 
old multiple abscesses due to the use of dirty needles. Such are usually on 
the right thigh or left arm of a right-handed person, and the needle is usually 
introduced directly through the clothing. 

The peculiar pallor sometimes present has been referred to elsewhere, 
the skin is likely to be dry in morphin users, the appetite poor and bowels 
constipated and the victims of either drug are subject to fits of profound 
depression succeeded by periods of buoyancy. " Nose rubbing " may suggest 
opium, and in the case of cocain users especially, formication is not an 
infrequent symptom. The excessive use of cocain may be honestly denied 
by one who has unwittingly contracted the habit through the use of the drug 
in the nasal passage or throat, the patient not realizing that absorption takes 
place in such instances as readily as if the drug were actually taken into the 
stomach. The overuse of such drugs as acetanilid may become a fixed habit 
and lead to serious or even fatal illness. 

Clouded or Misty Case Histories and Physical Findings. — Baffling and 
indeterminate histories and findings should particularly suggest the possibility of 
larval syphilis, drug habit, some abnormality of the internal secretions, mineral 
poisoning, hysteria, or actual malingering. 

MARRIAGE. — The question of marriage is important chiefly in rela- 
tion to the matter of pregnancy or child-bearing in women and its after- 
effects. Many obscure ailments in the female are traceable to unrecognized 
or neglected lacerations, while endometritis, uterine" displacements, pelvic 
abscess and epithelioma are especially common in multipara. 

The number of pregnancies, the duration and severity of labor, miscarriages, 
the stage of pregnancy at which they occurred, and the circumstances attending 
them, the number of children living and dead, the health of survivors and the 
causes of death of those diseased, are important. 

Marks of syphilis in a child at once direct attention to the parents and 



Mental state. 



Innocent 
victims. 



Pregnancy, 
childbirth and 
miscarriages. 



OCCUPATION AND OCCUPATIONAL NEUROSES 



63 



vice versa, and tuberculosis and other diseases may be suggested in a similar 
manner. 

Bachelor vs. Benedict. — Insurance experience seems to show that the 
benedict is a superior risk and, on the average, outlives his bachelor 
fellow. 

OCCUPATION. — Sedentary vs. Active. — Occupation and environment 
are important factors in diagnosis and prognosis and may throw light upon 
degenerative processes, functional and organic nervous disease and accidents. 
City dwellers and indoor workers in sedentary occupations sutler especially 
from dyspepsia, tuberculosis, and similar disorders. On the other hand, 
even country dwellers and out-of-door workers may suffer from the poor 
ventilation and deficient sanitation to be noted in many farm houses, and 
among them the transmission of tuberculosis from one family member to 
others is equalled only in the city slums. 

Exposure. — So also must one consider the effect of unusual exposure to 
cold, wet, and to such poisons as malaria. 

The best conditions are to be found in camp life or in the homes of the 
better class of agriculturists, the worst in the slums, sweat shops or improperly 
ventilated factories of great cities. On the one hand, there is the maximum of 
fresh air, sunshine, and healthful exercise; on the other, foul air in the shop 
and home, constant use of the same muscles and in cramped positions, and, 
as a rule, deficient or improper food. 

The Fatigue Neuroses. — Certain occupations involving the continuous 
use of one neuro- muscular unit produce specific ailments as dp those involving 
pressure, or irritation of a particular portion of the body. Cases of nystagmus 
have been reported as due to the cramped position of miners working with 
eyes fixed upon a particular point. 

"Penman's cramp" or "scrivener's palsy" is a familiar example, and the 
chronic laryngitis of military men, clergymen, auctioneers and public speakers 
falls under the same head. 

Among the commonest examples of these localized impairments of co- 
ordination are: "telegrapher's cramp," "dancer's cramp," "piano-player's 
cramp," "tennis-player's cramp," and "seamstress's cramp," but the list 
might be extended indefinitely. 

Another example of occupational disease is the inflammation of the 
patellar bursa especially common among floor scrubbers and known as 
"housemaid's knee. ,} This condition is encountered also in roof shinglers, 
tile layers and others working under similar conditions. 

"Charlie Horse." — This is a peculiar occupational disease affecting 
professional athletes, especially base-ball players, and to some extent the 
amateur as well. 

It is characterized by a localized myositis causing induration of the 
muscles of the thigh and a peculiar limp. 

"Going to boarding school" is one of the worst of occupations if the school 
work is overhard, the heating and ventilation insufficient, the food poorly 
prepared, lacking in quantity and variety and out-of-door exercise scant. 



City vs. 
Country. 

Tuberculosis. 



Best and 

worst 

conditions. 



Miner's 
nystagmus. 



Housemaid's 
knee. 



Potent for 
good or evil. 



64 



MEDICAL DIAGNOSIS 



Barkeepers. 



Combined 
factors. 



Value of 
vacation. 



A neglected 
topic. 



Nothing breeds more chlorotics than a poor boarding school or makes 
healthier women than a good one. 

Habits in Relation to Occupation. — The excessive use of intoxicants is 
often definitely related to certain callings. The manager of a large hotel 
syndicate has said that he has yet to see one barkeeper who failed to develop 
the drinking habit, and this statement undoubtedly expresses a rule subject 
to few exceptions. 

A traveling man who sells bar supplies, cigars, or even mineral waters is 
constantly subjected to a pressure which too often results in the formation 
of the liquor habit. 

Occupation Involving Continuous Mental Strain. — In this day of great 
enterprises a not inconsiderable proportion of the chronic ailments en- 
countered by the physician may be traced in part to continuous mental over- 
strain, usually combined with lack of exercise, improper diet and too often 
with overindulgence in liquor or tobacco. 

No one who has seen the remarkable improvement in chronic disorders of 
the heart, stomach, kidneys, or various diseases of the nervous system that 
follows a period of complete rest and freedom from worry can doubt the 
potency of mental overstrain as a factor in the etiology and prognosis of 
disease. Railroad men, financiers, and especially board of trade operators 
suffer greatly from this cause. 

The Physician. — The life of a practising physician is of such a nature as 
to readily explain the high early mortality encountered in this class, for in 
the physician's calling are combined constant exposure to infections, defi- 
cient and interrupted sleep, lack of exercise and recreation, excessive and con- 
tinuous mental strain, and an exhausting demand upon his kindly emotions. 

MINERAL POISONING.— A complete volume would be required to 
do justice to this aspect of our topic, and there can be no doubt that too little 
attention is paid to the possibility of occupational poisoning by physicians 
other than those practising in large manufacturing centers, where the condi- 
tions are exceptionally favorable to the development of occupational disease. 

Arsenic. — Aside from poisoning due to the inhalation of fumes or dust 
during the processes of milling, grinding and smelting, one encounters cases 
among workers in anilin dyes, toy or artificial flower ' makers, dyers of 
woolen or cotton goods, playing-card makers, taxidermists, lithographers 
and shot makers. 

Anilin. — This derives its harmful effect from three sources, viz. : itself, the 
arsenic often combined with it,, and the nitro-benzol used in its manufacture. 

Bromin and Iodin. — The fumes of this substance cause bronchitis 
and predispose to tuberculosis. 

Carbon Bisulphid. — This highly poisonous substance is used as a solvent 
for sulphur, iodin and oils, and is largely used in the manufacture of rubber 
goods. 

Chlorin. — In the bleaching of linen, cotton, bones, ivory and rags the 
fumes are irritating to the bronchial mucous membranes and predispose to 
tuberculosis. 



OCCUPATIONAL POISONING AND STIGMATA 



65 



Chromium. — This enters into chrome yellow and chrome green, and is 
used in staining glass or porcelain, printing bank notes, and dyeing linen, 
wool and silk, and, as potassium bichromate, is used in photography. 

Copper. — Workers in brass, nickel platers, bronzers, copper-sheet scrap- 
pers, pin makers, bell-metal workers, stone workers, engine wipers, and others 
handling, copper, bronze, brass or nickel may suffer from chronic poisoning. 
It should be remembered that brass is composed of copper and zinc, with or 
without tin and lead; bronze, of all four metals, and that nickel plating is 
sometimes done with an alloy composed of copper, nickel, iron and tin. It 
is further combined oftentimes with lead and arsenic. One of the most 
severe cases of lead poisoning ever encountered by the author was caused by 
polishing an alloy of this kind. 

Lead. — The possibility of lead poisoning in obscure gastrointestinal 
affections as in connection with its well-known nervous manifestations should 
never be forgotten. Not only is it found in lead smelters, refiners, sheet- 
lead rollers, lead-pipe makers, shot makers, typesetters, plumbers, toy 
makers, and painters, but also in lacquer polishers, gilders, bronzers, enamel 
workers, glaziers, pot, pan, card, cardboard or brick makers, makers of 
brass instruments, file cutters, flint glass workers, workers in white or red 
lead and litharge, calico printers and those engaged in the manufacture of 
lace, artificial flowers and wall papers. 

Mercury. — Chronic mercurial poisoning may result from idiosyncrasy, 
long-continued overdosage, or employment in smelters, quicksilver mines and 
felting rooms. 

Phosphorus. — This is now comparatively rare, and is almost wholly 
limited to those engaged in the manufacture of the parlor match. 

Turpentine. — Some persons are peculiarly subject to turpentine poison- 
ing, and painters working in poorly ventilated rooms may become chron- 
ically affected. 

Occupations Involving Excessive Heat. — Extreme dry heat can be borne 
without serious results in persons habituated; nevertheless, firemen on 
ocean steamers or naval vessels, and bakers suffer from heat, moisture, 
foul air, and the effects of chill and exposure due to extreme temperature 
variations. 

Miscellaneous Diseases of Occupation. — Millers, potters, file cutters, 
grinders of edged tools, wool and cotton spinners, marble and stone cutters 
are peculiarly susceptible to tuberculosis, particularly in its fibroid form. 
Handlers of rags and skins occasionally acquire anthrax, internal or external. 
Female domestics are peculiarly liable to anemia, gastric ulcer and tuber- 
culosis. Butchers or slaughterhouse men suffer from septic infections, 
stablemen from tetanus and glanders, brewers, saloonkeepers, bartenders and 
others of the same class show an enormous mortality from alcoholism, tuber- 
culosis, diseases of the nervous system, pneumonia, diseases of the liver and 
kidneys, and suicide. 

OCCUPATIONAL STIGMATA.— Those who follow certain occupations 
often present somewhat characteristic deformities: the lowered shoulder of 



Alloys. 



Moist vs. 
dry heat. 



Tuberculosis. 



Anthrax. 



Sepsis, 

tetanus, 

glanders. 



The lowered 
I shoulder. 



66 



MEDICAL DIAGNOSIS 



the desk worker, pack peddler and tailor are familiar to everyone. Few 
railroad trainmen escape the loss of one or more fingers. 

Furthermore, even the study of the callosities associated with certain callings 
prove helpful occasionally in identification, and a few of the occupations 
thus suggested are given briefly below. Callosities are shown at the points 
indicated: 

Banjo, Guitar, and Harp Players. — Finger-tips both hands. 

Zither Player. — Finger-tips of left hand, under surface and tips of index, 
middle and ring finger of right. 

Violoncello or Violin Players. — Tips of fingers, left hand only. 

Hand Compositors. — Palmar surface of thumb and index finger, right 
hand. 

Fencing Masters. — Ulnar border, right palm. 

Hand-organ Man (carrying own organ). — Outer side of right hip and 
thigh. 

Seamstresses. — Roughened radial border of terminal phalanges of left 
thumb and index. 

Tailors. — Ring-shaped callus on right thumb and index finger, left 
thumb and index roughened, enlarged bursae over external malleoli. 

Turners. — Outer border of right little finger. 

Clerk, Using Pen or Pencil. — Outer surface of terminal joint, right little 



The rough callous hand of the day laborer contrasts sharply with the soft 
hand of the sedentary worker, as does that of the seamstress or domestic 
with those representing the lighter occupations of her sex. 

The tan of the sailor contrasts sharply with that of the soldier, the one 
wearing his shirt open at the front, the other a high collar and close-buttoned 
coat. 

Idleness a Disease Breeder. — Want of occupation, mental and physical, 
is often deleterious and the psychasthenic hysteria, morbid irritability and 
ennui so commonly seen in spoiled, pampered, pleasure-loving, and responsibil- 
ity-free women, are seen rarely in the hard-working housewife. 

The man who for years has given his attention to active business or pro- 
fessional work may find complete idleness both boresome and dangerous, and 
few men or women, can be well mentally or physically without some definite 
occupation, however trivial. 

Every man who in later years forsakes his life's work should cultivate a hobby. 

RESIDENCE. — The novice frequently fails to secure the full name and 
Postal address, postal address of a public service patient under examination, forgetting that 
future communication is sometimes most important, in that some of the most 
valuable information results from following unusual cases. 

With respect to the medical history proper, both present and past residence 
should be known, and in general, information upon this subject is of value in 
relation to the following points: 

(a) The possible introduction of epidemic disease by persons coming from 
an infected area. 



Sailor and 
soldier. 



The domestic 
parasite. 



Value of a 
"hobby." 



RESIDENCE AND FAMILY HISTORY 



6 7 



(b) In tracing its distribution, as in an epidemic of cholera or typhoid 
affecting certain portions of a city or larger district. 

(c) In tracing its individual sources as illustrated by the detection of care- 
less dairymen, who spread infection along their route; and finally, 

(d) The special liability to certain diseases in definite districts or countries, 
as illustrated by diseases of the tropics, such as malarial fever, dengue, yellow 
fever, and plague, the hydatid disease of the Icelander, or the leprosy of the 
Sandwich Islander. 

The Home. — Specific inquiry concerning the exact situation of the 
patient's house, its elevation, exposure, the character of the surrounding soil, 
and the location of the sleeping chamber, is sometimes important. 

FAMILY HISTORY. — The transmission of special structural vulner- 
ability and predisposition is just as marked and as well-proven as is inherited 
likeness in form or feature. 

In taking a family history, one should secure full information as to the 
terminal illness of family members, often going back two generations and 
including collateral branches if significant facts develop. It is often of the 
utmost importance that the state of health or cause of death of the husband, 
wife and the children of the patient be established. 

It is seldom sufficient to ask whether any members of the family, immediate 
or remote, have suffered from hereditary disease, or even to put the question in 
the somewhat more specific form of an inquiry concerning tuberculosis or cancer. j 

Apoplexy, heart disease or Bright's disease may be readily admitted, but I 
insanity, epilepsy, tuberculosis and malignant disease are often concealed, 
either intentionally or quite as often, innocently. Deliberate concealment 
or actual lying are far from infrequent in ordinary case histories and are 
especially so in life insurance applications. 

The questions must bring out if necessary, the leading symptoms of the 
illnesses of deceased family members. One may ask if there was chronic 
cough, spitting of blood, emaciation, night sweats, or fever, the vomiting of 
blood, or the presence of a tumor, associated with emaciation and failing 
strength, in the given case. 

Certain Euphemisms of Case-taking. — Deaths from "childbirth," "ex- 
haustion," "grief," "broken heart," "general decline," etc., must never be 
accepted without careful and tactful cross-examination. "Senility" and 
"old age" are much abused terms and in the lay mind cover death at any 
age above fifty. 

No man ever passed his novitiate as a casetaker without saying hard 
things of "malaria," "chills," "fever," "decline," and especially "marasmus" 
and "don't know," and no student can give better evidence of his skill and 
tact than is furnished by an adequate, unambiguous family history. 

Alternatives in Heredity. — Few diseases are directly transmitted as such, 
hereditary influence usually taking the form of more or less marked predisposition. 

Thus the disease of the descendant may be but the congener of that of the 
forebear and is then termed an alternative, or the inheritance may be that of 
marked vulnerability or its opposite, relative invulnerability. 



Tracing 
epidemics. 



Climate an 

etiologic 

factor. 



Inherited 
predisposition. 



Extension of 
inquiry. 



Specific 
inquiry. 



Concealment 
common. 



Direct trans- 
mission raie. 



68 



MEDICAL DIAGNOSIS 



Resistance and 
non-resist- 
ance. 



Congenital 
asthenia. 



Alternatives. 



Specific 
inheritance. 



Cardiovascular 
alternatives. 



Age and sex 
incidence. 



Short- vs. Long-lived Families. — To the former class belongs the family 
whose members show a low average lifetime, the ready acquisition of, and 
feeble resistance to, acute or chronic ailments. To the latter class apper- 
tains a vigor of constitution and strength and harmony of structure which 
ensures resistance to disease and long life. 

Congenital weakness of structure, imperfect or unstable function, and a 
peculiar nutritional instability, characterize large groups of people in all 
civilized countries, and the condition has been well named by Berthold 
Stiller "Asthenia Universalis Congenita.'''' This is now widely accepted by 
European clinicians as the condition underlying many bastard syndromes 
which, in the past, have been considered and treated as clinical entities. 

Nearly all cases of so-called "nervous dyspepsia" ("gastric neuroses") 
fall under this head and an understanding of this fact supplies the means of 
their successful treatment.* 

The Nervous System in Heredity. — A strong alternative relationship 
exists between alcoholism, insanity, epilepsy, hysteria, and criminal impulse. 

In some families, however, there is little variation, insane grandchildren 
follow insane grandparents and epilepsy in the father means the same disease 
in the child. Some remarkable cases of hereditary alcoholism have come 
under the author's observation. In one, especially, it seems impossible for 
any male family member, or even collateral branches, to escape the curse. 

Apoplexy. — The hereditary tendency to cerebral hemorrhage is one of 
the most striking facts in medicine but is of course inseparable from its 
etiologic causes and apparent alternatives, arteriosclerosis, chronic Bright' 's 
disease, aneurysm and the degenerative diseases of the heart, f 

Cancer. — Few physicians of experience will be found who deny an 
hereditary predisposition to cancer, yet it is well to minimize it and to avoid 
too radical statements in regard to.it, as tending to create undue appre- 
hension in the minds of members of tainted families. Like apoplexy, the 
tendency in this disease is toward death in middle age, the tendency to 
transmission seeming to be more marked from mother to daughter than from 
father to son. J 

Diabetes. — Few diseases are more distinctly hereditary than diabetes, if 
we regard it as one of the alternatives of inheritance in nervous and mental 
diseases. According to recent observers it is possible to separate from other 
types a distinctly hereditary form which is characterized by an equality in 
predisposition as between male and female, or even the predominance in the 

* The author has been especially interested in these dyspepsias and in the narrow, atonic, 
dilatable, symptom-producing heart which is associated with this condition, and deals with 
both, in their appropriate sections. 

f The author has reported a case in which, of nine family members, five died of apoplexy, 
two of chronic Bright's disease, and one of heart disease, every death occurring between the 
ages of forty and fifty-five. The then surviving brother has since died of the dominant 
disease. In each case, doubtless, chronic interstitial nephritis, and associated arterioscler- 
osis, myocardial degeneration, and arterial hypertension coexisted. 

J Undoubtedly the hereditary element has been exaggerated in the past, but quite as 
certainly the present tendency on the part of some writers to deny it represents an over- 
reaction. 



HEREDITY 



6 9 



female. The best examples of inherited disease are found in the race showing 
the greatest vulnerability, namely, the Hebrew.* 

Gout. — This distinctly hereditary ailment is potent in the production 
of arteriosclerosis, apoplexy, Bright's disease, gastrointestinal ailments and 
certain forms of diabetes as well as all forms of gout. 

Hemophilia. — This extraordinary disease is atavistic in its transmission, 
the deadly tendency to excessive bleeding, spontaneous or induced, being 
transmitted through the females of a family to certain of their male issue. 
In certain families it has been traced back for hundreds of years in an 
unbroken sequence. 

Syphilis. — In relation to family history direct inquiry is usually im- 
possible and the physician must ordinarily depend upon the disclosures of 
parents or the recognition of inherited syphilis in the patient. 

TUBERCULOSIS.— Direct Transmission vs. Environment.— That, in 
excessively rare instances, tuberculosis may be transmitted from mother to 
child in utero cannot be doubted, and it is certain that the incidence of tuber- 
culosis is greater in those of tainted family record. 

Inheritance is due chiefly to a congenitally asthenic structure and a con- 
stitutional Junctional inadequacy, which render the tissues of the child of tuber- 
culous parents more vulnerable and less resistant to the tubercle bacillus than is 
the case in one of sound, vigorous and untainted stock. 

Even predisposed children, if favored in climate, nutrition, and environment, 
need seldom or never develop the disease under conditions eliminating the pos- 
sibility of contact with the living germ, the exception being found in a latent 
prenatal glandular or bone infection. 

Unfortunately, however, these child victims of predisposition born in 
tuberculous households are in every way exposed, during the earlier years 
of life, through their creeping over dirty floors, their tendency to carry dirty 
hands and infected articles to the mouth, and especially through the em- 
braces and caresses of the infected parent, brother, or sister. 

The peculiar shape of the chest associated with tuberculosis and found 
most frequently in those of tainted stock is merely one of those many struc- 
tural peculiarities and deficiencies of chronic congenital asthenia which 
become factors in infection and favor the progress of the disease. 

Naso -pharyngeal Obstruction. — Of great importance are the obstruc- 
tions in the naso-pharyngeal passages, especially adenoid growths and 
hypertrophied tonsils. These, in themselves favorable soil for the tubercle 
bacillus and other microorganisms, embarrass respiration, hamper the 
development of the lungs and permit collapse of the lower chest, while further 
contributing to infection through frequent recurring colds and chronic 
catarrh. 

Life Insurance. — One has only to consult insurance manuals to under- 
stand the importance of physique and family taint as factors in tuberculosis, 
yet, admitting certain exceptions, it is generally true that, the attainment of 

* M. Loeb: The Hereditary Form of Diabetes. Zentralblatt fiir innere Medizin, Aug 
12, 1905, No. 32, p. 786. 



Race and 
heredity. 



Potent and 
protean. 



Atavism 



Direct trans- 
mission rare. 



Inherited 

physical 

deficiencies. 



Importance of 
environment. 



Direct 
exposure. 



Thoracic 
conformation. 



Invites infec- 
tion and lowers 
vitality. 



7o 



MEDICAL DIAGNOSIS 



Physique vs. 
Heredity. 



Degree of 
relationship. 



Vitally impor- 
tant data. 



"White 
plague" 

households. 



Ground 
ailments. 



Use plain 

language. 



full manhood, an exceptional physique, and freedom from direct exposure, 
largely overbalance a bad family history. 

The victims of congenital universal asthenia possess every characteristic 
of tuberculous predisposition and an astonishingly large proportion of them 
show positive tuberculin reactions or skiagraphic signs suggesting or proving 
past infection of the lungs even though at the time free from active symptoms. 

It must be remembered that the greater number of men and women have 
at some time become infected and will yield signs under tuberculin tests or the 
X-ray, even though they may never afterward show any evidence of an active lesion. 

Special Conditions Affecting Heredity in Tuberculosis. — With respect to 
the individual of tainted stock, the significance of tuberculosis in the parents 
is apparently but slightly greater than that in brothers or sisters, but probably 
this is because arrested tuberculosis in the mother or father is seldom to be 
traced in case-taking, such past events being usually either forgotten or 
concealed. Anyone who has practised in a region frequented by cured con- 
sumptives will appreciate the truth of this statement. 

Physical Resemblance. — Mere facial resemblance is of little impor- 
tance, but general structural likeness is of decided import. 

Direct Exposure to Infection. — The health of living family members and 
especially of the children of parents under examination, or vice versa, as well as 
the condition of parents affected by, or dying of, tuberculosis at or near the time 
of the birth of any individual under examination are vitally important factors. 

The member of a family or household in which active tuberculosis exists, 
and the individual who associates with infected persons outside the family, 
is exposed to great risks from infection if proper precautions are not faithfully 
and intelligently observed. 

PREVIOUS ILLNESSES.— Cardinal Importance.—^ knowledge of the 
general state of health and past illnesses of a patient may assist the diagnosis, 
either by excluding some immunity-conferring disease, or by fitting a symptom 
group to the known after-effects of some previous illness. The exanthemata 
and yellow fever illustrate the one, syphilis both. 

A patient reporting "stomach trouble" may present a clear history of 
previous gastric ulcer, appendicitis, gall-stone colic, or the morning vomiting 
of advanced interstitial hepatitis. 

Another may have repeated attacks of acute rheumatism or gout and 
our attention is thus specially directed to the heart, blood vessels and kidneys 
which may reveal changes wholly adequate to explain his symptoms. A 
history of severe nocturnal headache may be explained by an ancient syphilis, 
an intractable periodic neuralgia, by past malaria, or of tener by a history of 
accessory nasal sinus infection. 

In such interrogation the simplest and most homely phraseology should be used 
in dealing with the ignorant, and leading questions cannot wholly be avoided* 

* An ignorant patient of the author dying of perforating but previously unrecognized 
duodenal ulcer readily admitted having formerly "puked" blood and suffered much "mis- 
ery in his guts," though on repeated questioning he had denied "pain," "nausea" and 
"vomiting." 



FEVER THERMOMETRY 



71 



HISTORY AND ANALYSIS OF THE "PRESENT AILMENT" 

Interrogating the Witness. — The patient should be led to tell, almost 0} his 
volition, but in as few words as possible, the symptoms of his disease and their 
duration. 

Any attempt to theorize or drag in immaterial facts should be tactfully 
checked. To guide and direct the disclosures, check garrulity, verbosity 
and triviality, to systematize the disclosures and yet use few leading questions, 
constitutes an art both valuable and rare. 

General vs. Specific Symptoms. — One should discriminate between symp- 
toms that are general in their nature, common to a large number of diseases and 
subject to various interpretations and those that are local, peculiar or specific. 

Some of the principal general symptoms will be described in this connection 
and only their special features referred to in other sections or under the symp- 
tomatology of specific ailments. 

FEVER. — Thermometry. — Fever as a clinical manifestation is merely an 
elevation of the body temperature, formerly determined roughly by the hand, 
but nowadays accurately registered by the clinical thermometer. In such 
diseases as pneumonia and typhoid the skin is dry and hot, yet on the other 
hand, a high rectal temperature may exist in cholera even when the surface 
temperature is as low as 70 . 

The thermometer is ordinarily applied to one of four points, those being 
in the order of frequency, the mouth, the rectum, the axilla, and vagina. 

Rectal readings will exceed mouth temperatures by about one degree Fahren- 
heit and constitute the only accurate registration in the aged and in cases of pro- 
found weakness. 

There is no poorer investment than a cheap thermometer and the test 
scales supplied with some of those of the lower grades are worthless by reason 
of improper calibration and imperfect seasoning of the instrument and mis- 
representation on the part of irresponsible manufacturers. 

Precautions to be Observed. — In the use of a thermometer , certain precau- 
tions must be observed: 

(a) It should be cleaned before and after use. (b) The scale should invari- 
ably be inspected, as the thermometers are self-registering and require to be 
shaken down after use. (c) If used in the mouth, it should be placed well under 
the tongue and held by the tightly closed lips (not teeth) of the patient. 

If for any reason the lips cannot be closed, if the patient be unconscious 
or delirious or if an acute stomatitis or tonsillitis be present, the temperature 
should be taken per rectum. 

(d) Axillary temperatures should be avoided whenever possible, as being 
subject to maximum error variation. 

If so taken, the thermometer should be placed deeply in the previously 
dried axilla and the corresponding elbow should be kept close to the body and 
carried well forward. 

Axillary readings are particularly misleading in incipient or but slightly 
febrile tuberculosis and their use is seldom necessary or justified. 



Tactful 
guidance. 



Checking 
garrulity. 



Misleading 

surface 

temperatures. 



Selective 
points. 



Worthless 
thermometers. 



72 



MEDICAL DIAGNOSIS 



Temperature Range in the Human Body. — Subfebrile temperatures are 
classification, those running from 99 to ioi.5°F.; moderate fever, 101.5 to io3°F.; high fever, 
103 to io5°F.; hyperpyrexia 105 plus. 

•Note. — To convert Fahrenheit readings into centigrade subtract 32, multiply the 
remainder by 5 and divide the product by 9. To convert centigrade readings into Fahren- 
heit, multiply by q, divide by 5 and add 32. 

There is a normal daily variation reflected in nearly all fevers, the range 



Diurnal range, being about I C 



to i. 5 °F. 



The lowest reading occurs in the early hours f ollow- 



„A dubious 
normal." 



Obscure 
infections. 



ing midnight, the highest between four and six oclock in the afternoon. 

Faulty Figures. — Granting that 99°F. to 99. 5 or even 99. 8° may represent 
a normal variation in infants, the author believes that the body temperature 
range in adults, as ordinarily given by the physiologist, is too high and is 
based upon collective observations which included persons having unrecog- 
nized chronic infections or an incipient disease, such as pulmonary tuberculosis. 

Years of observation in private and public practice have convinced him that 
in adults under ordinary conditions, a persistent maximum mouth temperature 
exceeding or even reaching gg°F. is strongly suggestive of existent incipient tuber- 
culosis, chronic infections of the tonsils, accessory nasal sinuses, prostate, gall- 
bladder, the appendix, the ovaries and tubes in women, peridental abscesses, or 
the insidious onset of some acute ailment. * 

Tropical Diseases and Endocarditis. — In the case of persons returning 
from, or resident in, the tropics, the possibility of amebic dysentery and 
malaria should receive special investigation if any fever be noted. Endo- 
carditis of the chronic recurrent type gives rise to many errors. 

Heat and Exercise. — It should be remembered that violent exercise and 
excessive heat slightly and temporarily raise body temperature and that in 
Age and youth, infants and very old persons it may range half a degree or more higher than 
in those of intermediate age. 

The temperature of children is extremely labile and may reach a high 
degree without serious significance, often subsiding as suddenly as it came. 

Febricula (Ephemeral Fever). — Fevers of short duration and unknown 
causation affect adults, but with the advances made in diagnosis, have become 
relatively rare, and "febricula" means little more than an obscure, trivial 
and transitory fever, and is unworthy of further description. 

For variable periods in certain cases of tuberculosis, acute or chronic, the 
morning temperature represents the daily maximum. 

PATHOLOGIC VARIATIONS IN TEMPERATURE.— Malingerers.— 
Hyperpyrexia of extraordinary degree has been reported, but has probably 
been due to deception on the part of the patient, it being a common trick 
of the malingerer or hysterical patient to heat the thermometer bulb by 
friction, by taking hot drinks just before the tube is applied or by cleverly 
utilizing a hot water bag. 

The highest genuine temperature observed by the author was no°F. 

* A recent investigation of nurses' temperature undertaken by the author in a local 
hospital has further strengthened this opinion. 



A nonentity. 



Inverse 
temperature. 



Clever 
artifices 



FEVER 



73 



under the tongue, and occurred in a woman of hysterical temperament suffer- 
ing from the extreme pressure pain of a spinal caries.* 

Fever in Hysteria. — Elevation of temperature may occur in hysteria 
alone, a fact never to be forgotten. The highest personally observed (io4°F.) 
was obtained during an hysterical paroxysm following great emotional shock, 
and the attack and the fever subsided almost instantly under sharp ovarian i 
pressure. In this particular instance the physical exertion represented by the 
violent convulsive movements might account for the high temperature in 
part, at least. 

Some authorities claim that temperature may persist for weeks in hysteria 
and even simulate typhoid, but until we know more of the real nature of hysteria i 
and find fewer examples of its confusion with organic ailments, it might be safer 
to assume that genuine, long-continued fever excludes it. 

Interaction of Infection and Resistance. — The significance of high read- 
ings is variable and depends upon the nature and virulence of the toxin, the age 
and nervous condition of the patient, and also upon the degree of his vital 
resistance. 

Certain hyperpyrexias seem to indicate little more than an intense infec- 
tion associated with vigorous constitutional resisting power, such cases being 
seen in connection with lobar pneumonia, in which a temperature of io5°F. is 
neither uncommon nor necessarily of fatal import. On the other hand, one 
finds instances of virulent and fatal infection with but slight febrile reaction. 

Extremely high readings, if long sustained, indicate a most serious prognosis, 
and a sudden rise ("agonal fever") sometimes precedes death. 

Subnormal temperatures may be observed in those suffering from Subnormal 

„ ,.,.,. ,. . . temperatures. 

collapse, extreme exhaustion, chronic exhausting or wasting diseases, insanity 
(especially melancholia), chronic incompensated heart disease, adrenal 
insufficiency and myxedema. 

Oftentimes the surface temperature is subnormal and the rectal reading high, 
notably in cholera and certain cases of tuberculosis. 

Febrile Types. — Fortunately for the clinician, the fever in many of the 
acute diseases pursues a more or less characteristic course or bears a peculiar 
relation to the appearance of other symptoms of the disease. 

Fevers may be placed under four general heads: (i) Intermittent. 
(2) Remittent. (3) Continuous. (4) Indeterminate or irregular. 

An intermittent fever, however far it may rise, drops to or below normal 
during some part of the twenty-four hours. A remittent fever shows marked 
remissions during the twenty-four hours ; while in continuous fever the remis- 
sions are slight. These are but the types and one must understand that a 
continuous fever may at some stage show remissions, or a remittent fever 
encroach upon the intermittent; indeed, the temperature charts covering 
long periods may in such diseases as tuberculosis show every type of fever 
and yet be predominantly intermittent. The intermittent fever of this 
disease is often given the name hectic. 

* The record case reported by Teale was one of spinal injury and the temperature 
recorded was i2 2°F. 



74 



MEDICAL DIAGNOSIS 



Rough 
standards. 



Fastigium and 
defervescence. 



Differential 
value. 



A deceptive 
type. 



Ptomains and 

metabolic 

poisons. 



Cerebral. 



Starvation. 
fever. 



Roughly speaking, one may say that when the maximum daily variation 
in a moderately severe fever is less than 2 it is continuous. When more 
than 2 and yet with an average minimum distinctly above the normal, it 
is remittent, and any fever showing a tendency to periodically fall below 
normal is intermittent. 

The maximum stage of fever is known as its fastigium, the term being 
applied especially to the fevers of the continued or remittent type and to the 
stage of the disease as well as to the fever itself. Its 
opposite is called the period of defervescence or decline. 

Diagnostic Import of Fever. — Putting aside the rare 
cases of hysterical temperature and excluding deception 
and faulty technic, one may say that fever is primarily 
of diagnostic value in proving the existence of some organic 
ailment or definite toxemia, as opposed to a functional 
disorder, a matter of no little importance in dealing with 
neuropaths and malingerers. 

Afebrile Cases. — The absence of fever, however, does 
not rule out any one of these conditions, for there is no 
disease ordinarily febrile that may not, though in rare 
instances, exist without fever or even with subnormal 
temperature. This fact is best exemplified in the case 
of typhoid, occasional pneumonias, especially those of 
old age, and certain cases of general peritonitis. 

Chief Causes of Fevers. — By far the greater number 
of fevers are due to the action of pathogenic germs and 
their toxins, whether these be developed within, or, more 
rarely, without the body, as in the case of ptomains. 
Some nevertheless are due apparently to other toxic 
substances, even such as are generated by the vital 
processes of the living body itself. Such are the curious 
auto-intoxications associated with deficient or faulty metabolism as illus- 
trated by acute gout.* 

The terminal stages of diseases of nutrition, malignant disease, and certain 
of the severer types of anemias are associated with fever and doubtless in 
many such instances obscure infections play an important part. 

Fever of central origin may be encountered in cerebral embolism, thrombosis, 
apoplexy, brain tumor, and direct injury, or even \he changes incident to heat- 
exhaustion and sunstroke. 

Inanition is sometimes associated with fever, usually of mild grade, which 
' ordinarily occurs after severe exhausting ailments associated with much 
wasting of tissue and loss of strength, f 

* This statement may require modification in the near future if \ the increase in our knowl- 
edge of basic sub-infections continues. The author confesses his inability to believe that 
the clinical phenomena of acute gout are adequately explained by any existing knowledge of 
its metabolic disturbances. 

t The so-called "hunger" temperature may be most misleading in convalescent typhoids 
who have been too long starved. It is seldom observed under modern methods of feeding. 



DAY OF 

DISEASE 


1 


2 3 


4 £ 


6 


HOUR 


A ? 


A P A. 


m £££ 


PAP 


107 










































106 




































































105 










2 104 

s 

■3 103 



























































3 102 




-4h- 






























t3 

< 101° 










































s 10 ° 




































































































— Vf- 


98' 




























97 


















96 



































Fig. 18. — Clinical 
chart of tertian ma- 
laria. Typical and 
extreme example of 
the "intermittent" 
type of fever. (From 
Wilcox's "Fever 
Nursing") 



PHENOMENA OF FEVER 



75 



Occurring under such conditions, it is more likely to be due to a smouldering 
infection but it cannot be denied that cases of exhaustion temperature do occur 
and subside promptly when proper nutrition is attained. 

THE PHENOMENA OF FEVER.— Owe must first determine whether the 
fever came on suddenly or gradually, whether it was associated with chill or, in 
the child, convulsions, for liow long it has endured, whether it is to be classified Consider 
as distinctly intermittent, remittent or continuous, and, furthermore, whether anTckSe! 

it is associated with any history of infection or with 
the appearance of an exanthem. If the latter be 
the case its exact time of appearance and its rela- 
tion to any rise or fall in the temperature must be 
noted. 

Condition of the Skin.— Heat and Moisture. 
— In most fevers the skin is dry and palpably 
hot, but occasional cases depart from this rule 
and certain diseases such as acute rheumatism 
and cholera almost consistently violate it. 

Digestive Organs. — Nausea, vomiting or 
diarrhea (initial, persistent or terminal), consti- 
pation, loss of appetite and a coated tongue are 
present in varying degrees in all severe acute 
febrile ailments. 

The Nervous System.— Headache, and pain 
in the limbs are present in nearly all cases of 
fever, though often only at its onset. 

Mental Condition. — The mind may be clear 
or clouded and delirium may be present at the 
onset only or for long periods, continuously, or only 
at night. 

Delirium. — This may take the form of 
transitory illusions or hallucinations, may be 
violent and maniacal, mild, or of the low mutter- 
ing, mumbling type of the typhoid state, the 
patient perhaps lying with open but unseeing 
eyes (coma vigil). Persistent delirium of the 
violent or low muttering type is of unfavorable 
prognostic significance and the exhausting effect of the former constitutes 
a serious peril and demands prompt therapeutic measures. 

Children show an especial tendency to delirium even in fever of moderate Readily 
intensity, whereas, it is rare in adults save in the most severe types of infection, children? 
in the intoxications or in central disturbances. 

Acute Febrile Delirium {BelVs Mania). — This consists essentially of a 
violent, continuous, exhausting and maniacal delirium, associated with high 
fever and a typhoid state. 

It is a rare condition, peculiar to women and of unknown causation, is Probably 
initiated by shock or other emotional strain, and may be associated with the sepsis? 6 " 



OAY OF 

DISEASE 


1 . 


8 


4 


5 b 




a 


9 


HOUR 


A P A 
V V V 


PAP 


V> V 


A P A 


PAP 


A P 


A P 


107 








































































106 








































































■5 105 








































































| 10M 


































— \ — 


Tl~ 


! 




















*"* 103 














































^h- 


*- 


/- 








w — 

2 102* 




-| — i 


Hr 





















































3 

? 101 














| 












































s 

H 100 








































































99 






























































. 






1 




V^ 


96 






























97 








































































96 








































































150 






























140 






























130 






























a m 






























5 no 
















\ 














D 100 
















k 














* "90 




^ 














>, 












80 








/ 










-^ 


NT7 


\~ 


-v 






60 














7p 
















50 






























40 




























L 



Fig. 19. — Clinical chart of a 
yellow fever patient, showing 
a pulse typically slow in com- 
parison to the height of tem- 
perature. (From Wilcox's 
"Fever Nursing") 



Its many 
varieties. 



7 6 



MEDICAL DIAGNOSIS 



Pulse-respira- 
tion-tempera- 
ture ratio. 



Watch the 
heart. 



Myocardial 
"weakness. 1 



Pulse, 

strength and 
weakness. 



convalescent state. No specific pathologic findings are present after death 
and the disease may readily be confounded with the acute maniacal delirium 
occasionally present at the onset of pneumonia, typhoid and uremia. 

It may be rapidly fatal, running its course in from one to three weeks. 
The differential diagnosis is one of exclusion and the author's experience 
would indicate that the condition is usually one of acute cryptogenetic 
sepsis.* 

The Pulse and Respiration in Fevers.— Both pulse and respiration bear 
a definite relation to the temperature curve. The increase in pulse rate is 
ordinarily from 8-10 beats per minute for 
each degree of fever, but a departure from 
this rule is commonly noted in typhoid 
fever, yellow fever and lobar pneumonia, 
and favorably affects prognosis in these 
diseases. 

Heart -muscle Impairment. — The 
heart muscle suffers to a variable degree 
in all severe infections and intoxications 
and must be carefully watched for signs of 
weakness, degeneration or valvular inflam- 
mation, this being especially true, as re- 
gards the valves, heart muscle and pericar- 
dium alike, in attacks of acute or subacute 
rheumatism, scarlet fever, severe true influ- 
enza, and diphtheria. 

In any infection, the examinations of 
the heart should relate, not alone to mur- 
murs, but to variations from the normal in 
the heart sounds, extension of the cardiac 
borders and important variations in the 
cardiac rhythm. 

The author believes that much of the weakness associated with acute 
infections is due to myocardial toxemia and that in no other way can one 
explain the rapidly induced and unduly persistent exhaustion evident upon 
exertion in various acute infections even though actual power on the part 
of the skeletal muscle groups is relatively well retained. 

"Sthenic" vs. "Asthenic" Fevers. — The pulse of high fever- of the so- 
called sthenic type is not only rapid but full and bounding. In asthenic 
fevers (those attended by profound exhaustion) it becomes soft, weak, and 
in the typhoid state, dicrotic. 

* In three instances the author has encountered precisely this disease picture with 
recovery, as a late and apparently isolated sequel of child-bearing. Blood cultures were 
negative but each attack showed a sharp leucocytosis at the onset. 

It is at present described by some authorities as an "exhaustion psychosis" but the 
element of infection cannot well be disregarded. It may present many variants and need 
scarcely be considered as a clinical entity. 



DAY OF 
DISEASE 


1 


2 


3 


4 


5 


6 


; 


6 


9 


10 


11 


12 


13 


HOUR 


A 


F 


A P 


^ ? 


A P 


A P 


fflS 


A P 


A P 


A P 
MM 


A 'P 


A P 


A P 
M M 


A P 
M M 


107 














































































































































106 








































































































, 














105 




















: 


e — 1 








































































































% 104 


































































































































.a 
2 103 






















~*~K 












































































































w 102 

W — 

P, 101 















































































































































































































































2 c 
?iuo 
































































rV 




























3 

H 99' 








































































































































































































98 






















































97 



































































































































L*» 
























































Fig. 20. — Clinical chart of measles, 
showing "fastigium" developed with 
eruption, primary rise, secondary fall, 
and defervescence following appear- 
ance of exanthem. (From Wilcox's 
"Fever Nursing") 



FEVER — TYPES — ONSET — TERMINATION 



77 



OAT OF 
OISEASE 


1 


. 


•3 


1 


5 


6 


• 8 


9 


10 


HOUR 


A P 


A ? 


V V 


m|m 


V V 


A p A 


PAP 


M 


f.' 


M 


P 

M 
















































107 






























































,. 




















•§ 105 




~T 






































































1 104 





























































































"" 


T 






r 






























d^(w 








































3 






























































a — 










































a 










































S 101 










































100 






























































































































































.88 


























































. 


















































































— __ 







OAY OF -i 

DISEASE 




! 4 


5 6 


; 


8 


'j 


10 


HOUR * 


PAPA 


P A,P A 


f A r> 


A P 


A P 


h|h 


A P 


















107- 


















































































































"=ft^ 
















=P 


% 












a 104 - 


^ 


v-* 












2108 - 


S ^= = 


-~Y 








— • 




a 














14 


§M8 _ 






^ = = 










i 101 B 






4rrt 










£ 






r"*i 
















: , \ 










§1Q0 _ 
















89 - 


























gU 


V^- 


M 


















97 - 




1 












96 - 






- — - 











Fig. 2i. — Clinical chart of acute lobar 
pneumonia. This typical case has termi- 
nated by crisis on the seventh day of the 
disease. (From Wilcox's "Fever Nursing.") 



Fig. 22. — Clinical chart of scarlet fever. 
(From Wilcox's "Fever Nursing.") 



Measles. — In measles the temperature recedes twenty-four hours or there- 
abouts after the onset, rising with the coming of the rash on the fourth or 
fifth day. 

German Measles (Rotheln). — In rotheln the eruption appears on the 
first day or more rarely the second, and is usually the first thing noted. 
The fever rising much the same, but usually less than in measles. 

Scarlet Fever. — In scarlet fever the rapidly spreading rash appears on 
the first or at the beginning of the second day, following an abrupt onset 
with high fever. 

Varicella {Chicken-pox). — In varicella the rash appears within twenty- 
four to thirty-six hours, associated with trifling fever. 

Variola (Smallpox). — In variola the violent onset, usually with chill and 
high fever, is followed by a marked remission, usually at the end of the third 
day, during which the rash appears in its papillary stage. During its sub- 
sequent changes the temperature rises, reaches its maximum with the purulent 
transformation of the vesicles and then gradually subsides. The diagnostic 



toneal" pulse. 



Temporary extrasystolic irregularity or even partial and temporary Hypertension, 
heart-block may occur and in acute and chronic affections of the kidney the 
pulse may be of high tension. Such a pulse should always direct attention 
to the kidneys and calls for examination of the urine if this duty has been j wiry "peri- 
neglected. In inflammation of the peritoneum it is small, hard and wiry. 

Helpful Types. — The accompanying charts show the peculiarities of 
fever in certain diseases, but the student must not demand in his practical work 
that infections shall conform invariably to the text-book description. 

It is most important that the ride be known, but the common exceptions also 
must be recognized. 



Rash on 4th or 
5th day. 



Rash on 1st or 
2nd day. 



Rash on 1st or 
2nd day. 



Rash after 
24-36 hours. 



True eruption 
on 4th day. 



78 



MEDICAL DIAGNOSIS 



Adults vs. 

Children. 



Overwhelming 
infections. 



Insidious 
onset. 



Lysis vs. 
Crisis. 



value of these differences in the relation of body temperature to the eruption 
is readily appreciated. 

The Mode of Onset and Termination. — In adults, the more severe acute 




Fig. 23. — Typhoid fever chart, showing temperature typical, and unmodified by treat- 
ment. A rare combination at the present time. Serves to illustrate the so-called "step- 
ladder" temperature of the first week, "continuous" and "remittent" fever curves, and 
termination by "lysis." (From Wilcox's "Fever Nursing") fc 

infections are usually preceded by a decided " chilliness" or actual chill, with or 
without gastric disturbance* and, in children, by either chill or convulsions and 
frequently, by nausea and vomiting. 

In the malignant forms of typhus 
fever, smallpox, bubonic plague, 
yellow fever, malaria, and even of 
scarlatina, certain cases may die 
before the disease has reached its 
frank development, f 

In several febrile diseases, the 
onset is insidious and without marked 
initial phenomena, and in senile cases 
this may be true of ailments ordinarily 
frank. 

Abrupt Cessation vs. Gradual 
Recession. — The termination of 
fever is in most cases a gradual 
recession (lysis), but certain ail- 
ments of which classical lobar 
pneumonia is the type terminate 
suddenly (crisis). 

The critical phenomena vary 
somewhat, but usually the temper- 
ature falls to or below normal within 



DAV OF 
DISEASE 


1 


2 3 


4 5 6 


7 8 9] 


1 12 13 1 


4 15 16 


HOUR 


A P 
M M » 


\ P A 

it M M 


P> A p A P A P 


A P A P A P A 


P A|P A|P A 


P A P A P 
M W M M M 


107 






























































106 


















-§M 


^~— 










-a| L 


- - g QD ~ 










- Em 


— £&--- 






105 






— SJ 


So- 






^ 104 




kT 


\ 


3. 1 


















= 1: 


.LI. 










am 














3 J02_ 

^ ioi c 














S 100 


























99 
96 


































Z 


3==== 



Fig. 24. — Clinical chart of smallpox, 
showing high initial temperature, rapid tem- 
porary defervescence following appearance 
of eruption, and the abrupt secondary rise 
just preceding pustulation. (From Wilcox's 
"Fever Nursing") 



* A severe rigor is certainly less generally observed even in pneumonia than the student 
is usually led to believe. 

f In an epidemic of malignant scarlet fever observed by the writer a considerable pro- 
portion of the cases proved fatal within a period of less than twenty-four hours. 



COMA AND ITS CONGENERS 



79 



twenty-four hours, or often yet more abruptly. Profuse sweating, copious 
urination or perhaps profuse diarrhea may occur, suffering being replaced 
by relative comfort, and the contrast often most dramatic. 

Pseudo -crisis. — A similar fall in temperature in diseases not associated 
with true crisis points usually to a serious complication, in typhoid, for 
example, to a hemorrhage or perforation. In pneumonia, a false crisis of 
marked degree is often followed by renewal of fever, the true defervescence 
occurring ordinarily on the day following. If true crisis does not follow one 
must suspect an extension and renewal of the process or the onset of some 
complication such as myocarditis, endocarditis, pericarditis, or empyema. 
Profound myocardial toxemia may be associated with most misleading temper- 
ature recessions. 

In one case of migratory pneumonia observed by the author, lobe after 
lobe of the lungs went through a typical pneumonic cycle, the critical fall 
being promptly followed by chill, renewed fever and the usual signs of con- 
solidation in the adjacant lobe. 

COMA AND ITS CONGENERS.— Coma covers any state of prolonged 
unconsciousness from which a patient cannot be aroused by external 
stimuli.* 

The dividing line between different states of unconsciousness and profound 
sleep is ill-defined and one merges into the other. The term coma vigil is 
applied to the peculiar complete or semi-unconsciousness of certain cases of 
typhoid fever associated with an open-eyed, low muttering delirium. 

Stupor and lethargy both represent morbid sleep, the former profound 
as in alcoholism, the latter a mere drowsiness as in the premonitory stage of 
freezing. 

COMA. — Assuming that a patient is seen for the first time on the street, 
in the ambulance, hospital, or the home, and is comatose or stuporous, the 
difficulties in diagnosis are so great as often to baffle the diagnostician, but 
many avoidable errors occur through lack of proper method, ordinary knowl- 
edge and carefulness. 

Information as to the conditions under which the attack of coma occurred 
should be first sought through some friend, relation or bystander. 

The appearance of the patient at the time of the attack, his movements and 
the direction and force of any fall he may have sustained, are also to be considered 
and oftentimes his habits or even his previous health may be ascertained. 

The state of the atmosphere may at once suggest heat^exhaustion or 
sunstroke. 

Inquiry must be made as to what the patient has taken into the stomach, 
having in mind the possibility of ptomain or drug poisoning, or sudden 
deaths or severe prostration following the overloading of the stomach in 
victims of the diseases of the heart and arteries. In public services, and es- 
pecially ambulance cases, the history is often entirely lacking or untrust- 
worthy, and the physician is thrown upon his own resources. 

*In most instances profound coma is associated with a relaxed jaw, stertorous 
breathing and dry tongue, e. g., morphia poisoning or apoplexy. 



Five crises. 



Coma vigil. 



Sources of 
error. 



Falls. 



Heatstroke. 



Stomach con- 
tents. 



Ambulance] 
cases. 



8o 



MEDICAL DIAGNOSIS 



Poisons. 



Flushing and 
cyanosis. 



Usually 
complete. 



Useful tests. 



Conjugate 
deviation. 



Consciousness 
long 

maintained. 



One must consider epilepsy, malingering, uremia, apoplexy, cerebral embolus, 
brain tumor, meningitis, diabetic coma, poisoning by opium, chloral and other 
narcotics: if delirium is present, belladonna; if convulsions, strychnia or uremia, 
and investigate the following points: 

(a) The Eyes. — Are the pupils equal or unequal, contracted or dilated? 
Do they react to light, is the conjunctival reflex present, and is there resistance 
to the separation of the lids? 

Unequally dilated pupils (the larger usually on the side of the lesion) 
suggest cerebral hemorrhage or general paralysis of the insane. 

Contracted pupils suggest opium poisoning, or pontine hemorrhage. 
In uremia they are usually dilated* and in all these conditions they fail to re- 
spond to light and the conjunctival reflex is absent. The same is true of 
cocain and the latter stages of chloral poisoning. 

If convulsions are present with fixed, dilated pupils and the conjunctival 
reflex is absent, epilepsy or poisoning by strychnia, belladonna, or some 
other convulsant is at once suggested. 

In alcoholism the pupils may be dilated, but usually respond to light. 

Hysteria and malingering are, as a ride, readily detected by the prompt 
response to light, and the resistance almost invariably offered to the separation 
of the lids by the physician. 

(b) Color. — In alcoholism the face is usually flushed. In cerebral lesions 
it may be flushed but is also usually cyanotic. In uremia there are ordinarily 
pallor and cyanosis and the latter condition may be excessively marked in 
the coma of acetanilid poisoning. 

(c) The Degree of Unconsciousness. — In the more serious forms of coma, 
insensibility is, as a ride, complete. The conjunctival sensitiveness and resist- 
ance of the eyelids to separation shoidd be tested in all cases and deep, sharp 
and unexpected pressure over the ovarian region may resolve doubt in hysteric 
females, being often accompanied by a sudden complete or partial return to 
consciousness. 

The malingerer and even the "alcoholic" can seldom resist moving if the 
skin of the inner surface of the upper arm is suddenly and sharply 
pinched. 

(d) The Character of Attendant Convulsive Movements.— In cerebral 
hemorrhage conjugate deviation of the eyes and head is most common.- In 
the comatose terminal stage of strychnia poisoning both head and trunk 
muscles are convulsed, opisthotonos or emphrosthotonos are likely to be 
present, but between the attacks the patient may be conscious and rational. 

In tetanus the convulsive seizures are likely to be limited to the neck and 
jaw, and complete relaxation between seizures does not usually occur. 

Neither in strychnia poisoning nor tetanus does complete, persistent un- 
consciousness supervene prior to the terminal stage, and often not at all. 

In epilepsy the sequence of the seizures, if present or, as described by eye 
witnesses, i.e., clonic followed by tonic convulsions, involuntary micturition, 
and perhaps tongue-biting are suggestive. 

*A widely dilated pupil and moderate photophobia may precede the outbreak. 



COMA AND ITS CONGENERS 



8l 



The ordinary malingerer is foolish to attempt convulsions on account of 
the many difficulties attending accurate simulation which can be overcome 
only in exceptional instances by certain of the elect of the brotherhood. 

The Ophthalmoscope. — Albuminuric or diabetic retinal changes may be 
present or the choked disk of brain tumor may be revealed, and the ophthalmoscope 
often proves invaluable. 

Hysteric Coma. — Although the convulsive movements are often strikingly 
epileptiform or tetanic, they are usually irregular and are associated with the 
typical hysteric fades. 

Furthermore, though the lips may be bitten, the tongue is not, whereas 
in true epilepsy biting of the tongue is a frequent accident and incontinence 
of urine almost a constant accompaniment of major seizures. In hysterical 
tetanus the eyes are usually closed during a seizure and emotional utterances, 
sobbing, and crying are prominent. The peculiar premonitory exhilaration 
and hyperacuteness of the special senses observable in strychnia poisoning 
are absent in hysteria and the onset of spasm is atypical. 

In females sudden sharp pressure over the ovarian region may resolve doubt. 

Frothy Lips. — Froth about the lips, if blood-stained, points to epilepsy, 
but is common to many of the convulsive states attended by unconscious- 
ness. Malingerers usually use soap in the mouth for this purpose. 

(e) Paralysis. — The limbs should always be handled to ascertain if 
paralysis be present in any member, the peculiar lack of all muscle tonus being 
usually readily determined and paralysis of the eye and face easily noted. 

Atrophy. — Paralysis of the extremities associated with marked atrophy 
suggests an old lesion which may or may not be related to the patient's 
present state. 

(/) The Pulse. — In cerebral compression the pulse is slow, in uremia and 
apoplexy its high tension may be suggestive, in malingerers and hysterical persons 
it is the pulse of exertion, rapid, full and bounding and in -other conditions it 
is, as a rule, of little value. 

(g) The Heart and Blood Vessels. — A searching examination of both the 
heart and the accessible arteries is usually demanded and arterial hyperten- 
sion, and sclerosis, together with an increased cardiac area, may prove of 
great importance. If valvular lesions are evident and especially if mitral 
stenosis be detected, the question of cerebral embolus at once arises and one 
might encounter the dying victim of a ruptured, slowly draining aneurysm 
which is emptying the patient's life blood into some closed cavity such as the 
pericardial sac, though death from aneurysm is oftener sudden. 

(h) The Temperature. — In all cases the rectal temperature should be 
taken, even in those comas apparently alcoholic in their nature. 

One of the commonest mistakes on the part of ambulance and police surgeons 
results from the failure to remember that pneumonia, like cerebral lesions both 
central and traumatic, is extremely common in the drunkard. 

As before stated, the presence of fever does not absolutely exclude hysteria 
and it is present in cerebral hemorrhage, the surface temperature being usually 
a degree or more higher on the paralyzed than on the non-paralyzed side. 
6 



Simulation 
difficult. 



Bright's and 
brain tumor. 



Many signs 
lacking. 



Muscle tonus 



Antecedent 
lesions. 



Arterial 
hypertension. 



Acute 
dilatation. 



Embolus. 
Aneurysm. 



Fatal errors. 



82 



MEDICAL DIAGNOSIS 



(i) The Lungs. — Extensive pulmonary infarction, the acute onset of a 

Unusual but ; massive pleural effusion, the sudden production of pneumothorax and the 

I internal rupture of a large pulmonary abscess constitute some of the unusual 

causes of sudden unconsciousness observed by the author, and one must 

\ always bear in mind the possibility of internal hemorrhages and, as before 

stated, of fulminant acute disease. 

(j) The Breath. — An alcoholic odor, though suggestive, does not prove 
drunkenness. The so-called uremic breath is reasonably characteristic, but 
closely approximated by that encountered in other conditions, and is a dis- 
agreeably aromatic odor that must be learned by actual experience. The 
sweet breath of diabetic acidosis is far more characteristic and often extremely 
penetrating.* Certain poisons, like laudanum, carbolic acid, hydrocyanic 
acid, ether and chloroform, yield a characteristic odor. 

(k) The examination of the blood often proves of decided diagnostic 
value and should be applied in doubtful cases whenever possible. 

Open hemorrhage may have occurred and at once suggests injury, self- 
inflicted or otherwise, hemoptysis, hematemesis, aneurysmal rupture or 
possibly the hemorrhagic accidents of hemophilia, leukemia or purpura. 

(I) Examination of the Urine. — At the earliest moment a specimen of 
urine should be removed by catheterization and carefully examined with 
reference to contained solids, serum albumin, pus, blood, casts, or sugar, drug 
reactions and the like. 

Diagnosis often Impossible. — In conclusion it must be emphatically said 
that but few of the differential points given are absolutely distinctive, and 
there is no condition that more severely taxes the skill and common sense of the 
practitioner. 

If the breath of a patient smells of laudanum, the pupils are contracted, 
the breathing stertorous, the skin cyanotic and clammy, and particularly 
if a bottle that has contained laudanum is found empty, the proof is suffi- 
ciently conclusive. Stertorous breathing, a flushed countenance, slow, hard 
pulse and the evidences of paralysis are sufficiently characteristic of a 
cerebral lesion. 

On the other hand, one often meets with conditions in which he is misled 
by a reversal of ordinary symptoms, confused or contradictory findings and a 
failure on the part of the 'underlying ailment to strictly observe the man-made 
laws of differential diagnosis. 

Diabetic Coma. — (Coma of -acidosis). Usually this form is readily 
Fruity breath, recognized by the fruity, vinous, odor of the breath and the character of the 
breathing which is usually that of strong, deep, deliberate or unhurried 
inspiration and a somewhat short, sighing, expiratory phase (so-called 
" ' Kussmaul dyspneic type")-t 

* The author not long since detected it in passing upon the open street the little 
babe of a friend, which was supposed to be in perfect health, but was suffering from 
terminal diabetes, as determined by the family physician upon notification. 

f Inasmuch as this type of breathing has been noted by all clinicians for centuries, 
the propriety of such a descriptive term is questionable. 



Few pathog- 
nomonic signs 



Simple cases. 



Blind cases. 



PHENOMENA AND SIGNIFICANCE OF PAIN 



83 



The onset of such attacks always is preceded by an excess of diacetic 
acid and acetone in the blood and urine and, often, by irritability, fretfulness, 
headache and dyspeptic symptoms, concerning the possible significance of 
which family members should be warned. 

Constipation, often extreme, is often present and may be a factor in 
exciting an attack, and starvation, colon flushing and brisk catharsis will 
often abort one presenting prodromal symptoms. 

According to the author's personal observation, these attacks are quite 
frequently precipitated by cardiac overstrain, the heart being atonic and 
even readily dilatable in many advanced cases. Showers of short, broad 
casts may precede the attack. The pupils are usually widely dilated during 
a seizure. 

The term "air hunger" as applied to the typical breathing described is 
peculiarly apt and interprets exactly the clinical picture. 

The author feels that two distinct types of breathing encountered in 
practice merit the application of this term, viz: (1) The deep, urgent, 
strong, dominantly inspiratory type; (2) the superficial, hurried, gasping type 
with inspiratory dominance seen in many conditions associated with states 
of unconsciousness and extreme weakness. 

To him, at least, the latter clearly expresses "air hunger," usually justi- 
fied by the oxygen shortage present, from whatever cause, terminal or 
otherwise. 

PAIN 

A Purely Subjective Symptom. — Pain as a symptom is purely subjective 
and may be trivial or agonizing, true or false, localized, referred or diffuse, mo- 
mentary, temporary or persistent. 

Descriptive Terms. — Its differences are indicated by such descriptive 
terms as "dull," "aching," " sharp," " acute," " stabbing," "boring," 
"gnawing," "lancinating," "shooting," "colicky," "radiating," "diffuse," 
"tearing," "rending," "suffocating," "griping," "bursting," "smarting," 
"scalding," "burning," "grasping," "clutching," and the like, all of which 
doubtless reflect accurately the sensations of the victim. It may be deeply 
seated or superficial and may or may not be associated with tenderness due 
either to actual inflammation or to hyperesthetic areas. 

Deceptive "Zones." — In this connection the student is warned against a too 
implicit faith in the so-called "painful zones" which, though valuable and in 
general fairly suggestive, cannot be wholly trusted and too often lead one far 
afield. 

A painful area, dedicated by the usual diagram wholly to appendicitis, 
for example, serves as well for a local growth, post-operative adhesions, 
arrested ureteral calculus, incipient hernia, and even for the referred pain of 
certain pneumonias or an obstruction of the ileocecal valve. Furthermore, 
the early pain of appendicitis is likely to be diffuse and far removed from 
"McBurney's point." 



Danger signals 



Cardiac 
overstrain. 



Air hunger. 



Two types. 



Sources of 
confusion. 



8 4 



MEDICAL DIAGNOSIS 



Transposed 
pain. 



Acute 
inflammation. 



Parenchyma 
insensitive. 



Activity and 
pain. 



Effect of 
exudate. 



Neuralgia and 
neuritis. 



Referred Pain. — The site of pain is often far distant from its true source, 
and indeed certain referred pains may be dangerously misleading. 

The author has observed a case* in which an aneurysm of the left iliac 
artery caused pain over the appendix; others in which appendiceal pain was 
referred to the left side; yet others in which the pain of gall-stone colic first 
appeared in the region of the heart, and vice versa. 

As has already been suggested, nothing is commoner than for the pain of 
pleurisy and pneumonia to be referred to the surgical regions of the abdomen 
along the terminal endings of an* intercostal nerve, or for renal calculi, lodged 
in the lower portion of the right ureter, to closely simulate appendicitis. 
The referred abdominal pain of the insufficient heart is extraordinarily 
common and misleading. 

The Character and Seat of Pain in Relation to Diagnosis. — The pain of 
an acute inflammatory disease is usually associated with fever, and often with 
localized tenderness, the degree of either depending upon the nature of the affected 
structure, the individual susceptibility and resistance and the extent and situation 
of the inflammatory process. 

In surgical diseases of the extremities, for example, the pain is ordinarily 
associated with distinctly localized tenderness and is of great value as a 
symptom. On the other hand, a central or a senile pneumonia may exist 
with little or no pain, or in other cases, by involvement of the pleura in a dry 
pleurisy, produce excessive distress. 

Pain in Solid vs. Hollow Viscera.- — In any disease of a solid viscus inflam- 
mation of its parenchyma is a relatively or wholly painless process until extension 
to the internal or external limiting layers occurs; and even the hollow viscera are 
relatively insensitive to rough handling and trauma, though intense pain may 
attend their abrupt overdistention or violent contraction. 

Pain usually is distinctly related either to bodily movement in general or 
to functional activity of the part affected. 

Friction of the dry and inflamed serous surfaces causes respiratory pain 
in pleurisy, while in acute rheumatism the slightest movement of the affected 
joint is distressing. In all such instances nature seeks to relieve the condition 
by pouring out a fibrinous or serous exudate which fact explains the partial or 
complete relief of pain in fully developed cases of exudative pleurisy and 
pericarditis. 

Radiating pain is most characteristic of neuralgias and neuritis, and is 
recognized by its tendency to follow the known distribution of nerve trunks 
and by its association with marked tenderness over certain nerve paths or 
points of emergence. 

Dull pain may take the form of general aching as in acute infectious dis- 
eases, or may attend congestion, capsular stretching or chronic low-grade 
inflammations, particularly such as affect the mucous or serous membranes. 
Recent vs. Old Ulcers. — Irritation, acute inflammation, or recent ulcera- 
tion of certain mucous membranes may be attended by severe pain, such, 
for example, as that of renal colic and of certain cases of gastric or duodenal 
* Through the courtesy of my colleague, Dr. Archibald MacLaren. 



PHENOMENA AND SIGNIFICANCE OF PAIN 



85 



ulcer. On the other hand, extensive but ancient ulcerations may be strik- 
ingly painless. 

Gnawing or boring pain is frequently encountered in caries of the spine, 
aneurysm of the aorta, carcinoma of the stomach and inflammation of bone. 
It is also met with in some cases of old gastric ulcer, in gout, gall-stones and 
renal calculus. 

Misleading Absence of Pain. — In many of the conditions ordinarily asso- 
ciated with more or less severe pain this symptom may be wholly lacking in 
certain cases, even in the absence of stupor or coma. This statement applies, 
for example, to -pericarditis, pleurisy, cholecystitis, cholelithiasis, gastric and 
duodenal ulcer, high grade coronary arteriosclerosis, pneumonia, certain cases 
of appendicitis of the gravest type, and even cancer of the stomach or bowels. 

Actual perforation of the appendix, stomach or duodenum may occur with 
entire absence of pain. 

When Delay may be Fatal. — Abrupt, atrocious abdominal pain with local- 
ized or general tenderness or decided defensive rigidity, symptoms of shock or 
collapse and an initial sharp drop in blood pressure, will represent almost 
invariably a critical surgical emergency. 

PAROXYSMAL PAIN. — Gall-stones, renal colic, colon colic, splanchnic 
arterio-spasm, spasm of the pylorus, appendicitis, locomotor ataxia, 
neuralgia and angina pectoris furnish the best examples of paroxysmal pain 
and nearly all radiating pains are of this type. 

Colic. — The term colic applies chiefly to paroxysmal abdominal pain 
caused by overstretching or spasm of a hollow muscular organ, and more 
often, both combined. It includes that of biliary or renal calculus, appendi- 
citis, lead poisoning, floating kidney (Dietl's crises*), mucous colitis, spastic 
constipation, strangulated hernia and abdominal aneurysm. 

Many of these attacks were formerly covered by the convenient term 
"gastralgia," but modern progress has proven that an actual primary gastral- 
gia (neuralgia of the stomach) is so rare as to be almost negligible. 

Cases of simple transitory colic due to acute indigestion are common in 
both children and adults, but the utmost caution must be observed in the inter- 
pretation of an apparently simple abdominal pain, particularly if unduly 
persistent and associated with fever and tenderness on deep pressure. 

Intestinal Parasites. — In all obscure cases of abdominal colic or indeed of 
chronic intestinal disturbance the stools should be carefully examined for parasites 
or their ova. 

Appendicitis. — Many cases begin with general abdominal pain of a colicky 
type and twelve or twenty-four hours may elapse before it becomes distinctly 
localized at a point of maximum tenderness in or near the area lying midway 
between the anterior superior iliac spine and the umbilicus (McBurney 's point) McBurney's 
and associated with a more or less sharply defined defensive rigidity of the right 
rectus muscle. 

The tenderness may be apparent before the pain becomes localized and 

* Much less common than formerly supposed and usually attributable rather to 
pyloro-spasm, gall-stones, duodenal ulcer, spastic constipation, renal calculus or pyelitis. 



Hollow viscus 
pains. 



An almost 
obsolete term. 



Transitory 
colic. 



Onset. 



86 



MEDICAL DIAGNOSIS 



Ureteral colic. 



Chronic cases. 



Colon 

inflation. 



Pain, character 
and 

distribution. 



Usually 
afebrile. 



Pressure point. 



Ureteral and 
vascular kinks. 



Somewhat 

passi. 



Pain and 
tenderness. 



both are simulated by certain cases of renal colic in which a small calculus 
has become engaged in the lower portion of the ureter and, in children 
especially, by certain right lobar pneumonias. Nausea and vomiting at the 
onset, with fever, assist the diagnosis. 

In many instances encountered by the author, the referred pain of a 
developing pleurisy or pneumonia has been mistaken primarily for appendicitis . 

Chronic appendicitis often remains unrecognized or is only revealed by 
exploratory operation, but usually it may be determined by the history, by 
temporary exacerbations, or rarely by actual palpation of the affected member 
or manipulative roentgenography. 

The disease is frequently associated with symptoms of chronic indigestion 
of an indeterminate type. Appendix pain induced by inflation of the colon 
is said to resolve doubt in many cases and sharply localized distress occasioned 
by pushing inward upon the cecum, the fingers having first been deeply 
forced to its right side, is a sign of considerable value. 

Renal Colic. — Sudden, intense and agonizing paroxysmal pain may result 
from stone or gravel, either in the kidney pelvis or when passing downward 
through the ureter. It has a maximal point over the kidney posteriorly and tends 
to shoot downward over the course of the ureter into the groin along the inner 
portion of the thigh and into the testicle, which is oftentimes retracted during the 
paroxysms. There may be grunting and straining expulsive movements. 

Unlike appendicitis, with which it is not infrequently confounded, renal or 
ureteral colic is usually afebrile, and dysuria and frequent micturition are asso- 
ciated with albumin, blood, and oftentimes with gravel or actual calculi in the 
urine. 

Nausta and vomiting are common, and in several instances of such colic, 
as well as in acute lobar pneumonia, the author has known of narrow escapes 
from or actual operation for appendicitis, apparently because of temporary 
lodgment of calculi in the lower end of the ureter on the one hand or mis- 
leading referred pain on the other. 

In renal colic, tenderness is usually found over the kidney posteriorly, and 
often anteriorly, being best elicited by deep pressure over the twelfth rib or, 
according to the author's experience, just beneath it at the acme of deep 
inspiration. 

The DietVs crisis of floating kidney may be associated with pain of the 
same type, with more or less tenderness over the region occupied by the 
displaced or displaceable organ or even a decided intermittent hydro- 
nephrosis, but it more closely simulates gall-stone colic than renal colic, 
so far as pain distribution is concerned. 

The incidence and severity of supposed DietVs crises bear but slight relation 
to the degree of kidney mobility and in the light of recent knowledge we must 
regard this condition as a possible but extremely rare manifestation. 

Gall-stone Colic. — In typical cases this is indicated by the sudden onset of 
intense paroxysmal pain in the epigastrium or right hypochondrium, radiating 
both downward and upward, but chiefly upward, being often felt in the right 
shoulder-joint and under the right scapula. It is associated with localized 



Till NOMINA AND SIC'.Nl F1CANCK (IK 1'AIN 



87 



tenderness on deep, forcible, sustained, upward and backward thumb pressure 
over the gallbladder throughout a deep inspiration followed by deep expiration. 

It is accompanied by nausea or vomiting, which latter does not give as 
much relief to pain as in the case of ulcer of the stomach or duodenum, and 
may or may not be associated with jaundice. 

Colon Colic. — A paroxysmal attack oftentimes nearly or quite as severe as 
that of many renal colics may occur in cases of mucous colitis or spastic 
constipation* 

It is usually left-sided, the maximum point being over the region of the 
kidney, posteriorly, but ordinarily it lacks the typical thigh and groin radia- 
tion of renal colic and is either wholly or in a considerable measure relieved 
by emptying the bowel with hot enemata. 

Lead Colic. — A paroxysmal, diffuse, persistent pain, associated usually 
with obstinate constipation and relieved rather than increased by pressure, should 
lead one to search for a "lead line" on the gums or that substance in the 
urine and inquire as to sources of possible lead poisoning. 

Tabetic or Splanchnic Crises and Abdominal Aneurysm. — The curious 
paroxysmal pain associated with the crises of locomotor ataxia, the obscure pain 
of spastic splanchnic abdominal crises, the referred pain of myocardial origin 
or abdominal aneurysm must always be borne in mind. 

Colic Due to Gastric Ulcer. — Violent paroxysmal pain may be encountered 
in connection with certain cases of active gastric ulcer and the pain is usually 
epigastric, deep-seated and often seems to pass through to the back. It is usually 
associated with nausea and vomiting which ameliorates or relieves the pain 
and in its recurrences bears a definite time relation to the taking of food. 

Pressure Tenderness in Ulcer. — During acute attacks the pain of gastric 
ulcer may be relieved by pressure; more often, however, as in the chronic form, 
any pressure is distressing and the maximum tenderness is distinctly localized. 
Dyspepsia, anemia and often a history of antecedent hematemesis may assist 
the diagnosis. In by far the greater number of ulcers, such violent and local- 
izing symptoms are lacking. 

ACUTE INTESTINAL OBSTRUCTION.— In general, acute obstruction 
is characterized by severe or extreme, paroxysmal, colicky pain, becoming con- 
tinuous, the vomiting of stomach contents, bile, and ultimately of fecal material. 
The obstinate constipation is often preceded by evacuations from that portion of 
the bowel lying below the point of obstruction, and in acute intussusception there 
is a characteristic or suggestive bloody dysentery. Tenesmus without bowel 
discharges is present in some cases of volvulus. 

Symptoms Vary with Site. — If the obstruction involves the colon there is 
less vomiting, but marked abdominal distention and a relatively slight 
indicanuria. In obstruction of the lower ileum or ileocecal valve, the dis- 
tended coils may form a "ladder pattern" on the abdominal wall and, if in the 
sigmoid or rectum, the descending, transverse and ascending colon may be 
projected by distention as a visible horseshoe curve. 

* Of late, this condition is attributed by some authorities to insufficiency of the ileocecal 
valve but the sequence may be the reverse. 



A source of 
error. 



Seek gingival 
"lead line." 



Diagnostic 
pitfalls. 



Misleading 
diarrhea. 



Important 
distinctions. 



"Ladder 
pattern" and 
"horseshoe 



88 



MEDICAL DIAGNOSIS 



Ileocecal 
tumor. 



Adults chiefly. 



Sigmoidal 
cases. 



Many possible 
causes. 



Often a deadly 
combination. 



Common and 

often 

misleading. 



Channeled 
impactions. 



Cause and 
associations. 



Ancient 
ulcerations. 



Meteorism, 
vomiting and 
indicanuria. 



An actual tumor is rare save in fecal accumulation or intussusception. In 
the latter condition three-fourths of the cases represent an obstruction at the 
ileocecal junction. It is most often encountered in infants, rarely in young 
adults. 

Volvulus. — Obstruction due to axial twist seldom occurs in youth, most 
often involves the sigmoid flexure or the region of the cecum and is associated 
with marked meteorism, rigidity and tenderness. Antecedent constipation 
and flatulence usually exist and in sigmoidal cases the obstruction may be 
so low as to make the condition evident when an attempt is made to introduce 
a large enema. 

Strangulation. — In the adult this is the most frequent source of acute 
obstruction and is usually caused by old adhesions, various openings and 
pockets, slits in the mesentery and omentum, rupture of the diaphragm, 
hernias, and adhesions of the tip of a persisting Meckel's diverticulum. 

Intestinal Paralysis. — In connection with abdominal operations and as 
a result of sepsis and peritonitis, there may be an entire absence of intestinal 
motility which constitutes what is essentially an acute obstruction associated 
with general distention. The stomach is often acutely dilated and overdis- 
tended with liquid, and there is an entire absence of normal sounds upon 
auscultation of the abdomen.* 

Fecal Impaction. — A fecal mass gradually accumulating in a sluggish 
or neglected bowel may be found either at the cecum or sigmoid flexure. 
It less frequently occupies the splenic or even the hepatic flexure, and may 
occlude the lumen wholly or contain a central channel through which a certain 
amount of material may pass. A localized peritonitis with pain and tender- 
ness may or may not be present in extreme cases, and in the absence of marked 
distention or a very thick wall, the mass is readily palpable. The condition 
occurs as a result of chronic neglect of the bowels, chronic partial obstruction, 
and in the aged, apathetic, hysterical or insane, may lead to serious errors in 
diagnosis if not considered in the differentiation of abdominal tumors (see 
" Abdominal Tumors"). 

Of tumors, strictures and occlusion by foreign bodies little need be said. 
Cicatricial contraction results usually from old ulcerations, whether syphilitic, 
tuberculous, dysenteric or simple; less often from adhesion. Occlusion by 
tumor may be due to development of local growths, direct pressure, or 
associated adhesions. 

General Comment. — Early and correct diagnosis is of cardinal impor- 
tance in connection with intestinal obstruction, hence the leading features 
should be kept clearly in mind. 

Important Diagnostic Points. — The higher the obstruction the less is the 
meteorism, the earlier the vomiting, the more rapid the transition to fecal vomiting, 
the higher the grade of indicanuria, the earlier and more severe the collapse and 
urinary suppression. 

* Prompt emptying of the stomach by the stomach tube, maintenance of the prone 
position, and elevation of the foot of the bed, is oftentimes of the utmost importance in 
such cases, huge amounts of fluid being present in many instances. 



PHENOMENA AND SIGNIFICANCE OF PAIN 



89 



Associated tumor points to an actual growth, intussusception or a fecal 
impaction. 

Intussusception is most frequent in infancy and childhood, and the tumor 
is usually in the ileocecal region or in the sigmoid flexure. Marked tenesmus 
and bloody stools are most frequent in intussusception. In intussusception and 
in volvulus the lack of fluid capacity of the lower bowel as tested by enemata may 
be an important aid. Volvulus is most common in the fourth decade. 

The passage of ribbon-like or greatly narrowed cylindrical stools suggests 
partial obstruction, but may occur in cases of fecal impaction possessing central 
calibration or be due to spastic constipation, hemorrhoids or rectal spasm. 
Furthermore, although acute constipation with retention of both gas and fecal 
matter is the cardinal sign of complete obstruction, the unoccluded lower 
portion of the bowel may still be able to eject its original content. 

Fecal vomiting may require twenty-four to forty-eight hours to develop fully 
its characteristic brownish color and specific odor. 

Foreign bodies of any kind may cause obstruction and are seldom suspected 
unless a clear history is obtained. Most frequently the victims are children 
or mentally defective patients. 

Obstruction by Drugs, Worms, Etc. — The persistent administration over 
long periods of large doses of bismuth or magnesia may cause obstructive 
masses, and among other rare conditions are bunches of intestinal worms, 
masses of hair, or massive gallstones, which have made their way by 
ulceration from the gall-bladder to the bowel.* 

Obstruction may be so low down as to be felt by rectal palpation; and in 
descending colon and sigmoid obstructions the sphincter may be strikingly 
relaxed. 

Fever is usually present, but is ordinarily slight, thirst is excessive and in 
a few days, the obstruction not being relieved, collapse appears and terminates 
promptly in death. 

Diagnosis of Obstruction of the Lower Bowel by Inflation and Liquid 
Injections. — An anesthetic is necessary and should be pushed to full relaxa- 
tion. Rectal palpation and direct inspection with the proctoscope and 
sigmoidoscope should be followed by the introduction of a long tube (Kelly's 
tube). Oftentimes the whole hand may be inserted though this procedure is 
not without danger. For the injection of water which is in every way 
superior to air, the patient should be placed in the knee-chest position, the 
warm water injected slowly under gentle pressure and its passage determined 
by both percussion and auscultation. 

Normal Colon Capacity. — A normal colon should hold about 8 liters 
(quarts) and the ileocecal valve usually blocks any flow into the lesser bowel. 
In children the injection may be varied according to age, though even an 
infant can take from 1 toij^ liters. 

COMMENT. — The following points should be remembered in connection 
with abdominal pains : 

(a) Jaundice when present and associated with colic and localized tender- 

* The only way that an excessively large gall-stone can escape. 



Tumor and 
bloody stools. 



Ribbon or 
pencil-like 
stools. 



Misleading 
stools. 



Unusual 
causes. 



Anal 
'■ relaxation. 



Sigmoidoscopy 
and palpation. 



Injection of 
air or liquid. 



Ileocecal valve 
a barrier. 



go 



MEDICAL DIAGNOSIS 



Afebrile vs. 
febrile colics. 



Significant 
findings. 



Sudden onset. 



A fact of 
importance. 



Often 
determinative. 



Examine for 
hernias. 



Weakened 
hernial rings. 



Necessary 
data. 



ness suggests gall-stone colic, but its absence is of little consequence in 
disproving that diagnosis. 

(b) Fever is entirely absent, as a rule, in colon colic, spastic constipation, 
lead colic, gastric ulcer, and abdominal aneurysm. It is almost invariably 
present in acute appendicitis, frequent and sometimes of a septic type in 
gall-stone colic, and absent usually, but not invariably, in renal colic. 

(c) The Urine in Abdominal Colics. — The examination of the urine should 
never be omitted and may reveal the blood, pus cells and albumin of calculus 
or pyelitis, the high-grade indicanuria of ileus, the pale color and increased 
quantity suggestive of hysteria, actual gravel or the stone fragments of 
renal calculus. 

(d) Blood. — The examination of the blood may reveal a leucocytosis 
pointing to an acute infective process; an anemia of etiologic or diagnostic 
importance; blood parasites, or the basophilic granulation of red cells 
suggestive of lead poisoning. 

(e) Onset. — In nearly all forms of abdominal colic the onset is sudden, 
with few or no prodromata, and nausea and vomiting almost invariably occur 
in the obstructive or inflammatory conditions. 

(/) Misleadingly Referred Cardiac Pain. — One of the most interesting 
manifestations of cardiac insufficiency is pain or discomfort in the upper 
abdomen, which may be so severe as to simulate gastric or duodenal ulcer or 
even gall-stone colic, though usually of the milder type which leads the 
patient to blame his stomach for a peculiar sense of constriction or oppression 
which may or may not also be felt under the sternum or over theprecordium. 
One of the commonest symptoms of cardiac insufficiency or overstrain in middle- 
aged patients is epigastric discomfort. 

(g) Past Illnesses. — These are of ten of great importance in the differential 
diagnosis of obscure abdominal pain. Preceding attacks of renal colic, 
appendicitis, spastic constipation, gall-stones, gastric or duodenal ulcer and 
the like, may have been clear and well-defined, and often lead one to an earlier 
and more accurate diagnosis of the individual attack than would have been 
possible in the absence of such a history. 

(h) Hernias. — Owing to the common failure to systematically examine hernial 
regions in cases of obscure abdominal pain, nothing is more commonly misinter- 
preted or overlooked than an incomplete hernia or one of unusual location. 

Abdominal pain occurring during the day and absent at night when the 
patient is in bed, is especially suggestive, and actual protrusion may be absent 
though the application of a good truss to a relaxed hernial opening may relieve 
all symptoms. 

Important and Obscure. — Obscure dyspeptic symptoms, painful or pain- 
less, with or without nausea or apparently causeless vomiting, may arise from a 
tiny umbilical hernia, so small as to escape the eye or finger. Pain, localized or 
widely diffused, follows firm pressure over the umbilicus in such cases. 

HEADACHE. — The following points should be considered, viz. : (a) 
Location, (b) Character, (c) Severity, (d) Radiation, (e) Time of occur- 
rence. (/) Duration, (g) Local tenderness, (h) Hereditary predisposition. 



PHENOMENA AND SIGNIFICANCE OF PAIN 



91 



(i) The effect of internal medication (in syphilis, anemia, malaria, etc.). (j) 
The effect of external medication (shrinkage of turbinates, paralysis of 
accommodation, etc.). 

Anemic headache affects cither the forehead, orbits, vertex or occiput, being 
more often neuralgic in type. It is usually moderate and associated with a 
sense of pressure, but in extreme chlorosis is occasionally so severe as to resemble 
the headache of meningitis. 

Bilious or Dyspeptic Headache. — This toxemic variety includes as 
etiologic factors or associated conditions, gout, jaundice, the dyspepsias, 
and constipation. 77 is irregular in duration and occurrence, frontal and 
congestive in type and associated with nausea. There is a subjective sense 
of pulsation; it is increased by motion and by stooping, and more or less 
promptly relieved by emesis and catharsis. Frontal sinus headache is often 
interpreted wrongly as bilious headache. 

Brain Tumor. — This causes persistent headache, usually increased at 
night, associated with nausea and vomiting, and sooner or later with optic 
neuritis. 

Brain Abscess. — This may cause severe and persistent headache resem- 
bling that of brain tumor, but is usually accompanied by a septic tempera- 
ture curve, and optic neuritis is usually absent. 

Eye-strain headaches may be either occipital, orbital or frontal. They 
are usually associated with the use of the eyes for close work, or, in certain 
cases, for distance; are relieved by sleep and properly fitted lenses and 
are frequently associated with conjunctivitis, tenderness of the eyeball or 
eye muscles and, sometimes, blurred vision. 

SINUS HEADACHES.— These headaches have only recently been as- 
signed the important place they deserve. 

Inflammation of the accessory nasal sinuses with blocked drainage 
is one of the most frequent causes of headache of a type often attributed 
to other causes, and it would be humiliating to know how many headaches 
of this origin have been treated vainly as sick headache, uterine headache, 
facial or cervical neuralgia, bilious headache and especially that of eye 
strain. 

Sinus headaches vary somewhat in their manifestations but are alike 
in their tendency to start with mild or dull pain and increase more or less 
rapidly to an almost unbearable intensity. They are, moreover, for the 
most part, strikingly and suddenly ameliorated by the reestablishment of 
sinus drainage, by means of vasoconstricting douches or special local pro- 
cedure, and are significantly associated with and responsive to naso- 
pharyngeal congestion. 

Frontal Sinus Headache. — The pain is chiefly frontal, usually throbbing 
and more intense in the early morning and often increased by the movements 
of the eyeball. Tenderness may be marked over the frontal wall of the sinus or 
the inner aspect of the orbital roof. Like the bilious headache, it may be intensi- 
fied by stooping, sneezing, or coughing, and is often associated with intervals 
of vertigo, nausea, and even vomiting. 



Ordinarily 
mild. 



Toxemic. 



Frontal and 
congestive. 



A common 
type. 



Source of 
error. 



Significant 
factors. 



02 



MEDICAL DIAGNOSIS 



Silent cases. 



Inquire as to 
use of drugs. 



Arterial hyper- 
tension the 
rule. 



Unrecognized 
factors. 



Therapeutic 
test. 



Antrum of Highmore Headache. — This is characterized by a sense of 
pressure and tension over the outer wall of the sinus and very often by severe 
frontal pain and toothache. 

Ethmoidal Headache. — In this form the pain, though often diffuse, usually 
affects chiefly the region of the root of the nose. 

Sphenoidal Sinus Headache. — This may be widely diffused but is usually 
manifested by maximal pain at the occiput. 

77 should be remembered that each or all of the sinus lesions may cause 
general headache and that chronic sinusitis may be quite silent except at intervals 
when, through a coryza, an acute or subacute process supervenes and blocking 
occurs. 

Drug Headaches. — The overuse of drugs may lead to headaches which 
have no distinguishing features. A dull throbbing headache associated with 
ringing in the ear often follows the administration of a salicylate or quinin 
in full doses. 

Blight's Disease. — The headaches of nephritis are of varying localization 
and for the most part associated with arterial hypertension. Neuralgia is a 
frequent complication of Bright's disease, but the true uremic headache, 
which in chronic interstitial nephritis may appear years before any acute 
outbreak, is usually maximally occipital, and in all forms of nephritis may 
be the immediate precursor of uremic coma or convulsions. 

It is often an early morning headache of modemte or extreme intensity and 
relieved by black coffee, but sometimes closely simulates migraine. High 
arterial pressure from other causes produces heaaache of a similar type.* 

Arteriosclerosis. — These headaches are seldom severe, though often per- 
sistent; are associated with transient vertigo, impaired memory and intellection; 
and are often forerunners of cerebral hemorrhage. 

The cause is suggested by rigid temporals or radials and by the fact that 
the headaches are often relieved by the administration of such a drug as 
nitroglycerine. 

In the author's experience the so-called arteriosclerotic headaches have been 
seldom unassociated with chronic renal changes and arterial hypertension. 
Furthermore, they are often accompanied by distinct cardiac weakness and vary- 
ing degrees of dilatation and may respond promptly to treatment directed solely 
to the relief of this latter condition. 

Malaria. — Both persistent headache and obstinate neuralgia may be 
encountered in connection with malaria. Unless it is distinctly periodic, 
the only characteristic feature is its subsidence under appropriate drug 
treatment (quinin). 

Migraine ("Sick headache," "megrim," "hemicrania"). — Heredity plays 
a large part in migraine which is regarded by some authorities as an epileptic 

* Unilateral, predominantly temporal headaches are quite common in certain cases 
advanced chronic nephritis with hypertension and in such instances apoplexy constitutes 
a relatively common complication. It would seem from the author's observations that 
in such instances the corresponding side of the brain is the more likely to be the seat of 
such a lesion. 



PHENOMENA AND SIGNIFICANCE OF PXlN 



93 



equivalent or actual variant.* It is characterized by its unilateral localiza- 
tion, nausea, vomiting, and subjective ocular phenomena. 

Females are attacked most severely and typically and a considerable 
proportion of the cases (30 per cent.) commence in childhood (fifth to tenth 
year. Eye strain, adenoids, carious teeth, pelvic disease, food sensitization, 
gastric disorders, overexcitement, overstudy, shock, unhygienic sur- 
roundings, and dietetic errors are common exciting factors, but all are often 
lacking. 

The author has seen a large number of typical cases of the most extreme and 
persistent type, occurring in middle-aged women especially, associated with 
a renal insufficiency, without other signs of the chronic nephritis with which 
headaches of this type are occasionally associated, f 

Periodicity may be marked even to the hour of the day, or it may bear a 
definite and invariable time relation to menstruation. Unquestionably, as 
suggested, this condition is often confounded with the headaches of renal 
insufficiency and arterial hypertension. 

Symptoms. — The attack appears usually in the early morning, often 
preceded by localized numbness and tingling, hippus, vertigo, visual pares- 
thesias (flashes of light, % fortification figures), cramps, spasms, or even 
aphasia associated with mental excitement or decided depression. 

The headache is unilateral, usually right-sided and sharp, stabbing or boring 
in character. Nausea and vomiting are common symptoms, movement, 
light and sound increase it; it may become bilateral and extensive and pallor 
or flushing may be marked. 

Usually the duration is one day or less, sometimes two or three days, a 
night's sleep and oftentimes a long day nap bringing relief. In children the 
possibility of a larval meningitis or brain tumor must be remembered. 

It may be present in childhood and absent in adult life and even when 
persistent often becomes less frequent and less severe in middle age. 

Hysteria. — There is no headache characteristic of hysteria and the classical 
" clavus" (pain at the vertex as if a nail were being driven into the skull) has 
been encountered but rarely by the author and in such instances it was associated 
with extreme anemia or arterial hypertension. 

* Both statements rest upon decidedly insufficient grounds one would think after 
examining the testimony. Of 3000 individuals questioned, only 2 per cent, were found to 
have been wholly free from headaches identical with or closely allied to migraine. "With 
such a wide prevalence heredity is a negligible factor. It is like the doctrine of original 
sin" (JeUiffe). As to the close relation of migraine to epilepsy one can say only, that 
when radical differences exist between two ailments and absolutely nothing is known as to 
the pathology of either, we have no right to link them together because of minor and frag- 
mentary resemblances. To attach, either by direction or indirection, the taint of epilepsy 
to this common condition is wholly wrong, until some substantial proof is obtainable. 
Exactly the same protest may be made against the universal assumption that somnambulism 
is an epileptic equivalent. Anaphylaxis is assuming great importance as an etiologic 
factor. 

t Several of these interesting patients, originally recorded about fifteen years ago, 
have since died of a frank interstitial nephritis with hypertension. 

X "Scintillating scotoma." 



Renal cases. 



Periodicity. 



Aurae. 



Hemicrania. 



Duration. 



Clavus. 



94 



MEDICAL DIAGNOSIS 



A common 
form. 



Points of 
tenderness and 
distribution. 



Seek source 
of toxemia. 



Sinuses, teeth 
and kidneys. 



Seek focal 
infection. 



Often agoniz- 
ing and 
intractable. 



Herpes 
frequent. 



Asthenic and Psychasthenic* Headache. — Usually mild and indetermi- 
nate, frequently occipital, as in mild uremic headache, the important char- 
acteristic of this form is its morning maximum and the tendency to disappear 
after eating and under physical exercise and mental preoccupation. 

NEURALGIA. — The pain of severe neuralgia is acute, radiating, distinctly 
localized and associated with superficial points of tenderness. Its character- 
istic feature lies in its definite relation to known nerve trunks, their points of 
exit and their distribution. 

It may affect any portion of the body, though most common in the 
head, and is probably always an expression of chronic infection, toxemia, pres- 
sure or injury, though frequently initiated by extreme fatigue, particularly 
when this is associated with subnutrition and exposure to cold and damp. 
Severe attacks are remarkable for their persistence, intractability, and tend- 
ency to irregular or periodic recurrence. 

Sinus infections and peridental septic foci doubtless account for a large 
proportion of so-called neuralgic cases affecting the head, and neck and an 
astonishingly large number of such headaches occurring in the author's 
middle-aged patients are associated with high arterial tension. 

The possibility of an actual nephritis or a renal inadequacy, as indicated by 
an insufficient excretion of urinary solids should always be borne in mind, and 
invariably a definite source of chronic infection or toxemia must be considered 
and sought. 

The tender points in neuralgia represent points of nerve trunk emergence, 
their entrance into muscles, or their terminal filaments. Maximum tender- 
ness is usually easily determined and widely diffused sensitiveness of the 
most extreme type is sometimes encountered. 

Trifacial Neuralgia {Tic douloureux). — Either the ophthalmic, the upper 
maxillary or the lower branches of the trifacial nerve may be affected; the last 
being the most common; the first, the most severe form. In all varieties the pain 
is intense and the points of tenderness marked. 

Ophthalmic. — If the ophthalmic division be chiefly affected, the pain is 
especially severe about the region of the eye, which is often injected and 
tender. Lachrymation may be present, and there is marked tenderness in 
the supraorbital region, over the bridge of the nose, and occasionally at the 
occiput and upper cervical spines. Transient blindness may occur in severe 
cases. This form and the next one are frequently associated with accessory 
sinus and dental infections. 

Superior Maxillary. — If the upper maxillary is chiefly affected, the maxi- 
mum tenderness is at the infraorbital canal and disease of the antrum of 
Highmore is often a cause. 

Inferior Maxillary. — With involvement of the lower branches the pain 
radiates to the ear, and along the lower teeth, the maximum painful points 
corresponding to the auriculo-temporal nerve. 

All branches are usually more or less affected, and a severe herpetic eruption 

* The term is used in its literal sense as meaning "brain fag" or the mental instability 
usually called "neurasthenic" (see "Neurasthenia"). 



PHENOMENA AND SIGNIFICANCE OF PAIN 95 

, ^ 

may occur along the track of the superficial nerves in all three forms. The 
condition of the maxillary and frontal sinuses should always be determined. 

Cervico-brachial Neuralgia. — This variety, frequently associated with 
rheumatic affections, involves especially the sensory nerves of the brachial 
plexus. It is not infrequent, occurs chiefly in women, may be due to remote 
primary causes, such as locomotor ataxia, uterine disease, sinus or tonsillar 
infections or carious teeth, and is characterized by the distribution of the 
pain and points of maximum tenderness, which may be over the ulnar nerve, Maximal 
at the elbow, near the wrists, in the axilla, at the inferior angle of the scapula . tenderness - 
over the deltoid muscle, or even on either side of the lower cervical spine. 
Herpes, anesthesia and vasomotor disturbances may occur. 

Cervico-occipital Neuralgia. — This affects the sensory branches of the 
upper cervical nerves, is often caused by cervical caries and usually associated 
with a point of maximum tenderness midway between the mastoid process 
and the atlas. 

Intercostal Neuralgia. — This occurs most frequently in those debilitated 
by overwork, malnutrition, toxemia or co-existing diseases, and chiefly in 
young adults of the female sex. It is characterized by sudden pain in the 
chest, of the neuralgic type and but slightly affected by respiration, yet 
following the intercostal distribution. The maximum points of tenderness 
correspond to the exits of both dorsal and anterior branches an d it chiefly affects 
the left side. It is ordinarily of brief duration, but may last several weeks. 

A Source of Erroneous Diagnosis. — Intercostal neuralgia is of special 
importance in connection with angina pectoris, pleurisy and the acute pain 
of intra-abdominal diseases. 

Furthermore, the hitherto accepted statement that intercostal neuralgia chiefly a common 
affects the left side is significant. Mild pains of cardiac origin and even the e " 01 ' 
severer atypical manifestations of angina pectoris are frequently so miscalled. 

Xo less important is the relationship of thoracic pain and tenderness to 
the dilated, insufficient drop heart so often encountered in the asthenic 
individual. 

Herpes zoster cannot be distinguished from intercostal neuralgia until 
the eruption appears. It is usually unilateral, rarely bilateral and is asso- 
ciated with an herpetic eruption appearing in patches over the affected inter- 
costal nerve. 

Its pain is atrocious, and inasmuch as it may precede the eruption by many 
hours, is oftentimes most puzzling and misleading if zoster be forgotten. 

Sciatica (Sciatic neuritis, sciatic neuralgia). — In the presence of the 
ordinary etiologic factors, toxemia or actual infections, sciatica is usually 
initiated by exposure to cold, wet and excessive fatigue, direct injury, pressure 
from pelvic tumor, a faulty chair seat, chronic constipation, preexisting dis- 
ease of the vertebrae, disease or relaxation of the sacro-iliac joint or lesions of 
the spinal cord. 

Leading Symptoms. — Acute seizures are characterized by a sudden onset, Painchar- 
the intense pain following the course of the sciatic nerve, and often extending 
well up into the lumbar region. Intervals of comparative immunity alter- 



9 6 



MEDICAL DIAGNOSIS 



Tenderness. 



Common cause 
of backache. 



Easily tested. 



Long 
symptomless. 



Source of 
symptoms. 



Effect of 
posture. 



nate with paroxysms of a most excruciating type, the pain sometimes shoot- 
ing from above downward and giving the sensation of an actual shock as 
it reaches the heel. 

Subjective numbness, tingling, and disturbed temperature sense may be 
present. Many cases with imperfect clinical manifestations occur. Very 
similar symptoms may be encountered in cases of impaired circulation due 
to productive or obliterative endarteritis of the lower extremities. The 
pulsation of the dorsalis pedis and posterior tibial arteries should, therefore, 
invariably be tested and bilaterally compared. 

Pressure Points. — Pressure applied to the middle of the thigh posteriorly, 
the sciatic notch, the posterior aspect of the knee and calf, the external 
malleolus or the dorsum of the foot reveals the points of tenderness. 

Sacro-iliac Pain. — This is usually a dull pain felt chiefly over the sacro- 
iliac joints, and, aside from actual disease, is encountered usually in joint 
strain or displacements. It is relatively common in pronounced "chronic 
congenital asthenia" in association with the tendency to poor nutrition, deli- 
cate physical structure, gastroptosis, nephroptosis, and the generalized muscu- 
lar and ligamentous relaxation which characterizes that common ailment. 

It is one of the commonest causes of chronic backache in women and 
may often be promptly relieved by a proper hip band, belt, or special corset 
which steadies and fixes the sacro-iliac joints. 

The condition, if of any marked degree, is readily detected by the pain in 
the joint and spasm of the musculature which results from any attempt to stoop 
low with straight knees. 

Cervical Ribs. — This congenital anomaly may be bilateral (80 per cent) 
or unilateral, palpable or impalpable, troublesome or symptomless, and the 
accessory rib itself may be either long, or, short and "stubby," but all, or 
practically all arise from the 7th cervical segment. 

If bilateral they may be wholly unlike in the degree of development. 
If symptom-producing, this effect is manifest only in adult life, coincident 
with increasing rigidity of the bony structures and the dropping of the 
shoulders which usually initiates and confirms the pressure symptoms. 
Even when bilateral and palpable as to one, the other may be revealed only 
by roentgenography. 

Oftentimes both are easily detected by the fingers in the supraclavicular 
fossa. 

The condition is unquestionably commoner than previously assumed, 
but, relatively, is rare. 

Symptoms reflecting pressure upon the brachial plexus (chiefly repre- 
sented by neuralgia or neuritis along the area supplied by the nerve of 
Wrisberg or the ulnar), the subclavian artery and its vein. The phrenic is 
sometimes affected and in a few instances disturbances of the sympathetic 
have been reported. 

The condition should ever be in one's mind when meeting obscure symp- 
toms such as might result from this condition. 

In some instances pain is present only when certain postures are assumed 



PHENOMENA AND SIGNIFICANCE OF PAIN 



97 



and is relieved by standing erect with shoulder- thrown back, raising the 
arms above the head or sleeping on the back without a pillow. 

Miscellaneous Neuralgic Pains. — Pains of a neuralgic type may of course 
occur in any region of the body, and be confined to a single trunk or even a 
single terminal. Thus it may be limited to the breast (mastodynia), finger 
(digital neuralgia), the plantar nerves (plantar neuralgia), or be associated 




Fig. 



-Double cervical rib. A frequent source of diagnostic errors, with relation 



to«neuritic or neuralgic pain and obscure localized circulatorv disturbances. 
5. Bissell.) 



{Dr. Frank 



with the stretching of the plantar ligaments in incipient flat-foot, in which 
case the pain is in some instances limited to the third and fourth metatarso- 
phalangeal joints (Morton's foot). 

Persistent moderate pain or discomfort, associated with hyperesthesia 
about the lower zone of the left breast, is a common and important, though 
inconstant, sign of a cardiac insufficiency, often temporary, with or without 
associated valvular lesions, and in most instances easily remediable. 
7 



9 8 



MEDICAL DIAGNOSIS 



Tenderness 
extreme. 



Trophic 
changes. 



Tenderness on 
pressure. 



In many cases the area of maximum tenderness follows the lower left 
border of a dilated insufficient laboring heart as it contracts toward the 
median line under rest and cardiac stimulation.* 

Lumbo-abdominal neuralgia is characterized by pain in the back, buttocks 
and loins, radiating to the genital and hypogastric regions, and by areas of 
superficial tenderness. It is commonly associated with chronic toxemia, 
general debility, chronic constipation, disease of the pelvic organs and 
exposure to wet and cold under conditions of fatigue. 

In femoral neuralgia the pain is limited to the front of the knee and outer 
front of the thigh. In diseases of the hip-joint the reflex knee pain (inner 
aspect) is extremely common. 

NEURITIS.— The distribution of neuritic pains and their general char- 
acteristics are of necessity much the same as in neuralgia, though much more 
severe and persistent. 

Pain Severe and Persistent with Exacerbations. — The disease may be 
acute or chronic, circumscribed, and limited to a single trunk, or widespread 
and multiple. 

Distinctly inflammatory in type it tends to produce primarily and essen- 
tially a degeneration of the affected peripheral nerves. Aside from the more 
persistent and constant character of the pain, and its intensification by 
movement or passive congestion of the affected area, the exquisite tenderness 
on pressure over the nerve itself is characteristic. 

Furthermore, in severe cases there is a special tendency to marked 
cutaneous hyperesthesia followed by anesthesia and such marked changes 
as redness or pallor, edema or joint swelling and herpetic eruptions. 

In the extremities the skin often becomes characteristically glossy 
through trophic changes, and the disturbances of nutrition are indicated by 
muscle atrophy, the reaction of degeneration, loss of dependent reflexes, 
changes in the nails, loss of hair, desquamation of the epidermis, etc. True 
swelling of the nerve trunk and an erythema indicating its course may be 
present and if the. motor fibers are affected, changes appear, varying from 
easily induced fatigue and slight loss of power to actual paralysis. 

Many, if not most, of the cases characterized by shoulder -girdle pain, a type 
extremely common and usually termed neuritis, are attributable to bursitis rather 
than neuritis. 

MUSCULAR RHEUMATISM.— This common and painful ailment most 
often affects the lumbar muscles {lumbago), muscles of the chest {pleurodynia) 
and the cervical muscles {rheumatic torticollis). 

In all its forms, the chief characteristic is pain on movement, which 
produces more or less characteristic attitudes, almost complete loss of function 
and voluntary rigidity. 

Fundamental Diagnostic Points. — One of the most important points of 
distinction as between this painful affection of the muscles, and neuralgia, 

* A beautiful demonstration of the onset of such pain and localized tenderness was 
recently given by an acute gross dilatation of the heart, occurring in the author's office, from 
the effect of fright. 



PHENOMENA AND SIGNIFICANCE OF PAIN 



99 



neuritis, pleurisy, and such other affections as it may simulate, lies in the fad 
that diffuse tenderness of the involved muscles themselves, when grasped, is a 
prominent feature; that pain is distinctly related to muscular contraction, and 
that it is absent or greatly ameliorated when the muscle is at rest. 

The disease is due undoubtedly to a definite infection in most instances 
and is closely allied to that form of acute or subacute rheumatism which 
primarily and chiefly affects the tendons. 

GENERAL COMMENT. — In the majority of painful ailments the seat 
of pain represents more or less exactly the location of the affected part, and any 
attempt to list the enormous variety is j 'utile and useless. 

The more important referred pains are described under the diseases of the 
different organs. 

Shoulder Pain. — It should be remembered, however, that shoulder pain 
may be due to local disease of the joint, sprains or fractures, neuralgia, 
neuritis, bursitis, tenosynovitis, myalgia, trichinosis, disease of the diaphragm 
or of the colon flexures, angina pectoris, aneurysm, the minor anginas of 
cardiac insufficiencies of various types, and, on the right side especially, to 
inflammatory diseases of the liver, gallbladder, duodenal abscess, and, it is 
said, to movable kidney.* 

Pain at the inside of the knee suggests hip-joint disease; down the front of 
the thigh, ovarian and testicular disease, or sometimes a developing or established 
femoral or inguinal hernia. 

Pain radiating to the fold of the groin or to the testicle is common in renal 
colic. 

Headaches have already been discussed and the author is convinced that they 
will not conform to any arbitrary classification according to location, though 
such has been attempted under the older, etiologically inaccurate, grouping. 

Sacral and mid-lumbar pain is frequently due to the drag of a large, fat, 
pendulous abdomen or is of uterine origin, and movable kidney is often asso- 
ciated with a painful area over the corresponding sacro-iliac joint, probably 
due to coincident ligamentous relaxation so common in the congenital 
asthenia of which visceroptosis is part and parcel. Neuralgic coccygeal 
pain indicates coccygodynia, but equally sharp pain may accompany rectal 
fissure. 

Aside from these factors backache, usually low down, may indicate 
asthenia, pelvic disease, excessive fatigue, spinal caries, renal disease (loin 
weariness is especially common), excessive venery, sacro-iliac disease, strain 
or displacement and various other conditions. 

"Flat-foot" must be borne in mind as a cause of pain, not only in the 
feet and legs, but, occasionally, of the back as well. 

Pain under the scapula, when not pleuritic, most commonly indicates 
hepatic lesions if on the right side; cardiac, gastric, colonic or splenic 
disturbances, if on the left; but may be due to any one of many other 
causes. 

* The last is a most dubious statement with relation to one of the commonest of con- 
ditions. No such connection has been observed by the author. 



Muscle con- 
traction pain. 



Seek a focal 
infection. 



Knee, groin, or 
thigh pain. 



Futile 
classification. 



Lumbar pain. 



Lower spine. 



Common and 
important. 



roo 



MEDICAL DIAGNOSIS 



Often cardiac. 



Lower-abdominal-quadrant pain suggests colitis, sigmoid irritation, ap- 
pendicitis, hernia, ovarian or uterine disease or varicocele. 

Pubic pain is chiefly attributable to the pelvic organs and cystitis. 

Epigastric pain covers gastric and duodenal ulcer, certain cardiac insuffi- 
ciencies and actual anginas, splanchnic arteriosclerosis, early appendicitis, 
functional gastric disease (pyloro-spasm, neuroses, displacement), pancreatic 
and vertebral diseases, the referred pain of pleurisy, pneumonia, etc. 

The "girdle sensation" follows the waist line, represents constriction 
rather than pain, and points to injuries or tumors of the spinal cord and its 
meninges, chronic myelitis or locomotor ataxia. 

In the back interscapular pain is often troublesome and usually indicates 
mere indigestion or flatulent distention, though aneurysm, cardiac insuffi- 
ciency, gastric ulcer and caries must not be forgotten. 

Median dorsal pain at the shoulder level may also occur in aneurysm, 
pericarditis, and diaphragmatic irritation. Ulcer of the stomach may pro- 
duce median pain lower down, with tenderness to the left of the spine over the 
tenth and eleventh interspaces. 

Pain in' the heel may be due to sciatica, gout, ovarian and testicular 
lesions, intra-abdominal growths or prostatic disease. 

General aching is a common symptom of nervous and muscular debility 
or fatigue, usually precedes the onset of acute infectious diseases, and is 
common in acute and chronic rheumatism, trichiniasis, scurvy) locomotor 
ataxia, gastrointestinal or hepatic diseases and anemia. 

A loaded, overstretched colon, spastic constipation or mucous colitis may 
produce most extreme paroxysmal distress. 

TENDERNESS 

Usually Indicates Structure Involved.^ — In inflammations of accessible 
structures tenderness is associated with pain and usually conforms in position 
to the organ affected. 

The Head. — A tender scalp suggests syphilis, hysteria, rheumatism, 
neuralgia and migraine; tenderness of the malar bone, neuralgia or antrum 
disease; of the mastoid process, a neuralgia, periostitis, inflammation of the 
local gland or mastoiditis. Tenderness at the back of the neck suggests caries, 
sinusitis or asthenia; linear or interrupted spinal tenderness, asthenia, rheu- 
matism, caries, periostitis, actual spinal disease or hysteria. Lumbar tender- 
ness is common in lumbago and inflammatory disease of the related intra- 
abdominal structures; dorsal tenderness in advanced thoracic aneurysm or 
posterior, mediastinal tumors of any kind. A tender sternum or ribs suggests 
ostitis or periostitis but is often encountered in the major and minor anginas 
of cardiovascular disease. Abdominal tenderness is related to all acute and 
many chronic diseases of the contained viscera, and if wholly superficial 
suggests neuralgia, referred pleuritic pain or hysteria. Hypogastric tender- 
ness is usually directly related to acute or chronic inflammation of the under- 



VARIOUS SENSORY PHENOMENA 



TOI 



lying structures. The tenderness of sciatica like its pain occurs chiefly at 
the sciatic notch, the middle of the thigh and knee, the ankle and heel. 
Joint tenderness is often puzzling and suggests rheumatism, arthritis defor- 
mans, synovitis, gout, gonorrhea, tuberculosis, sepsis, hysteria, or simple 
sprain according to the conditions developed by the case history. 

PERVERSIONS OF SENSATION.— Paresthesias.— Those disturbances 
of sensation so denominated may be wholly unrelated to organic disease of 
the brain and cord. Among the more important are: 

1. Subjective Sensations of Heat and Cold. — These sensations suggest 
asthenia, malnutrition and anemia, as well as hysteria, lateral sclerosis, 
syringomyelia and locomotor ataxia. In profound toxemias, such as 
alcoholism or in actual disease of the cord, they are usually combined with 
other paresthesias. The distribution may be general or local, the sensation 
indefinite or exactly like actual contact with a hot or cold object. Hot 
flushes both subjective and visible are among the commonest events of the 
menopause. 

2. Formication and Itching. — Itching may be pronounced in hysteria, 
neurasthenia, chronic alcoholism or gout, lead poisoning and various diseases 
of the cord. It is almost invariable in jaundice and one of the signs indicating 
the taking of morphin (nose rubbing). Both itching and formication may 
antedate or foHow an apoplexy and the latter is a common symptom as. a 
result of actual irritation, diseases of the brain and cord, diabetes, cocainism 
and pelvic disturbances. 

3. Numbness and Tingling. — Often associated with decided burning 
sensation, these symptoms are especially common in connection with the 
exacerbations of high arterial pressure of chronic interstitial nephritis, in 
productive or obliterative arteriosclerosis of the extremities, neuritis, or 
pressure irritation of nerves and the use of such a drug as aconite, in addition 
to the causes of formication and itching before mentioned. 

Oppression.— The sensation known as precordial oppression or compres- 
sion is common in mediastinal tumors, cardiac and aortic disease and arterial 
hypertension with myocardial disease as well as in certain pulmonary lesions. 
In hemoptysis it may either precede or accompany the visible hemorrhage. 
Epigastric oppression may also be present in gastric and hepatic disease, but 
is more common in the functional digestive disorders or in hematemesis. 
It is a very common symptom of minor, but important, cardiac insufficiency. 

Head constriction is almost invariably associated with hysteria or psychas- 
thenia, and pelvic oppression or "bearing down," is usually due to actual 
pelvic disease or in the male to diseases of the bladder or prostate. 

Faintness and "Sinking" Sensations. — In major angina pectoris such 
sensations, together with severe precordial oppression, extreme pain, and a 
sense of impending dissolution, form an agonizing and terrifying complex. 
Lesser degrees are common in gastrointestinal ailments (chiefly functional), 
concealed or open hemorrhage, in all of the cardiac diseases, in asthenia with 
dilated or readily dilatable drop heart, hysteria, and especially in asthenic 
hypochondriasis. 



Morphinism 

and 

cocainism. 



Precordial 
type. 



Epigastric 
type. 



The "band 
sensation." 



Serious vs. 
trivial causes. 



102 



MEDICAL DIAGNOSIS 



Wide etiologic 
range. 



The attack. 



Fatal syncope. 



False syncope 



Heart-burn. 



Psychic vs. 
Physical fag. 



Test of 
brain fag. 



May be 
cardiac. 



Important 
distinction. 



Syncope. — This maybe purely a nervous manifestation, sometimes related 
to terrifying sights and sounds or violent emotion. It may accompany actual 
disease of the heart or blood vessels, follow the aspiration of ascitic or pleural 
exudates, a large hemorrhage, or surgical operation, arid may also be the result 
of pain, exhaustion, excessive heat, or the overadministration of certain 
drugs. 

The sudden and extreme pallor and the weakness of respiration and heart 
action which may cause the loss of the pulse beat at the wrist and an apparent 
arrest of breathing, are usually momentary and often preceded by vertigo 
and nausea. Temporary loss of consciousness occurs in all severe seizures 
and in some instances, demonstrable, transitory cardiac dilatation is 
coincident. 

Fatal syncope is a not uncommon event in many serious diseases and may 
constitute a most distressing accident in pneumonia, diphtheria, pericardial 
effusion, endocarditis, the removal of large exudates or transudates, and 
many other conditions aside from primary diseases of the heart muscle. 

Hysterical women frequently simulate syncope but the hysterical facies, 
retained color, the pulse and usually, a lack of the absolute immobility and 
relaxation characterizing true syncope, make detection easy. In doubtful 
cases, sharp and sudden pressure over the ovaries may resolve all doubt as 
the malingerer often shows an excessive tenderness in the ovarian region. 

Subjective Sensations of Heat and Morbid Flushing. — Fatigue, hysteria, 
pelvic disease and the menopause are the most frequent causes of troublesome 
flushing (" hot flashes") and in certain individuals causeless blushing is a 
troublesome phenomenon. The sensation of epigastric heat known as pyrosis 
is frequently associated with a sense of excessive fullness as distinct from the 
pressure sensation previously described and is most common in the functional 
disturbances of the stomach. 

Subjective Weakness. — In hysteria and asthenia or in mere temporary 
"brain fag," a patient may experience a sense of positive physical fatigue; 
or, in the former, pseudo-paralytic symptoms either transient or persistent 
may occur. 

In mere "brain fag" the factitious sensation of physical " exhaustion" 
may entirely disappear under active and strenuous exertion or be forgotten 
in the interest excited by a good play or book. It is frequently due to 
lack of exercise, the overuse of tea, coffee. and tobacco, or to insufficient 
sleep. 

Fatigue, persistent or readily induced, is also one of the commonest symptoms 
of cardiac insufficiency, as is demonstrated in the myocardial toxemias of acute 
infections and must be given its full value in diagnosis and treatment. 

"Globus hystericus ,, is a sensation of obstruction, constriction, pressure 
or tickling referred to the throat. It is common in hysteria, and may be 
associated with troublesome spasm, but represents too often a misinterpreta- 
tion of the genuine choking, sense of oppression, compression, or clutching 
so commonly present in minor and major cardiac insufficiencies, with result- 
ing errors of omission more or less disastrous to the patient. 



INSOMNIA AND VERTIGO 



IO 



Causes 
manifold. 



Scope of 
inquiry. 



INSOMNIA. — This troublesome symptom may take the form of inability 
to sleep, disturbed sleep, starting during sleep, early waking or prolonged 
wakeful periods. 

Its causes, too varied to permit full discussion, vary from mere worry 
or temporary nervous excitement to actual disease of the cardiovascular 
system or of the brain itself. 

Inquiry should include the condition of the stomach and bowels, a careful 
examination of the urine, heart and blood vessels and the estimation of 
arterial tension, the mental work done, quantity of tea, coffee, tobacco 
and alcohol consumed, exercise taken, unusual sources of worry and 
mental strain, excessive study at night, eyestrain, and the age of the 
patient. 

Frequently a light lunch at bedtime, slight modification in the diet, 
hours of meals, relation of exercise to the meals, the cutting off of excesses I 
of any kind or the mere admission of fresh air at night to the sleeping-room Trivial or 1 

mi , , • * , , . intractable. 

will put an end to attacks of insomnia. If asthenia be the cause, nothing 
short of a prolonged rest or recreation cure is of any use. Occasionally 
climatic change alone will produce sleep and permanently correct the dis- 
turbance, while, not infrequently, relief follows a complete cessation of all 
conscious efforts or devices to induce slumber. 

In both acute and chronic disease the amount of sleep obtained by the patient 
is important and should be as carefully noted as is the food intake. Insufficient 
sleep during the twenty-four hours is always the chief point to be determined, 
rather than the question of how the nights pass. 

One frequently finds that naps during the day are accountable for dis- 
turbed and broken nights and that the total slumber for twenty-four hours 
is actually in excess of the needs of the patient. ' 

It is perhaps unfortunate that a minimum of eight or ten hours of sleep 
has become a fixed standard regardless of occupation and individual require- 
ment. 

The small amount of sleep which suffices for the needs of healthy indi- 
viduals who are habituated is oftentimes most striking. 

Drowsiness during the day and early waking or disturbed sleep at night a much 
constitute a common symptom of cardiac insufficiency, and are often promptly cause. 
relieved by appropriate measures directed to the strengthening of the heart. 

Old people undergo a slowly progressive circulatory inadequacy and are, 
as a rule, early wakers and light sleepers, the conditions of childhood being 
reversed. 

VERTIGO. — (Giddiness, li Swimming of the Head"). — 

Vertigo is , in most instances, a trivial and transitory symptom depending 
upon impacted wax in the auditory canal, disturbances of digestion, eye- 
strain, or asthenia, but nevertheless should always receive careful attention. 
In the young the causes are usually trivial and removable, though in per- 
sistent cases brain tumor and minor epilepsy must always be considered. The young vs. 



Usually 
trivial. 



In the middle-aged and old it is much more significant, 
gation indicated are as follows: 



The lines of investi- 



104 



MEDICAL DIAGNOSIS 



Varieties of Vertigo. — Vertigo is usually sudden in onset and intermittent 
or periodic in type. Usually a sudden change from the recumbent to the 
erect posture initiates it, and it may be limited to the early morning 
hours. It may take the form of a subjective sensation of whirling or falling 
which persists with the eyes closed, or may occur only when looking at moving 
objects, as in riding, driving, swaying, or swinging. 

77 usually disappears or is greatly relieved when the patient is tying down, 
but in some instances, and, notably in its arteriosclerotic form, is often increased 
by lying down. 

Points to be Remembered. — Persistent vertigo not distinctly associated 
with the eye, accessory sinuses, ear, digestive disturbances, or asthenia, demands 
a thorough investigation of the heart and blood vessels, the urine, the reflexes, 
syphilis, possible epilepsy and even brain tumor and shoidd include an examina- 
tion of the fundus oculi. 

(a) The Existence of Asthenia. — This condition covers by far the greater 
number of persistent or persistently recurrent cases in persons under the 
age of forty and is often associated with coincident digestive trouble, cardiac 
overstrain, eyestrain, anemia, hysteria, malnutrition, or even the habitual 
use of narcotics or stimulants. 

(b) Meniere's Disease. — This condition is supposed to be due to disease 
of the labyrinth or semicircular canals and is characterized by the association 
of vertigo with tinnitus aurium and a tendency to fall to the left or right 
(see "Meniere's Disease"). 

(c) Arteriosclerosis and Cardiac Disease. — This vertigo covers the 
greater number of cases observed in elderly people. It is important as re- 
lated to exacerbations of high arterial pressure and the threat of apoplexy, 
to aneurysm, aortic regurgitation, arteriosclerosis, arterial spasm, and other 
cardiac lesions or cerebral disturbances due to other causes. 

(d) Sunstroke or heatstroke sometimes leaves behind a marked 
vertiginous tendency. 

(e) Eye Strain. — Errors of refraction and ocular insufficiencies should be 
carefully investigated. 

(/) Epilepsy. — Vertigo may be either an aura of major epilepsy, or repre- 
sent an attack of petit mal. The condition of the stomach and bowels is 
of great importance and constipation is frequently responsible for recurrent 
vertigo and pseudo-epilepsy in spasmophilic cases. 

(g) Lesions of the Brain and Cord. — Brain tumor, abscess, meningitis, 
cerebellar and pontine lesions, cerebral syphilis, cerebral thrombosis, general 
paresis, locomotor ataxia and disseminated sclerosis may be associated with 
varying degrees of vertigo. 

(h) General Diseases. — Vertigo is frequent in auto-intoxication, gout, 
Bright's disease, febrile states, extreme weakness, as in severe anemias, 
the cachexias and convalescence from acute diseases. 

(i) Reflex. — Auditory vertigo due to conditions other than Meniere's 
disease, as in cases of ear-drum pressure; naso-pharyngeal vertigo due to 
pressure within the nose or in the sinuses; laryngeal vertigo associated 



DYSPNEA 



10 



usually with a coughing tit in laryngeal affections — are the leading reflex 
types. 

(j) Gastric Disturbances. — These are held accountable for one of the 
commonest forms of vertigo. 

(k) Excesses. — The habits in relation to the use of tea, coffee, tobacco, 
alcoholics, and the question of sexual excess, should be carefully investigated. 

DYSPNEA 

Clinical Definition. — The term "dyspnea" should be limited to those cases 
of labored, regular, arrhythmic, or greatly accelerated, respiration in which 
there is insufficient oxidation of the blood, whether this be due to heart weakness, 
actual obstruction to the free ingress or egress of air, a diminished pulmonary 
area, or to other causes of impairment of its chemical exchanges. The term 
il accelerated breathing" or a specific descriptive term should cover other 
varieties. 

Subjective vs. Objective Dyspnea. — Dyspnea may be purely subjective 
and represent a sensation of oppression or respiratory inadequacy without 
marked increase in frequency or disturbance of rhythm, but severe dyspnea 
is usually both subjective and objective and associated with varying degrees 
of cyanosis. 

Subjective Dyspnea. — The mere sensation of dyspnea is practically limited 
to cardiac insufficiency, uremia, and psychasthenia, and even though orthop- 
nea be present there is oftentimes no associated cyanosis. 

Obstructive Type. — Any condition preventing the free entrance of air into 
the lungs will cause dyspnea, hence it accompanies severe quinsy, and marked 
narrowing or stenosis of the glottis, trachea or bronchi, whether the cause be 
direct obstruction, tumor or foreign bodies; inflammation, as in the case of 
laryngeal diphtheria and pneumonia; or spasm, as in croup or asthma. 

Stridor. — (Usually due to glottic obstruction). — Stridulous breathing is 
invariably of laryngeal origin and usually due to spasm, paralysis, edema, 
foreign bodies, membrane, tumor or severe inflammation of the glottis. 

In certain cases it represents pressure on the nerve trunks and resulting 
spasm or paralysis of the laryngeal musculature, as in aneurysm, enlarged 
bronchial glands, massive pericardial effusions, etc. It is typified by the 
"crowing" of a croupy child, and invariably represents true dyspnea of the 
obstructive or stenotic type. 

Its diagnostic features are stridor (whistling, hissing) and a pronounced 
inspiratory descent of the larynx; this movement being so great oftentimes, and 
especially in short-necked children, as to embarrass the surgeon in tracheo- 
tomy. 

The breathing is slow in obstructive dyspnea so long as respiratory power re- 
mains good. 

Circulatory Dyspnea. — Other cases are referable to circulatory dis- 
turbances, especially those of incompensated mitral and tricuspid lesions, in 
which instances the condition is largely one of pulmonary stasis, the aeration 



Both are 
important 



A vitally im- 
portant sign. 



Crowing." 



Pulmonary 
stasis. 



io6 



MEDICAL DIAGNOSIS 



Emphysema 

and 

pneumonia. 



Lung fibrosis 

and 

tuberculosis. 



Anemia, 
uremia, and 
diabetes. 



Snoring 
respiration. 



Diabetes. 



Of great 
importance. 



Significance. 



Inspiratory vs. 

expiratory 

dyspnea. 



Misleading 
paroxysmal 
dyspneas. 



areas being normal, but the blood current obstructed and its chemical ex- 
changes diminished. 

In other instances both factors are concerned, as, for example, in emphy- 
sema and acute lung diseases where there is both pulmonary stasis and insuf- 
ficient air exchange. 

To a less degree the same conditions prevail in pulmonary fibrosis, the 
pressure of tumors or of pleural or pericardial effusion and in advanced pul- 
monary tuberculosis. In the last instance the amount of dyspnea present 
when the patient is at rest is often strikingly disproportionate to the area of 
lung involved though usually evident upon exertion. In severe anemias the 
impaired hemoglobin content alone or a combination of circulatory and 
hemic insufficiency is accountable, and, in uremia and diabetes, toxemia is 
the prominent feature. 

Stertorous Respiration. — In cases of profound coma, extensive post-nasal 
adenoids or chronically enlarged tonsils, as well as in ordinary sleep in certain 
individuals, there is a snoring respiration which is not, however, a true 
dyspnea. 

Air Hunger. — This peculiar form of dyspnea is best illustrated in diabetic 
coma and best described by the name given. (See Diabetic Coma.) 

Dyspnea on Exertion. — This symptom, vitally important whether sub- 
jective or objective, accompanies severe chronic bronchitis, emphysema, 
early tuberculosis, pleural effusion of the latent type, anemias, uremia, ex- 
hausting diseases or debility, obesity and imperfectly compensated cardiac 
lesions. 

Persistent Dyspnea. — This indicates severer grades of the conditions 
mentioned in the preceding paragraph, stenosis of the air passages or certain 
profound toxemias. It is particularly marked in obstructive lesions, terminal 
cardiac incompensation and advanced emphysema. 

Inability to Hold the Breath. — Inability to hold the breath may be a part 
of any severe dyspnea, and is not infrequently the only evidence of that con- 
dition in certain minor cases of cardiac incompensation. 

Paroxysmal Dyspnea.- — The commonest pulmonary forms are croup, 
laryngismus stridulus, and true asthma; the two first mentioned being of the type 
of inspiratory dyspnea, the other predominatingly expiratory. 

Spasm of the glottis is a component of the spasmophilic diathesis but in 
various forms and degree may be associated with hysteria as well as with 
organic nervous disease. 

True Bronchial Asthma. — This may be perfectly simulated by the dy spneic 
paroxysms sometimes observed in uremia, by similar seizures due to medias- 
tinal pressure, and by that paroxysmal- dyspnea alternative of angina pectoris 
for which alone the term " cardiac asthma" should be reserved. 

The ordinary form of dyspnea associated with cardiac disease is non- 
paroxysmal, and extreme only under exertion, in cases of massive pulmonary 
embolus, or as the result of the pressure of secondary transudates. 

In terminal decompensation, certain cases of aortitis or an associated 
pulmonary edema, very severe types of dyspnea may occur, often paroxysmal. 



ORTHOPNEA AND VARIATIONS IN KJ'.SIM KA T< >K V RUN I MM 



IO7 



Pedunculated tumors below the glottic chink may cause violent and 
even fatal paroxysmal dyspnea. Cases of spasmodic paroxysmal dyspnea 
due to aneurysm of the aortic arc/; produce most misleading pseudoastlimalic 
seizures which repeatedly have deceived the elect. 

Associated Changes in the Chest Outline. — Certain permanent changes, 
such as the forced inspiration type of emphysema, the unilateral enlargement 
of chronic pleural effusion or tumor and the unilateral retraction of fibroid 
phthisis and pleural adhesion, need no further description here. In asthma, 
the lower diameters of the thorax are increased during the paroxysm because 
of the expiratory type of the spasmodic dyspnea. In broncho-pneumonia 
and other forms of obstructive dyspnea a marked inspiratory narrowing and 
recession of the interspaces occurs because of the inspiratory negative pressure 
and the direct drag of the diaphragm. This need not be confused with the 
slighter contraction sometimes observed in chronic emphysema, visceroptosis 
and even in normal individuals. 

Orthopnea. — This term refers especially to a dyspnea induced or intensified 
by recumbency and demanding the sitting attitude for its amelioration or relief. 
It is most commonly noted in cardiac incompensation, spasmodic asthma, 
advanced emphysema, certain of the pleural or pericardial effusions, thoracic 
aneurysms, mediastinal growths and abscesses, or gas or fluids causing pressure 
within the abdominal cavity sufficient to embarrass diaphragmatic movement 
and obstruct the action of the heart or lungs. 

In some instances, as stated previously, the patient must not only sit up, but 
at times stand erect. In others he is comfortable only when leaning forward.* 

In some instances a subjective sense of suffocation may compel the abrupt 
assumption of a sitting or even erect posture. As stated previously, death 
may follow the natural attempt of the attendant to forcibly restrain the 
patient and outweigh the risk involved in the sudden exertion. 

The physician must decide whether the action is obligatory and represents 
a genuine uncontrollable necessity or is merely an expression of extreme nerv- 
ousness or intractability. 

VARIATIONS IN .RESPIRATORY RHYTHM.— Mere irregularity is 
common in children whether awake or asleep. It also appears as an ominous 
sign in massive cerebral apoplexies, brain tumor, meningitis, shock and 
collapse, and not infrequently as a symptom of chorea. 

Jerky Respiration. — This may be inspiratory as in hydrophobia or hy- 
steria, or expiratory and often grunting in intercostal neuralgia, acute pleu- 
risy, rib fractures, stab wounds, renal and gall-stone colic, or in the presence 
of any paroxysmal pain, especially of the abdomen. 

Wavy Inspiration. — This is characterized by an undulatory movement of 
the chest and may occur in severe typhoid, pneumonia, and other conditions 
associated with great prostration. 

Biot's Respiration. — This term applies to respiration interrupted regularly 
or irregularly by apneic intervals of varying length. Seen most frequently 

* It has been stated that this latter position is pathognomonic of acute aortitis, but in 
the author's personal experience it is a common symptom in mediastinal tumor. 



Aortic 
aneurysm. 



Broncho- 
pneumonia. 



The obligatory 
sitting posture. 



Extreme 
instances. 



Scylla and 
Charybdis? 



Trivial or 
ominous. 



Inspiratory or 
expiratory. 



Respiratory 
undulation. 



io8 



MKDICAL DIAGNOSIS 



Portentous if 
marked. 



A precursor of 
death. 



Wide range 
of incidence. 



May exist 
for years. 



Exhaustion of 
center. 



Overaction. 



Recurring 
exhaustion. 



Prolonged 
seizures. 



An agonizing 

complication. 



in meningitis; it may be encountered in pneumonia in a moderate form, and is 
ordinarily a precursor of death. 

Cheyne -Stokes Breathing. — This term covers irregular breathing inter- 
rupted by apneic intervals but characterized by the fact that, following a pause, 
the respiration recommences as shallow slow breathing, steadily increasing in 
depth and frequency until a maximum is reached, when it subsides in the reverse 
order. 

It may accompany the coma of organic disease of the brain, apoplexy, 
tumor, uremia, opium poisoning, severe or terminal myocardial decom- 
pensation arid meningitis. It may also be observed in diabetes and various 
acute infections, such as cerebro-spinal fever, septicemia, typhoid, pneumonia 
and the exanthemata. In feeble children, and in the aged, it may occur 
during sleep and, in rare instances, in the adult suffering from the chronic 
diseases mentioned above it may be present both waking and sleeping for 
long periods. In an ambulatory case reported by Osier it was so severe 
and troublesome as to interfere with eating. 

Traube's theory of lowered irritability of the respiratory center, if com- 
bined with the fatigue hypothesis of Rosenbach, would adequately cover the 
phenomenon. This would assume a primary, progressive, preliminary ex- 
haustion of the respiratory center arising from the chronically insufficient 
blood supply, a resultant temporarily diminished excitability of the center, 
and a recurrent and more or less rhythmic overreaction which is due to the 
cumulative increase of the asphyxial stimulus during the period of apnea, and 
continues through the first imperfect series of renewed respirations. The 
deeper breathing of the fastigium temporarily adjusts the balance but so 
exhausts the center that no response occurs until the period of apnea has 
again so vitiated the blood as to. produce again an excessive stimulus. 

Increased Frequency. — Mere fever increases frequency as do most dysp- 
neas not stenotic in type, and it often accompanies pulmonary, cardiac, and 
renal lesions, andvneuroses. 

Slow breathing is commonly seen in coma, collapse, and all conditions 
associated with stertor. 

Hiccough. — This sudden spasmodic contraction of the diaphragm, often 
temporary and negligible, . may become one. of the most serious complications 
of acute or chronic disease. 

The attacks, ordinarily short, may be prolonged for days or. weeks and 
rapidly exhaust the patient. 

Causes. — Hiccough may be due to (a) organic or functional disease of 
the nervous system; (b) of the abdominal organs; (c) constitutional diseases, 
(d) miscellaneous causes, such as dyspepsia, flatulence, severe acute infections, 
the typhoid state, alcoholism, pneumonia, pulmonary gangrene, chronic heart 
disease, pregnancy, etc. 

It would be useless to give in detail the various conditions with which it 
is associated as it may occur in any exhausting disease, acute or chronic. Oc- 
curring with inflammation of the diaphragm, whether from the pulmonary 
or peritoneal side, it constitutes an agonizing complication. 



SHOCK AMi COLLAPSE 



iog 



SHOCK AND COLLAPSE.— Shock.— Patients suffering from the severer 
grades of shock show pallor, a lowered temperature, a cold wet body surface, 
a weak thready pulse, slow, shallow and often sighing respiration, great 
physical weakness and prostration. The Hippocratic countenance or at 
least an expression of great anxiety is present. All of these grave symptoms 
are combined in many cases with extraordinary mental calm and clearness 
and oftentimes with a great amelioration of, or entire freedom from, any 
preexisting pain. 

The ominous subsidence of any antecedent or initial pain and mental dis- 
tress is often misleading. 

Among other causes of shock are acute hemorrhagic or suppurative pan- 
creatitis, strangulated hernia, severe accidents, particularly those attended 
by crushing violence, and, in its lesser degrees, certain of the severe acute 
infections, renal and hepatic colic, angina pectoris, and other conditions 
associated with extreme pain* 

Collapse. — This is commonly associated in medicine with those intra- 
abdominal diseases which have a surgical side, for example, perforation of 
the appendix, of a gastric or duodenal ulcer or hepatic abscess, but the term 
applies to any case in which extreme depression of the vital forces and cir- 
culatory failure arise. 

Concealed Hemorrhage. — An extensive open hemorrhage almost in- 
variably alarms and excites its victim but serious internal and concealed 
hemorrhage presents symptoms of shock and collapse together with a certain 
curious restlessness and oftentimes yawning, nausea and air hunger. 

Sources of Concealed Hemorrhage. — Among the most common are 
hemothorax, aneurysmal rupture, duodenal ulcer, typhoid, gastric ulcer, 
ectopic gestation or pelvic hematocele from any cause, traumatism, the 
hemorrhagic diathesis, and very rarely in pulmonary tuberculosis a large 
hemorrhage into an old cavity which may for a time be concealed. 

In any obscure case of shock or collapse the stools should be carefully ex- 
amined for blood and in married women the possibility of ectopic gestation 
cannot be ignored. The clear mind so often encountered in the earlier stages 
may later yield to a low delirium and, occasionally, convulsions. 

* The student should read the recent papers of Dr. Crile as expressing the most modern 
theory of shock and its prevention. He shows the effect not alone of trauma but of psychic 
and toxic factors upon the cerebral and spinal nerve cells. 



Striking 
facies. 



Surgical 
associations. 



An important 
syndrome. 



no 



MEDICAL DIAGNOSIS 



Scope and 
value. 



Necessity of 

thorough 

training. 



DISEASES DEPENDENT UPON OR ASSOCIATED WITH CHANGES 

IN THE BLOOD OR BLOOD-MAKING ORGANS AND 

DUCTLESS GLANDS 

EXAMINATION OF THE BLOOD.— This department of medicine, valu- 
able alike to the internist and to the surgeon, affords a means of exact 
diagnosis in syphilis, malaria, the leukemias, filariasis, relapsing fever, typhoid 
fever, Malta fever and trypanosomiasis: fundamental evidence in cases of per- 
I nicious anemia, chlorosis, secondary anemia, Eodgkin's disease and diabetes 
mellitus, and valuable corroborative evidence in the acute pneumonias, ap- 
pendicitis, septic infections, trichiniasis , lead poisoning, gout, malingering, cer- 
tain cases of malignant disease and many other ailments. 

In addition one must consider the valuable information represented by 
negative blood findings. 

The blood is the circulating medium for the exchange of cell food, 
chemical substances acting as stimuli, and excretory and secretory products 
of the vital activities. 

The products of the glands of internal secretion, actual nutritive sub- 
stances and simple or complex chemical substances initiating heart action 
are examples. 

It removes alike the strictly excretory substances and the toxins of disease. 
Blood bacteriology, serology and parasitology and the refinements of blood 
chemistry and physics do not fall properly under discussion. 

This section has to do almost exclusively with blood morphology 
as modified by disease. 

Thorough laboratory training and accurate, painstaking work are 
essential to success and it is unfortunately true that a large proportion of 
the findings obtained under other conditions are quite worthless and often 
most damaging. 

Scope of Section. — It is obviously impossible to deal seriously with ser- 
ology or the refinements of blood pathology in a book of this kind and the 
reader is referred to the many excellent special works dealing with these 
interesting and complex subjects. 

Only such diseases and diagnostic procedures as are of direct clinical 
importance and ready availability are dealt with in what the author hopes 
may prove a practical and adequate way. 

Clinical Essentials. — (a) The determination of hemoglobin, (b) The red 
cell count, (c) The white cell count, (d) The examination of fresh blood, 
(e) The examination of the smear preparation (i) stained, (2) unstained. 
(J) The study of the various "clump" or agglutination reactions in certain acute 
infections (serum diagnosis), (g) The study of exudates, (h) Complement- 
fixation tests. 

Clinical Tests of Less Importance. — {a) Counting blood plates, (b) 
Estimation of alkalinity, (c) Cryoscopy. (d) Specific gravity determination, 
(e) Coagulation period. (/) Determination of blood volume and ratio of cor- 
puscles to plasma, (g) Viscosity tests. 



THE EXAMINATION OF THE BLOOD 



III 



Terms in Common Use. — Anemia, a deficiency in corpuscles, coloring 
matter, or total blood volume. Oligocythemia, a deficiency of red cells. 
Oligochromemia, a deficiency in hemoglobin. Oligemia, deficient total 
blond volume. 

The total volume of the blood is about one-twentieth (J-£oth) of the body 
weight* and in severe anemias may be reduced 50 per cent. 

This may occur temporarily in severe hemorrhage or, more persistently 
as the result of repeated severe hemorrhages and also in the hemolytic and 
cachetic or inanition anemias of the more serious grades. 

Hydremia. — -This state represents a disproportionate amount of water 
in the blood either from loss of solids or actual water increase, aside from 
accidental temporary variations due to sweating, excessive ingestion of 
liquids and the like. 

The color of normal arterial blood is due to the oxyhemoglobin con- 
tained in its erythrocytes. 

Normally, the hemoglobin content of such blood lies between 13 and 14 
grams per 100 c.c. with which is combined loosely about 21.6 per cent, by 
volume of oxygen, and 13 per cent., by volume, of CO2. 

Double that amount of CO2 is contained in the plasma of such arterial 
blood and the total C0 2 content of venous blood is by volume about 48 
per cent. 

Practically all forms of non-obstructive dyspnea clinically- encountered 
are due to deficient oxygen content however induced. 

Leucocytosis. — The term is commonly used to denote an abnormal in- 
crease in the number of leucocytes, the polymorphonuclear type predomi- 
nating. The average per cubic millimeter is normally about 7500. 

Lymphocytosis. — An unusual increase in the number of mononuclear 
non-granular leucocytes. 

Leucopenia. — The opposite of leucocytosis and equivalent to hypoleu- 
cocytosis, an abnormally or unusually low leucocyte count. 

Plethora. — A term covering what was formerly supposed to be a patho- 
logical condition, but now used to indicate an increase in the total quantity 
of blood. The term "plethoric" is applied to those individuals with a 
ruddy countenance due to dilated or unusually prominent capillary network. 
The condition is now of slight clinical importance, though it is certain that 
there is a direct relation of the blood volume to the musculature and to the 
size of the heart. 

Polycythemia, an abnormal increase in the number of red cells may, 
rarely, be a symptom of importance, particularly when associated with en- 
larged spleen and cyanosis (erythremia) or acetanilid addiction. 

Color Index. — The color index represents the result obtained by dividing the 
hemoglobin percentage by the percentage of red cells. 

The normal figure for hemoglobin is 100; the corresponding erythrocyte 
standard being 5,000,000 cells in men and 4,500,000 in women. 

* By Haldane's carbon monoxide method. By Keith's method it is found to vary 
between one eleventh and one thirteenth of the body weight. 



Normal count. 



112 



MEDICAL DIAGNOSIS 



Sterilization. 



Bleeders. 



Best 
instrument. 



Example i. — In a given case the hemoglobin is 30 per cent., the red cells 
number 3,000,000, or 60 per cent. 30 divided by 60 equals Jfo5 a l° w color 
index, indicating chlorosis. 

Example 2. — Hemoglobin 30 per cent., red cells, 1,000,000 or 20 per cent. 
30 divided by 20 equals 1.5; a high color index such as is found in pernicious 
anemia of the hemolytic type. 

Example 3. — Hemoglobin 50 per cent., red cells 2,500,000 or 50 per cent. 
50 divided by 50 equals 1; a color index suggesting secondary anemia. 

To Obtain Blood for Examination. — It is essential that the actual technic 
should be thoroughly understood, and intelligently and expeditiously carried 
out. 

Precautions. — One should not trust to the flow of blood for sterilization 
either of the skin or the instrument employed. 




Fig. 26. — Matthews' microscope lamp with iris-diaphragm. {Todd.) 

The ear lobe or the finger-tip should be carefully cleansed with alcohol, 
bay rum, or some similar substance always available, and the needle or lancet 
used should be sterilized in the flame. 

The patient may be asked whether he u bleeds easily" or the reverse with a 
view of determining the size, depth of the puncture, and avoidance of serious 
complications in cases of hemophilia. Two cases of this kind in the author's 
clinic bled steadily for several hours from a very minute puncture.* 

For making the puncture an instrument with a sharp cutting edge should 
be used. The Hagadorn needle or the spring lancet with a trocar point is 
most suitable, the ordinary needles being poor substitutes. Some workers 
prefer to use a suitable piece of broken cover-glass which is firmly grasped 
between the finger and thumb at the point required to permit necessary 
penetration and at the same time limit the depth of the puncture. I 

*As a matter of fact the risk of any serious or fatal hemorrhage is practically 
negligible. 



I 111 1 XAMIN'ATION OF THK HI.OOI) 



H3 



Form and size. 



quickly and smartly done the stroke is almost painless and the resulting 
blood-flow free. 

The puncture itself should be sufficiently free and deep to obviate Method. 
squeezing or excessive friction, and, furthermore, the instrument should 

permit a quick, painless stroke,* and the 
first two or three drops should be dis- 
carded. The blood should flow spontaneously 
and, to maintain it, light brisk friction serves 
admirably, but pressure should never be em- 
ployed. To check it, firm, steady pressure 
is sufficient, or in the case of the finger, 
vertical elevation of the arm. 

An edematous area or one in which local 
cyanosis is marked should be avoided in obtain- 
ing specimens for examination. The former 
yields a diluted bl,ood, the latter a mislead- 
ingly concentrated specimen. 

Care and Preparation of Slides and 
Cover-glasses. — All material should be of 
the best sort, % inch square cover-glasses 
being superior to the round, and both these 
and the slides should be thin. When received 
j ^r ; Y ^ from the dealer, they should be thoroughly 

1 1 • a washed in soap and water and then placed 

in the following solution: Hydrochloric 
acid 1 part, absolute alcohol 29 parts, water 
70 parts, or they may be placed in solution 
containing equal parts of alcohol and ether: 
When required, they should be wiped thor- 
oughly, polished with tissue paper or with 
soft linen, and, if convenient, passed through 
a flame. A small drop of blood will spread satisfactorily and evenly 
between a perfectly clean slide and its cover-glass or between two cover- 
slips, especially if these are slightly warm. 

Making the Smear. — To make a good smear preparation the cover-glass 
must be absolutely clean and a small drop only, should be lightly touched by 
one, the other placed quickly upon it, an instant allowed for the spread \ indispensable, 
of the blood, and the two separated by a sliding (not a 
lifting) movement, as shown. The cover-glass should 
never touch the skin. This is the best method for 
general use, for neither the "scrape" method nor the 
cigarette-paper procedure is well adapted to all specimens Fl ord^n7ry I me d th?d. ar ' 
of blood, least of all to smears taken in pernicious anemia. 

Another method consists in using the edge of one cover-glass and drawing 

it lightly across the drop or gently pushing the edge of the slide over the 

* Blood may be taken from young children in this way without arousing them from sleep. 




Fig. 27. — Handle-arm micro- 
scope: E, Eye-piece; D, draw-tube; 
T, body- tube; RN, revolving nose- 
piece; O, objective; PH, pinion 
head; MH, micrometer head; HA, 
handle-arm; SS, substage; S, stage; 
M, mirror; B, base; R, rack; P, 
pillar; I, Inclination joint. (Todd.) 



Preparation. 



Even spreads 







HJ.::. 1 .: : : a :-:•' : sn 



I-:.: : 



1 ~ - -i "- - = 




- 

another, involves the use of an ordinary sewing needle, which is 

:z.:z.-.i 'lz -:ly ':-: :u;:Vly i;::~ :ir riir :i :Jir 11: 

thwrngkomt large arras *j **f jfeatf mot look to tie eye 

smeary or thick. If carefully preserved the dry wmstaimed 

:■:■:: ■■■*; :.:'' ?-:■:•: /> ■■:;-■;'■■: 

J ::::: :■.:- i:: ire:-: i: iiy ;-.iit :: :ie ;::- 
:ri-rr. : _: ne 5iine: i:r7i:::::ii ire ~ ::e irlllii::: :■:•:•: 

.:' lie r_: ii ■ e-ii-L'.r'.y 11:1x1 =l:-*iy ii: :i:ei_lly _.1;.'_*;1 .- 

irlei :'::" r 1 line may :e (cvcotd 1 

emmbU ome to make gxd smears fort the resmlt is wefl worth ^%£tt<hvr,"b«ttbe 
;;-:• ;<:•;' .'ii;- ^; --;.:<•:. fagaer J^^ hod " 

Fixation of Dried Preparation.— The. use of the 

- -y ; " :::: iii± ~i>e< : 7::'.: ire: :es::i::::i :: lie :l:er ne.li.'ii 
: - ;::::;" 

5~eir= m; : t ll: :':•: 117 :i -^::k ~ 111 ::: : _ : -..-.7 .t r.i:i :y iiy ::e 
of four shnple methods: (r) Passing the cower-siip through a 



- - - , ■ ■ ,T ■ ■ " 



- "■', ' "■ T 



• -'• 




■ ~ ; ■ : ;' ?.*. 
;;,-'•; ; l';:--zzi 
index, (f) Appro 

X : :lei : e ■ : : e-: 

— "Jl i li~.-_lr viicll 



;';- : :■:' '■•-:: ..:■: : ; ; : /:' v-,.; ;.,"■;._- ; ;.;,":-: ;.; J :.:',:•", :;'■;■"-. :- 
". : ^ I /■;::•:: —,:;'/> ;;'-. ::/,-;i; ;,y>~,;.; :•*, r^p;' 
Tie :l:e: ieirlm ~e:li:.:E ire :el::i:e :e:__:e 
::: :•: : :::..:: : ?ie::il : ei :: :::yz; 5::re 2.1: ire 
-:■: leie^iiry :':: ::z\Lzzir/ :lm:il -:ri: 

:ei iily :::::.::: :y ill:— m 1 5 -ill 11:7 : : -ireiieveily 
. - t: i 7e:.e::ly iem n:'ie:i:e.y -urn ::ve:-5l;i i"i 
rare is valuable in the observation of : (a) Umkemia. (I) 
i~i iielr me': ::: n:ve-ei:i J ::t r.irt :i iiei: -i:~ x 
lapsing fever, (e) Trypanosomiasis, (f) Roulemmx forma- 
affltrim. (A) /jurrase o «,W >bfws. (i) Z#ar «Ifr 
rimate mmmber of red amd white eeOs. (h) Ceil deformity. 



--:•::-! .f .: 
::l::lfii i^ily :r::i::_T _ii:i 

- _ :.t:: :: :t_ ::zzzz-z:~ :: txzz 

r:ZT— — Ii::fiic :: ir-:rfii 

if.emizei :: _rliy if:er lie y> 

1: -Jir :: 
ixr-ilv :e 



my :e 
- _ 1 1 : es 



llir EXAMINATION HE BLOOD 



"5 



No smear is made, but the cover-glass lightly touches the blood drop and 
is then placed upon the slide. The stage should be dimly illuminated to 
show the nbrin threads which frequently radiate from groups of blood 
plates. 

Fibrin is increased in pneumonia, acute rheumatism and various septic 
infections, and diminished in leukemia and pernicious anemia, typhoid Hyperinosis. 
fever, malaria, measles, variola. Graves' disease and various conditions 
associated with extreme inanition. 

In general the hbrin increase (hyperinosis) occurs in diseases in which 
leucocytosis is present though in leukemia itself a diminution (hypinosis) Hypinosis. 
occurs. 

Examination of the Stained Specimen. — Modern staining methods de- 
pend upon the selective affinity shown by the different constituents of the Basis of stain- 
cellular elements of the blood for certain anilin dyes, which are divided into 
three groups: (a) basic, (b) acid, (c) neutral. 

By using combinations one may in a single step attain differentiation. 
The basic dyes, such as methyl violet, methylene blue or hematoxylin (chrom- 
atin stains act chiefly upon nuclei. Acid dyes, such as eosin, orange G. 
or acid fuchsin are protoplasm stains, while neutral dyes (resulting from the 
mixture of acid and basic colors in solution) color beautifully the "neutro- 
phile" granules of the leucocytes. 

Staining Solutions. — Ehrlich's triacid or triple stain now has been dis- 
placed bv Wright's modification of Tenner's stain, an alkaline eosinate Rapid and 

. . . .... simple. 

of methylene blue, which, by at once fixing and staining the specimen, eliminates 
the laborious and delicate heating process of the older method. 

Wright's Modification of Louis Jenner's Stain. — The student or practi- 
tioner had best purchase the "soloid" tablets* or procure a solution ready 
made through some drug supply house, as the formula is somewhat complex.* 
It should be kept tightly corked to prevent precipitation.! 

* The "soloid" tablets of Burroughs & Wellcome offer a ready method of making up fresh 
stain. 

One soloid is tritrated with 10 c.c. of pure methyl alcohol, the dissolved stain decanted 
and the undissolved stain again extracted with another 10 c.c. of alcohol. This process 
is repeated a third time so that 30 c.c. in all is used. The stain should then be passed 
through a filter. 

+ Formula. — (a) Make a 0.5 per cent, aqueous solution of sodium bicarbonate, place 
in Erlenmeyer plaque, add 1 per cent, of Griibler's medicinal methylene blue; place in steam 
sterilizer for an hour, (b) After cooling, add while stirring with glass rod. a 1-1000 aqueous 
solution of Griibler's water-soluble yellowish eosin until the color of the original mixture 
changes to purple and presents a lustrous yellowish scum upon its surface. (About one-fifth 
as much eosin solution as methylene blue solution will be found necessary.) (c) Collect this 
scum by filtration, dry it, and with it saturate methyl alcohol (100 c.c. of the latter will 
dissolve about1%o of a gram of the dry precipitate), (d) Filter and add 25 per cent, of 
methyl alcohol. The stain is now ready for use and, if kept tightly corked, should neither 
precipitate nor show impairment though kept for a long period. 

I The Giemsa stain is another Romanowsky modification of great value, but does not 
yield the best results with neutrophilic granules. 

T. M. Wilson's stain, yet another Romanowsky modification is used in many laboratories, 
but has no decided superiority to Wright's modification of the Jenner stain. 



n6 



MEDICAL DIAGNOSIS 



Technic of Staining. — (i) The dried but unfixed smear is completely covered 
with the stain for one minute. (2) Distilled water is added to the stain on the 
cover-slip drop by drop until a greenish metallic scum appears and the margins 
sJtow a reddish tint. (3) After three minutes the stain is washed off with water 
leaving a purplish specimen, which is washed until the film is yellowish or pink 
(4) gently dried between filter paper, and (5) mounted in balsam. 

Results. — The appearance of the various cellular elements is as follows: 
Action on ceils i the erythrocytes are orange or pink throughout. Erythroblasts show deep 
blue nuclei, blood-plaques are purple, mast-cell granules deep purple, poly- 
morphonuclear leucocytes show lilac or dark blue nuclei, neutrophile granules 
lilac, eosinophile granules pink, fine basophile granules a deep blue stain, 
bacteria and such organisms as malarial parasites blue. Myelocytes show 
a purplish or dark lilac nucleus and reddish or dark lilac granules. 

Ehrlich's Triacid Stain. — The ready-mixed powder for making this 
stain may be bought of any drug supply house and the student or practitioner 
should not attempt to make the original. 

Formula: Ehrlich-Biondi powder, gr. xv. Alcohol {absolute), 1 c.c. 
Distilled water, 6 c.c. 

Fairly good rapid work may be done with a good triple stain in the absence 
of Wright's stain by heating the smear carefully as in the staining of tubercle 
bacilli and staining for thirty seconds or less, washing, drying and mounting 
(Cabot). 

Other heat fixation methods are now so little used that a description is 
not deemed necessary. Scott fixes by a few seconds' exposure to formalin 
fumes before applying Jenner's stain and shows beautiful results. 

HEMOGLOBIN. — Hemoglobin or, more properly, oxyhemoglobin con- 
stitutes about nine-tenths of the bulk of the red corpuscles. It is a proteid 
substance containing 4 per cent, of hemochromogen, an iron-holding body, 
and 96 per cent, of concentrated, almost insoluble albumin which readily 
forms unstable compounds with oxygen. The great value of its determination 
by clinical tests may be readily appreciated. 

Tests for Hemoglobin. — An expert observer can make a rough estimate of 
the percentage of hemoglobin from the appearance of the ordinary stained or 
even the unstained smear preparation as may be readily appreciated by referring 
to Fig. 36, but for accurate work several forms of apparatus have been devised, all 
depending upon a comparison of a given specimen of blood, either whole or in a 
known degree of dilution, with a fixed color scale. 

Tallqvist's Hemoglobinometer.— 77ws, the simplest and least reliable, 
inaccurate. consists of lithographed color bands. Each has a central perforation and 
represents the color of blood in dilutions running from 10 percent, to normal.* 
A drop of the patient's blood is taken up by the absorbent paper and 
the resulting stain is placed under the central perforation of the color bands 
and comparison is made as soon as the stain has lost its wet gloss, not after, 
complete drying. 

* The color scale is bound with 50 sheets of special paper, each divisible into three parts, 
furnishing material for 150 tests. 






THE EXAMINATION OF THE BLOOD 



117 




This is a simple, rapid, but inaccurate method, permitting an error of 
at least 10 per cent., and the color scale fades, if not kept from the light. 
It is distinctly inferior to Dare's instrument which takes hardly a minute 
more of time. 

Dare's Hemoglobinometer. — A circular disc of tinted glass, representing 
variations in blood-coloring matter of a known degree, is brought into direct 
contrast by transmitted candle light with a film of the fresh whole blood 
drawn by capillary attraction between two glass plates, one transparent, 

the other translucent and white. 
A detachable observation tube and 
a circular shield protect the eyes 
from extraneous light, and the per- 
centage of hemoglobin may be read 
directly from the scale. This ex- 
cellent instrument may be used in 
daylight if pointed at some dark 
object, and its readings are not 
materially affected by an excess of 
leucocytes.* 

Von Fleischl's Hemoglobino- 
meter. — This well-known instrument 
or its more accurate modification 
has been largely superseded by the 
simpler and cheaper instrument of 
Dare. If it is used one should pro- 
cure Miescher's modification. The 
following precautions are necessary 
to good results: (a) The capillary tubes for taking the drop must be absolutely 
clean and should be tested out for equality of calibration when purchased. 
ib) All blood must be removed from the surface before mixing, leaving the caliber 
exactly filled, (c) The blood must be taken quickly, washed out into the chamber, 
and thoroughly mixed in the shortest possible time, (d) The observer should \ 
face the end of the movable colored wedge with the thumb-screw on his right, 
(e) Decision as to color should be made quickly to avoid- uncertainty and confu- 
sion. (/) The thumb-screw should be sharply turned in order to obtain as vivid 
a contrast as possible until the final match of color is achieved, (g) Should the 
blood solution appear turbid and lack proper color, as in the case of leukemia, 
add a few drops of a dilute aqueous solution of potassium hydrate, (h) Where 
the hemoglobin is below 30 per cent., double or treble the usual amount of 
blood should be used, the percentage obtained being divided proportionately . 
(i) The examination should be made in a dark room, or by means of a light- 
proof box by candle light, and in any case some form of tube shoidd be used 
for observation, a simple roll of black paper being ordinarily sufficient. 

Hemoglobin Estimation by Specific Gravity. — By the use of tables to be 

* This instrument is now made with a battery handle and pushbutton circuit 
breaker which adds greatly to its usefulness. 



Fig. 31. — Dare's hemoglobinometer- 
U. Observation tube. T. Shield. W- 
Removable plate with capillary opening for 
holding blood. X. Thumb-screw holding 
same. Y. Candle holder and candle. S. 
Case holding color disc R. Milled wheel 
or revolving color disc. 



Simple and 
reliable. 



n8 



MEDICAL DIAGNOSIS 



found in all the larger works dealing with this subject the hemoglobin present 
in a given specimen may be very accurately estimated by Hammerschlag's 
modification of Roy's method. The procedure is too cumbersome and fussy 
to be recommended to the practitioner and will not be described. 

Oliver's Hemoglobinometer. — As shown by Fig. 33, this instrument de- 
pends upon the scale of colors based upon diluted blood. Its use is suffi- 




Axt excellent 
instrument. 



Courtesy of A. H. Thomas 6* Co. 

Fig. 32. — Von FleischPs Hemoglobinometer (Miescher's Modification). — Description. — 
Milled wheel at left (T) moves a tinted glass wedge (R)' under the fixed metal stage sur- 
mounted by double chamber reservoir which receives light from the calcium sulphate 
reflecting disc (P S) below. Half of the same chamber is filled with the diluted blood con- 
tained in the measuring capillary pipette (Mel) . The other contains only plain water but 
receives its light from the colored wedge. By moving the wedge back and forth the colors 
are matched and the percentage reading is shown on a scale visible through the opening (M) 
just in front of the supporting-upright. The blood is obtained in exactly the same manner 
as for a blood-count, the diluent being calcium carbonate solution (0.1 per cent.) and the 
tube permitting the observer to use dilutions of 1 1200, 1 1300 or 1 1400 according to the 
height to which the blood column is allowed to rise (marks }{, %, % respectively) before 
diluting and thoroughly mixing. Increased accuracy is obtained by the use of a grooved 
cover glass (D') which fits over the slightly raised partition dividing the two chambers, 
which must each be so filled as to present a convex meniscus. The necessary narrowing 
of the field is secured by cap-diaphragm (Bl') The average of at least ten determinations 
is required for accurate work. 

ciently indicated by the diagram and it has no advantage over the two 
preceding methods. 

Gower's Hemoglobinometer. — This little instrument has the merit of 
extreme simplicity, yet in practice one may lose more time by its use than 
with the other more elaborate instruments, inasmuch as a slight error in dilu- 
tion means a repetition of the whole process. 

Sahli's Hemoglobinometer. — This admirable instrument resembles Gow- 
er's hemometer, but is well adapted to quick, accurate work. 



THE EXAMINATION OF THE BLOOD 



119 



The cm ply graduated tube is filled to the mark 10 with a deed normal solution 
of IICl which is saturated with chloroform. 

The blood is then added by means of a measuring pipette and the mixture 
made thorough and complete. Finally, after mixing for exactly one minute, dis- 
tilled water is added, guttatim, until the color corresponds to that of the control 
tube which contains an acid hematin solution. 

The color comparison is easy and definite, but 90 should be considered 
an average normal and the instrument should be kept in its case or in a dark 
place and inverted once or twice before using.* 




Fig. 33. — Oliver's hemoglobi- 
nometer. The discs shown as 
white in the illustration are 
colored to represent the various 
blood dilutions and direct com- 
parison is made with a solution of 
the actual blood obtained by a 
measured mixing capillary pipette 
furnished with the instrument. 
Intermediate readings are ob- 
tained by placing squares of 
tinted glass over the fluid under 
examination. 




Fig. 34. — Sahli's hemoglobinometer. 



The author believes that the hemometers of Dare and of Sahli best 
combine simplicity with adequate clinical accuracy. 

Universal Micro-colorimeter. — Dr. Theodore Kuttner of New York has ; 
devised a pocket-size colorimeter which apparently is well adapted to several 
procedures chief of which are (a) the hemoglobin test, (b) the estimation of j 
glucose in the blood by a modification of Benedict's method, and (c) the 
phenolsulphonephthalein test.f 

* The instrument registers a maximal normal represented by the blood of healthy 
young Swiss males. Ninety per cent, would represent fairly an average normal. 

^Journal A. M. A., July 17, 1915, pages 245 and 246. Journal A M. A., April 29, 
1916, 1370-1373- 



120 



MEDICAL DIAGNOSIS 



An abstract of Dr. Kuttner's description is appended covering its appli- 
cation to these three procedures. 

Description of the Instrument. — The same calibrated and color tube em- 
ployed in the Sahli-Gower hemoglobinometer has been adopted for this 
instrument. 

The Sahli allows both the calibrated and m color standard tubes to be 
viewed at full length; the new instrument, however, shows only a small 
part of the tubes when making color comparisons. This facilitates the color 
reading and is less fatiguing to the eye. An additional feature is a prism 
(A), to be described, which visually causes the contents of the tubes 
to approach each other more 




10 11 



closely, thereby accomplishing 
greater accuracy in the com- 
parison of colors. 

The instrument consisting 
of a closed upright box (dimen- 
sions 2.5 cm. by 8.5 cm.) is 
smaller than the Sahli. At 
the top there are two openings : 
one for the color tube, the 
other for the calibrated tube. 
Near the lower front part is a 
window provided with the 
above-mentioned prism (A — 
Helmholtz double plates), 
which serves the purpose of having the colors of both tubes appear close 
together, forming one continuous color band. The prism is easily removed 
for cleansing and can be quickly readjusted. A sliding door (B), which can 
be raised and lowered, protects the prism from dust and injury. The color 
standard and calibrated tube are separated from each other by a partition, 
which prevents light from being reflected from one tube to the other. 

Directions for the Estimation of Hemoglobin. — (Standard color tube 
" Hematein" = 15 gm. Hgb = 20 ex. 2 .) — Into the calibrated tube No. 9 
enough of a 34 normal solution of HC1 is poured to reach the mark 10. 
With the capillary pipette No. 1 blood is drawn to the 20 cmm. mark, the 
sides of the pipette wiped with absorbent cotton and the blood expelled while 
dipping the pipette to the bottom of the calibrated tube. Water is sucked 
up 2 or 3 times and these washings added to the tube. This is set aside for 
1 to 2 minutes and then compared with the standard color tube in the in- 
I strument. Water is added drop by drop, the solution well mixed after each 
addition, until the color matches that of the standard. When this is accom- 
plished, the percentage can be read off directly by noting the figure which the 
meniscus has reached on the scale. As percentages occurring much below 
50 are liable to error, it is best to use more blood when such anemic cases are 
encountered. Thus, in order to obtain greater accuracy, 2, 3 or 5 times the 
amount of blood should be taken, with capillary pipette No. 2 also twice the 



THE EXAMINATION OF THE BLOOD I 21 



amount of ] 10 normal HC1 and the same process should be followed, but the 
result must be divided by 2, 3 or 5. 

Directions for the Estimation of Sugar in the Blood. — (Standard Color 
Tubes A and B). — According to Dr. Epstein's modification of Benedict's 
method, the procedure is as follows: 

0.2 c.c. of blood is drawn with pipette No. 3 and discharged into a gradu- 
ated test-tube containing 1 drop of 2 per cent, fluoride of sodium solution or 
calcium oxalate, the pipette rinsed 2 or 3 times with water, the rinsings 
added to the test-tube, then water to the 1 c.c. mark. Saturated solution of 
picric acid is added up to the 2.5 c.c. mark, the mixture well shaken and now 
either filtered or centrifuged. Of the clear, supernatant liquid 1 c.c. is 
measured with a pipette and boiled down to 2 or 3 drops in a boiling test-tube, 
0.5 c.c. of a 10 per cent, sodium carbonate solution added and again boiled 
to crystallization, which occurs when the contents are concentrated to about 
2 to 3 drops and becomes brownish-red in color, according to the amount of 
sugar present, when the process is completed. A few drops of water are 
added, the tube w r armed and contents transferred to the calibrated tube of 
the micro-colorimeter. The tube is rinsed with sufficient water, a few 7 drops 
at a time, the total volume reaching the mark 50 and compared in color with 
the standards. If it is darker than A, but lighter than B, then the former 
is used as standard, and compared in the instrument by adding w r ater drop 
by drop to the fluid and mixing. When the colors have exactly matched, the 
height to which the fluid has risen is read off on the scale, this figure divided 
by 1000 representing the percentage of sugar in the blood. If the darker 
tube B is used, the result must be multipled by 2. Using this tube with the 
meniscus having reached mark 85 on the scale, then 85 X 2 = 170. 

170 -r- 1000 = 0.17 per cent. 

As it often happens that diabetic blood may contain 0.3 per cent, or more 
of sugar, it would be necessary to use less blood. It is better to take two 
specimens, one as already stated and another with pipette No. 2, which 
measures only 0.1 c.c. of blood, then proceeding in the same manner as 
already described, but multiplying all obtained figures again by 2. Com- 
putation would then be as follows: If the color matched the darker tube B 
at 85, but using only 0.1 c.c. of blood then 

85 X 2 X 2 = 340 

340 -s- 1000 = 0.34 per cent. 

If the color matched the darker tube B at 140, the computation is thus: 

140 X 2 X 2 = 560 
560 -T- 1000 = 0.56 per cent. 

Normal blood contains from 0.06 per cent to 0.12 per cent, sugar. It is 
best to take the blood before breakfast. 

Directions for the Phenol-sulphon-phthalein Test. — (Color Standard 
Tubes Xo. 1, Xo. 2 and Xo. 3). — The patient's bladder is emptied (if necessary 



122 



MEDICAL DIAGNOSIS 



with catheter), about 250 c.c. of water given to drink and 34 hour later 
1 c.c. of phenol-sulphon-phthalein solution containing 6 mgm. of substance 
is injected intramuscularly in the region of the buttock. Each ampule 
contains somewhat more than 1 c.c. of the sterile solution. 

The urine is collected in small beakers containing a few drops of Sodium 
Hydroxide solution every 2 or 3 minutes. When the first pink is seen as the 
urine comes in contact with the alkali, the time is noted. The patient is 
then required to urinate again in 1 hour and in 2 hours in two separate con- 
tainers. Each quantity is then measured, 10 c.c. of 10 per cent, of sodium 
hydroxide solution added and each made up to 200 c.c. with water. 

Of this red colored fluid 2 c.c. is withdrawn, using the 2 c.c. pipette and 
made up to 10 c.c. with water in graduated test-tube (No. 5 or 6). Enough 
of this solution is placed in the calibrated tube of the Micro-colorimeter by 
means of the transferring pipette to the 50 mark on the scale. It is now com- 
pared to the color standards 1 and 2. If it is darker than 1, it is diluted drop 
by drop with water until the color matches, the percentage being read off 
the same as in the Sahli-Hemoglobinometer. If tube 2 is used, the reading 
must be divided by 2. 

Should the color be too light, after it had been diluted to 10 c.c., then 
only a dilution to 5 c.c. may be used and compared the same way, but the 
final figure obtained is to be divided by 4. If the urine contains very small 
amounts of the excreted dye, then the urine should be used without further 
dilution directly in the calibrated tube up to the 50 mark, but it must be 
compared to special color tube No. 3, which has a yellowish tint, and the 
reading divided by 10. 

Between 40 and 60 per cent, (average 50 per cent.) of the dye is eliminated 
during the first hour and from 60-85 per cent, totally after 2 hours and only 
traces eliminated during the following hours.* 

Care and Use of the Pipettes. — Four pipettes are furnished with the 
instrument: No. 1., up to 25 cmm.; No. 2. 34 c - c - divided into ten 
divisions; No. 3. %0 c.c. divided into ten divisions; No. 4. 2 c.c. divided 
into ten divisions. 

Pipettes must be clean and dry before use. 

When the required amount has been drawn into the pipette the tip of 

] the tongue should be placed against the mouthpiece attached to the rubber 

tubing of the pipette. Before expelling its contents, the pipettes are held 

in a horizontal position and wiped with absorbent cotton. After use, they 

should be immediately cleaned, first with water, then alcohol and then ether. 



Chief normal 
forms. 



ERYTHROCYTES AND LEUCOCYTES 

Classification of Leucocytes. — The simplest modern classification deals 
with six normal varieties: (1) The polymorphonuclear neutrophiles which 
constitute from 60 to 75 per cent, {average 70 per cent.). (2) The small lympho- 
cytes, 20 to 25 per cent, {average 20 per cent.). (3) The large mononuclear 

* The test is described more fully in its proper section. 



PLATE I. 





~ 


■ ■ 


v. 










"• #0 ' '" ,2 




1 lHw ■ 


6 MR 




v 





I....I....I....I 



Chief varieties of cells encountered in health and disease (Wright's stain), i. Normal 
red cell. 2. Common form of polymorphonuclear leucocyte. 3. Lymphocyte. 4. 
Eosinophilic myelocyte. 5. Eosinophilic leucocyte. 6-6. Neutrophilic leucocytes: upper 
left, transitional form, on right neutrophilic myelocyte. 7-7. Large mononuclears. 8. 
Normoblast. 8. Normoblast showing division of nucleus. 9. Normoblast nucleus. 
io-ii. Basophilic leucocytes. 12. Megaloblast. 



THE EXAMINATION OF THE BLOOD 



123 



(averages 5 per cent.). (4) The transitional forms, 2 to 4 per cent. (5) 
Eosinophils 0.5 to 5 />(•/• cent, (average 4 />£r cew/.). (6) Basophiles, 

"mast" cells 0.1 to 0.5 /><t <y///. 

Sources of White Cells. — Ii was believed formerly that all granular 
leucocytes originated in the bone marrow and that the lymphocytes chiefly 
came from the lymphadenoid tissues, but the latest researches indicate 
that the red bone marrow is the chief source of all varieties. 

1. The Polymorphonuclear Neutrophile. — This cell measures 7.5 to 12/x, 
averages about ii/j., and is characterized by its irregular lobulated nucleus, 
staining dark blue and connected by chromatin strands, and the presence 
of neutrophilic granules in the protoplasm which take a lilac or pink color with 
Wright's stain.* 

2. The Small Lymphocyte. — This measures 5 to ioju and contains a single 
round deep-staining nucleus almost filling the cell and often obscuring the 
border of protoplasm, the latter being almost wholly unaffected by the triple 
stain, but colored sky-blue if the Romanowsky method be employed. 

3. The Large Lymphocyte. — This measures 10 to 15 n and carries a round 
or oval nucleus staining pale blue, and a relatively large amount of proto- 
plasm. It differs from 

4. The transitional leucocyte, only in lacking the indented crescentic 
or reniform nucleus of the latter. 

5. Eosinophils (8 to 11/z). — These are readily recognized by their coarse, 
acid-staining granules and polymorphonuclear type. The granules are 
especially brilliant in certain parasitic infections and septic conditions 
(Gulland). 

6. Basophiles (Mast Cells) (7.5 to 12/x). — The distinguishing feature of 
the basophile cell is the presence of its fine, basic-staining granules. The 
nucleus is polymorphous and stains a pale green with the eosin and methylene- 
blue mixtures. The characteristic granules are best shown by Wright's 
stain or that of Leishman and not at all by the triple stain. 

UNUSUAL OR ABNORMAL FORMS.— The myelocytes (marrow cells) 
(15-20^) are large immature forms of the granular leucocytes and may con- 
tain neutrophilic, eosinophilic or basophilic granules, thus constituting three 
sub-varieties. They are the dominant cells of the normal bone marrow. 

The nucleus is spherical or oval, tends to be eccentric, poor in chromatin, 
staining feebly or moderately with the blue, occasionally shows division and 
often a marginal light circle. 

The presence of the granules distinguishes the myelocyte from the myeloblast 
and large mononuclear forms and the lack of lobulation or twisting of the nucleus 
from the polymorphonuclear cell. Occasionally it is slightly indented. 

With Wright's stain the neutrophilic myelocytes show lilac or pink gran- 
ules with a purplish admixture. Eosinophilic myelocytes show the ordinary 
coarse, brilliant, eosinophilic granules, occasionally showing some basophile 
admixture. 



Lobulate 
nucleus. 



Single round 
nucleus. 



Relative 
excess of 
protoplasm. 



Coarsely 
granular 
" polymorphs." 



Basic 
"polymorphs.' 



Immature 
form. 



* Ehrlich's triacid stain is also very effective. 
dye is requisite. 



In general, a mixture of an acid and basic 



I2 4 



MEDICAL DIAGNOSIS 



Normally 
lacking in 
circulation. 



Significance. — Found in the circulating blood the cell is invariably 
pathologic, occurring in many cases of profound anemia or excessive 
leucocytosis, occasionally in lymphatic leukemia and Hodgkin's disease, 
but only in small numbers, whereas, in myelogenous leukemia they are 
the most characteristic and predominant of the white cells. 

The Meta-myelocyte. — This represents a transitional stage between 
the myelocyte and the transitional form of the polymorphonuclear 
leucocyte. 

The cell is relatively small, the nucleus is more strongly basophile and 
gives evidence of beginning segmentation. It is present only in association 
with the myelocyte. 

The Myeloblast. — This scantly-or non-granular form, dominant in embry- 
onic myeloid tissue, probably the mother cell of the granular (marrow) 
myelocyte, differs from the large lymphocyte morphologically, chiefly in 
the following particulars (Naegeli). 

(a) Constant absence of the clear perinuclear zone. 

(b) Decided differences in nuclear form and structure. 

(c) Greater number of nucleoli. 

(d) In strongly heated specimens stained with methylene blue the 
lymphocyte nucleus is pale and shows i or 2 nucleoli very distinctly; the 
myeloblast nucleus is stained intensively and does not show its nucleoli 
(2 to 6). 

The greater chromatin content of the myeloblast nucleus is also evident 
if the triacid stain is used. Small forms are occasionally encountered. 

Naegeli strongly recommends the use of the Schridde-Altmann staining 
process for differentiation. 

This is a tedious and prolonged procedure, the technic of which is to 
be found in Naegeli' s book or some of the recent works devoted wholly to 
this branch. 

These cells are rarely present save in the crises of myeloid leukemias and 
perhaps pernicious anemia and the infantile forms. 

Pro-myelocytes. — These represent a transition form between the myelo- 
blast and the myelocyte. 

The nucleus is large and poor in chromatin, nucleoli are present (none 
visible in fully developed myelocyte) and the protoplasm is strongly basophilic 
and contains a few, small, scattered granules. 

Turck's Irritation Forms. — These are large cells, probably identical with 
the " pathologic" myeloblast, containing absolutely no granules in their 
protoplasm, usually showing vacuoles, especially likely to appear during an 
acute infection and of little or no clinical importance or significance. 

Giant Marrow-cells. — {Megakaryocytes). — These progenitors of the blood 
platelets are huge cells with large convoluted nuclei. 

Their occurrence in the blood is rare, accidental and extremely brief, as 
they- cannot pass the capillaries. 

Lymphoblasts. — A replica of the small mononuclear cell in its 
morphology, but the equal of. the large mononuclear in size, is found 



THE EXAMINATION OF THE BLOOD 1 25 

occasionally in the blood of normal children and in the adult suffering from 
disease.* 

It is important only because confusing, when the possibility of its presence 
is not known. 

The Schridde-Altmann Granules are merely acidophil granules within the 
leucocytes brought out by the use of the special stains of Schridde or Freiteld 
and have no special clinical value or significance. 

"Azure Granules" within the lymphoblast protoplasm are said to be in- 
constant in ordinary leukemia of the lymphatic type but constant in 
the acute form. 

They are developed best by the Giemsa or Wilson stain and so shown 
occur only in the small lymphocyte as red granules. 

Giant Lymphocytes. — {Pathologic Lymphoblasts) . — These abnormally large 
cells carry a round nucleus, poor in chromatin, staining but slightly with 
methylene blue or the triacid stain, somewhat better with eosin-hematoxylin 
and showing very clearly its nucleoli. 

This form includes the cells with lobulate nuclei described by Rieder, but 
in these there exist only deep fissures or indentations (Naegeli). 

Such cells may constitute the dominant type in acute leukemia, and usu- 
ally indicate an extremely rapid and malignant type of case (Sternberg- 
Naegeli) . 

Melanemia. — Pigmented leucocytes occur in cases of melanotic sarcoma 
and, in malaria, free in the blood, during the segmentation stage of the 
disease. 

Iodophilia. — If a dry but unfixed smear be gently pressed down upon 
a generous drop of specially prepared iodin and potassic iodid solution! 
the normal blood cells take a uniform yellow tint, but in septic conditions 
both intra- and extra-cellular brown granules are seen or a diffuse proto- 
plasmic staining occurs, especially affecting the neutrophilic leucocytes 
and, rarely, the basophiles and myelocytes. 

The reaction is reasonably constant in septic conditions (not in pure 
tuberculous abscesses), but is present in many other diseases, such as purpura 
hemorrhagica, acute miliary tuberculosis, certain typhoids and malignant 
disease. It is of genuine value in the differentiation of septic from non- 
septic effusions and joint diseases. 

Perinuclear Basophilia. — Neusser's perinuclear basophilic granules 
occurring in specimens submitted to the triacid stain were regarded by him 
as indicating the uric acid diathesis, but now are proven to be artefacts 
and of no diagnostic significance. 

The Inclusion Bodies of Dohle. — These may be found in the blood smears 
of patients suffering from scarlet fever and in several other acute infections 
(syphilis, measles, erysipelas). 



* Probably the parent cells of the normal "large mononuclear leucocyte," and 
lymphocyte. 

f Iodin i, potassium iodid 3, water 100, gum Arabic 50. 



126 



MEDICAL DIAGNOSIS 



The normal. 



Polychro- 
matophilia. 



Erythroblasts. 



They are readily detected under simple staining with Loeffler's methylene 
blue, as coccus-like, irregular, rodlike or crescentic bodies lying usually 
within the polymorphonuclear leucocytes. 

Plasma Cells. — These may reach the circulation in congenital hemolytic 
jaundice, multiple myeloma and leukemia, though normally encountered in 
small numbers only in the bone marrow, lymph glands, spleen and connective 
tissue. 

Pathologically they are associated with the granulomata and are especi- 
ally prominent in syphilitic lesions. 

They are strongly basophilic and granular, often triangular in outline 
and the single nucleus of "wheel-spoke structure" is small and eccentrically 
placed. 

A clear perinuclear zone is invariably present in these cells. 

THE RED BLOOD CELL.— Each cubic millimeter of human blood should 
contain from 4,500,000 to 5,000,900 erythrocytes, the former number repre- 
senting the average normal for the female, the latter that for the male. A 
fluctuation of half a million cells may be assumed as within normal limits. 
The average size of these cells is 7.5/z, but a wide normal variation is possible 
(6.5 to 8.5/x). 

Under pathological conditions one may meet with (a) extremely small, (b) 
giant, and (c) nucleated, erythrocytes. 

Abnormal Erythrocytic Forms. — Variations in Shape and Size. — Deform- 
ity and great variation in size may occur in varying degrees in all profound 
anemias. Thus we may have poikilocytes, showing all sorts of bizarre forms, 
the megalocytes (9 to 20/4), and the microcyte (3 to 5/4). 

The megalocyte is especially common in anemias of the pernicious or the 
profounder secondary type, containing, according to Da Costa, an. excess of 
.hemoglobin in the former and a deficiency in the latter. 

The poikilocyte is characteristic of anemia in its more extreme forms, but 
is chiefly observed in pernicious anemia and leukemia. Cabot lays stress 
upon the abundance of the oval forms in the former disease. 

The microcyte is more commonly associated with chlorosis or relatively 
severe grades of secondary anemia. 

Unusual Erythrocytic Staining Reactions. — In severe anemias and espe- 
cially in myelogenous leukemia and pernicious anemia one meets with cells 
which have lost their normal affinity for an acid stain and take indifferently 
both acid and basic elements of a mixed stain. The coloring is often irregular 
and in the nucleated forms may affect the nucleus as well as the protoplasm. 
The greater the deficiency of hemoglobin in the individual cell the stronger is 
the polychromatophilic tendency and its affinity for the basic element in the 
mixed dye. The corpuscles of Poggi take the basic stain in fresh unfixed 
specimens. 

Nucleated Red Cells. — The erythroblasts are classified by their size as 
normoblasts, megaloblasts and microblasts. 

The normoblasts (7.5 to io/*) have a deep basic-staining nucleus with 
sharp definition and coarse nuclear structure, occupying usually about half 



THE EXAMINATION OF THE BLOOD 



127 



the cell body, but often very small and not infrequently divided or undergo- Small 
ing karyokinesis. They are said to occur in the course of severe anemias in 
successive crops or blood crises lasting but a few hours, but are seen chiefly significance. 
in severe chlorosis, myelogenous leukemia, pernicious anemia or after severe 
hemorrhage, and are in general an indication of blood regeneration. 




Characteristics. 



Significance. 



Fig. 36. — A. Normal blood. B. Chlorosis. C. Pernicious anemia. The plate shows 
the sharp contrast between cells normally rich in hemoglobin and the light cell of chlorosis 
and also the poikilocytosis and marked variation in size noted jnJpernicious_anemia. (A 
normoblast and megaloblast also appear.) Stained smears. j 

The megaloblast (n to 20/z) has a central or peripherally placed nu- 
cleus of fine structure which stains a faint blue or green and in triple stain the 
specimen is surrounded by a definite white ring. The nucleus is usually large, 
more rarely strikingly small and deeply staining like the normoblast or micro- 
blast. It represents defective hemogenesis and signifies degeneration, being 
found as a prevailing type of erythroblast only in primary pernicious anemia, 
nitro-benzol poisoning, and bothriocephalus anemia. In any severe anemia an 
occasional cell of this type may be found. I 

The microblast (5 to 6ju) presents essentially the same appearance, aside I 
from size, as the normoblast and has the same clinical significance. 

Unusual Forms. — Various mixed types are encountered (mesoblasts) | 
which defy differentiation, showing contradictions in size and staining Mesoblasts. 
reaction; some, which Da Costa regards as immature normoblasts, show a 
pale nucleus with acid stain stippling and polychromatophilic protoplasm. 
Yet others, large in size, contain a small deeply basic staining nucleus and 
faintly stained protoplasm. These he would classify as megaloblasts. « 



128 



MEDICAL DIAGNOSIS 



Differential 
value. 



Significance. 



Ring bodies. 



Of slight 
importance. 



'Jolly bodies. 



Instruments 
and technic. 



Pipettes, 
counting 
chamber. 




Fig. 37. — Basophilic 
stippling and Cabot's ring 
bodies. (After Cabot, 
Ewing and DaCosta.) 



Basophilic Erythrocytes may be encountered, showing fine, coarse, spicular 
or even ovoid granules of regular or irregular distribution. These cells occur 
in lead poisoning, in chlorosis with intestinal auto-intoxication and practically 
all of the profound or pernicious forms of anemia, but are absent in the anemia 
of renal and hepatic disease, the acute infections, syphilis and diabetes. . 

Cabot has described and drawn extraordinary intra- and extra-cellular 
ring bodies in lead poisoning, pernicious anemia and lymphatic leukemia. 
They have also been found by Da Costa in the 
profound anemias of sepsis. Basic ring bodies 
were previously described by Strauss and Rohn- 
stein. It is now known that these for. the most 
part take the acid stain of Wright's solution, 
rarely the blue. 

Maurer ? s Spots. — These bodies appear in the 
infected erythrocytes of victims of estivo-autumnal 
malaria, as irregular, dark violet-red, spots of 
variable size. 

Special staining is required* and they lack 
clinical significance other than their association 
with the (readily demonstrable) malarial organism. 

Schufifner's Stippling. — {"Schujfner's spots"). — These very minute dark 
red dots are seen chiefly in the infected erythrocytes of tertian malaria 
and are of no clinical importance. 

Howell's Bodies, f — These are perfectly round, sharply defined bodies 
occurring at times in the nucleated red cells, usually single, but, in rare 
instances multiple, staining precisely as nuclear substance would, occurring 
chiefly, as might be anticipated, in blood crises, but occurring oftenest in 
the normally staining, non-polychromasic cell. 

It will be noted that they are quite unlike the'nuclear fragments frequent 
in the many forms of anemia associated with the appearance of the ery thro- 
blast. 

THE BLOOD CELL COUNT.— The differentiation of the various 
types of anemia requires that the number of cells "contained in 1 cu. mm. 
of any given blood be determined directly and differentially and this is 
readily done with the modern apparatus. The whole process as hereafter 
detailed should be smartly carried out and the different steps outlined be 
carefully observed. 

The Thoma-Zeiss hemocytometer consists of two graduated capillary 
pipettes, i.e., the erythrocytometer and the leucocytometer for counting red and 
white cells respectively, and a stage carrying a ruled square millimeter which 
is itself divided into 400 squares of J^o mm - The plateau carrying the 
ruled surface is surrounded by a moat, the outer walls of which are 3^0 mm - 
higher than the ruled plateau. 



* Maurer's modification of the Romanowsky. 

f Often called incorrectly "Jolly Bodies." Reported by Howell in ii 
by Jolly in 1908. The term " Howell- Jolly " bodies is equally incorrect. 



ii; in Germany 



IIII KXAMINATION OK THE BLOOD 



129 



This, the older type of blood-counter, is still generally used though the 
newer counting chambers are much superior. 

The Red Count. — The blood is drawn into the pipette by suction or capil- 
lary attraction from the drop obtained by puncture until it reaches the point 
marked 1. The point is then rapidly wiped dry and the diluent quickly 
drawn in until it fills the bulb and reaches the mark 101.* 

While drawing in the diluent the pipette is revolved between the finger 
and the thumb to set in motion the mixing bead contained in the bulb and 
when rilled, again thoroughly shaken and revolved for half a minute. This 
mixing should be repeated each time before expelling a drop for examination. 






Or Carl B Drake 




Fig. 38. — Ruling of the Gorgajew- 
Pappenheim counting chamber. 



Fig. 39. — Thoma-Zeiss blood 
counter, showing pipette, count- 
ing chamber and a part of the 
ruled field. 



One has then a mixture, each drop of which presents a blood dilution of 
1 : 100. 

Many prefer a 1 : 200 dilution readily obtained by using the mark 0.5 
as the upper limit for the indrawn blood. The blood rises quickly if the 
pipette is perfectly clean and may exceed the proper level if not watched 
or checked by withdrawing the point and quickly wiping it. If the higher 
dilution is used any excess is readily blown out or better drawn down by 
touching the tip with filter -paper or blotter. 

The next step consists in expelling the diluent occupying the capillary 
portion of the tube, after which a small drop of the mixture in the bulb is 
placed upon the central disc (shown in Fig. 39 (B)), the cover-glass is placed 
in position and the cells given time to settle. 

The drop should just fill the central plateau without running over into the 

* The diluent usually used is Toisson's solution. Formula: Methyl violet 5B (0.025), 
sodium chloride (1.0), sodium sulphate (8.0), neutral glycerin (30.0), distilled water (160.0). 

Hayem's solution contains mercuric chloride (0.25), sodium chloride (0.5), sodium 
sulphate (2.5), distilled water (100.0). Any such solution must possess two qualities — 
it must prevent coagulation and be isotonic. 
9 



Accurate 
dilution. 



Thorough 
mixing. 



Higher 
dilution. 



Disposal of 
excess. 



Transfer to 
counter. 



Caution. 



13° 



MEDICAL DIAGNOSIS 



Test of 
accuracy. 



Proper field. 



Necessary 
checks. 



moat around it when the cover-glass is applied, else the process must be repeated 
after thoroughly cleaning and drying both the cover-glass and the counting 
surface. 

If the proper distribution of the drop upon the plateau has been attained, 
concentric color rings (" Newton's rings") should be visible when the surface 
of the applied cover-slip is held toward the light at, or slightly below, the 
level of the eyes. 

The absence of these rings vitiates the count and indicates usually dust 
or moisture on the glass. The correct size of the drop itself must be learned 
by experience. It should cover the plateau without overflowing. 

The specimen, when placed under a. microscope carrying a Leitz No. 6 
objective and No. 4 ocular or their approximate equivalents, should show 
a uniform distribution of blood cells over the entire field, ruled or 
unruled. 







Fig. 40. — Thoma-Zeiss ruling. 



Fig. 41 — Neubauer's ruling. 



Counting. — One must count now the number of red blood cells lying within 
a definite known number of ruled squares, including for each square those in 
contact with or overlapping two of its four sides. 

For thoroughly accurate painstaking work, such as would be necessary 
in actual research, the entire 400 squares should be counted and several 
drops of the mixture so treated. For clinical purposes a less number may 
be taken if the blood is well distributed, but several should be examined. 
With pencil and paper at hand an accurate record of the cell count should be 
jotted down as the work proceeds. 

Rationale. — The number representing the total cells counted must be 
divided by the number of lesser squares in which they were contained. 
The result of this division would represent the average number of cells in 
each ruled square. The sides of the small squares each measure J^o mm « 
and the depth of the liquid J^o mm - yields a third dimension. Multiplying 
}4o X Ho X }{o = Mooo cu - mm - as the cubic content of each square 
used during the test. 



THE EXAMINATION OF THE BLOOD 



131 



Rapid 
method. 



The blood itself has been diluted 100 times. The cubic area of each 
smaller ruled square is J4000 cu. mm. We desire to record the number of 
erythrocytes in each cubic millimeter of the blood under examination. 

We must, therefore, multiply the average number of cells per square by 4000 
/() get the number in 1 cu. mm. of the mixture, and this result by 100, the degree 
of dilution of the blood, to get the actual number of erythrocytes per cubic milli- 
meter of the undiluted blood itself. 

This resolves itself into the following simple formula in dilutions of 1-100: simple rule 
Divide the total number of red cells counted by the number of squares covered, 
and multiply the quotient so obtained by 400,000. 

Example. — One hundred squares are found to contain 1200 red cells: 
1200 -5- 100 = 12 cells per square = 12 cells in 3^000 cu. mm. of blood 
diluted 100 times. 12 X 4000 X 100 = 4,800,000 cells per cubic millimeter. 

// but 40 squares were covered, 480 cells would have been counted and, by 
an arithmetical coincidence, all 40-square counts with a dilution of 1-100, and 
all counts of 80 squares with a dilution of 1-200, may quickly be determined 
by placing four ciphers at the right of the figures representing the total cell 
count, i.e., 40 squares (1-100 dilution) contain 480 cells, 80 squares (1-200 
dilution) contain 480 cells; annexing four ciphers in each instance, we have 
4,800,000, the actual count per cubic millimeter. 

If the entire 400 ruled squares composing the large square were counted 
in this case, the total cells enumerated would have been 4800, or ten times 
the number of cells in our 40 squares and would represent the number of 
red cells in }{ q cu. mm. of blood diluted 100 times, i.e., 3^000 of the number 
contained in a cubic millimeter of the undiluted blood. 

Hence in counting 400 squares the exact number of red cells per cubic milli- 
meter of blood may be determined by annexing three ciphers to the number repre- 
senting the total of cells enumerated in the entire large square. 

If to be again used at once, air should be blown through the mixing tube 
by means of a hand bulb and rubber tube, not the mouth. The counting 
chamber should be cleaned with cold water only and should not be ex- 
posed to high degrees of heat or, for long, even to direct sunlight, for fear 
of softening the cement. 

The Leucocyte Count. — For this the large-calibered pipette is used with 
a diluent consisting of a 1 per cent, aqueous solution* of glacial acetic acid 
which leaves visible only the white cells and the nucleated reds. 

This pipette is graduated in tenths to a point 1 (one) for the measurement 
of the blood used and shows also a symbol 11 (eleven) above the bulb 
containing the mixture of blood and glacial acetic acid solution. When 
filled, the blood is ten times diluted. 

The most accurate counts are made by using 0.5 rather than 1 as the basis 
of dilution, and even this requires a good-sized drop of blood. Furthermore, 
the pipette must be kept nearly horizontal at the time and after the diluent is 
added, else it will run out of the tube. 

* A 1 per cent, solution of glacial acetic acid is more certain in its action and a few drops 
of methyl violet or gentian violet stain may be added to advantage. 



Precautions. 



Instruments 
and technic. 



MEDICAL DIAGNOSIS 



Tiirck's 
chamber. 



Basis of 
count. 



Use of erythro- 
cyte counter. 



Drops 
required. 



Laborious 
but valuable 



The diluent is added to the point n and the count made with the erythro- 
cyte counting chamber, or better with Tiirck's chamber in which the central 
ruled square {one square millimeter ( l {q cu - mm.) containing 400 small 
squares) is surrounded by eight partially ruled squares of the same size. 
The total obtained by counting the leucocytes in the nine square millimeters 
(representing 3600 small squares) is multiplied by 200 (dilution 20 by 10 to 
get cubic millimeters) and divided by 9, assuming a dilution of 1-20 as above 
described. 

The actual count is based, therefore, upon the total count of white cells 
in any number of square millimeters, multiplied by the dilution, multiplied 
again by the third dimension of the cubic millimeter (10) and divided by the 
number of large squares (square millimeters) covered in the count. 

If the ordinary counting chamber is used, the entire field of 400 ruled 
squares should be counted and the total number of leucocytes found multi- 
plied by 100 if the dilution be 1-10 or by 200 if it be 1-20. The process is 
greatly facilitated by inserting in the tube of the ocular an eyepiece diaphragm 
which will cut off exactly 100 of the small squares. This may be bought, 
or can be made by the physician from metal or cardboard. The leucocytes 
in 400 small squares of the erythrocyte chamber may then be rapidly counted 
together with as many additional outside diaphragm fields as are necessary 
to correct work. 

Accurate white blood counts require patience and the counting of a large 
n umber of fields, for a slight error has a disastrous effect. * Usually 2 drops of the 
1-10 or 4 drops of the 1-20 dilution will enable one to count 140 to 150 cells. t 

Differential Counting. — This involves the examination of from 500 to 
800 leucocytes in fixed and stained blood smears, and a determination of 
the exact number of each variety present. The field should be systemat- 
ically and carefully gone over, and if ordinary care is observed the procedure 
offers no difficulty for one who is sufficiently skilled to recognize the various 
types of white cells and the abnormal erythrocytes which should be included 
in any such procedure. The process is tedious but oftentimes necessary 
and valuable, and necessitates, as a rule, the counting of at least two or 
three entire stained smears. 

Important Detail. — The blood counter pipette must in every case be cleaned 
immediately after using : first, with water; second, with alcohol; third, with 
ether; and the glass bead should be absolutely free and movable after the process 
is completed. 

Many Types of Blood-counters. — There are many modified forms of the 
"blood-counter" of the Thoma type and amongst them is one of American 
make and easily procurable. 

This is the Thoma-Levy hemocytometer and is thus described by the 
manufacturers: 



* The ingenious self-filling and self-measuring pipette of Durham has many advantages 
but requires separate muring vessels. 

f In the leukemias the leucocyte count is best made with the ordinary erythrocyte 
counter and pipette for the dilution should be 1-100 rather than 1-10 or 1-20. 






I in: i:\amination OF THE BLOOD 



C33 



Ftg. 4^- — Vertical longitudinal section of slide, 
with cover glass in position, showing new method 
of construction. 



Y~ — " 

4 "5o sq.mm. 
^mm.deep. 




| 




MADE BV 
PHILADELPHIA, PA. 

u.s>- 

FOR 

ATthurK.TKomas Co. 



Fig. 43. — Thoma-Levy counting chamber 
with original Thoma ruling. 



" The Biirker type of counting chamber, of either the new or old construc- 
tion, has a further advantage over the original Thoma construction — which 
consists of a circular ruled disc cemented on the slide in the center of a circu- 
lar cell, also cemented on the slide — in that capillary attraction is used to 

fill the Biirker cell after the cover 



glass is in position. This method 
insures a much more uniform 
distribution of corpuscles over 
the entire field and the effect of 
atmospheric pressure upon the 
depth of the solution is materi- 
ally lessened. These new 
Thoma-Levy counting chambers 
of the Biirker type are now 
supplied with various rulings, 
i.e., Thoma, Zappert, Tiirck, 
Neubauer, Fuchs-Rosenthal, etc. 
The Neubauer ruling is now 
recommended as the most sat- 
isfactory for modern tech- 
nic. The method of ruling 
used in the manufacture of these 
chambers provides a line with 
absolutely clean-cut edges and 
of distinctly increased visibility 
when the chamber is filled with 
solution for the count. This 
increase in visibility of the ruling 
greatly lessens the eye fatigue 
experienced in making repeated 
counts. 

"In the old type of Biirker 
chamber two ruled areas are 
provided upon rectangular pieces 
of glass cemented on the main 



± sq.mm.. 

^ mm. deep. 




— 




PHILADELPHIA.PA.; 
: At thur^ Thomas Co. 



Fig. 44. — Thoma-Levy counting chamber, 
Biirker double type with two Neubauer rulings. 




Fig. 45. — Mixing pipette for red corpuscles. 




46. — Mixing pipette for white corpuscles. 



slide. These ruled rectangles were separated by a small moat to allow free 
passage of the diluted blood. On either side of these ruled rectangles two 
unruled rectangular pieces of glass were cemented which extended the en- 
tire width of the slide. These were exactly Ko mm - thicker than the ruled 
rectangles, so that when the cover glass rested on these the required depth 
of solution over the ruled area was attained. 

"In the Levy construction a rectangular depression is cut into the slide 
itself extending across the entire width. In the middle of this depression is 
permanently fixed a rectangular strip of glass, also extending entirely across 
the slide, and on this are the rulings. When the cover glass is placed in 
position on the slide itself the solution over the ruled areas is of the re- 



134 



MEDICAL DIAGNOSIS 



quired depth. The method of construction entirely removes the possi- 
bility of the loosening of the cell by the drying out of the balsam 
cement and reduces the possibility of the loosening of the ruled counting 
surface. 

"In the Burker-Neubauer counting chambers the rectangular glass in 
the center of the cell is divided by a central moat; each half being pro- 
vided with a Neubauer ruling, so that both red and white counts may 
be made at the same time without the necessity of cleaning and refilling 
the counting chamber." (Fig. 44.) 





Fig. 48. — Eye-piece 
ruling of Thoma-Metz. 



Courtesy of E. Leitz, New York. 
Fig. 47. — Hemocytometer (the Thoma-Metz). 

The Neubauer modification of the original Thoma ruling is probably the 
most satisfactory of all. In it the central square millimeter is exactly the 
same as in the original Thoma ruling. Surrounding this there are 8 addi- 
tional square millimeters, each subdivided into 16 smaller squares, and these 
are of extreme value by reason of the greater accuracy and convenience which 
they afford in counting the white blood corpuscles. (See Fig. 41.) 

The actual technic for using the Burker chamber is extremely simple and 
may be briefly summarized as follows: 

1. The ruled areas and slide are carefully cleaned and made absolutely 
free from dust. 

2. The cover glass is applied and Newton's rings* must be obtained as 
evidence of the approximation of the two surfaces. 

3. The tip of the projecting ruled rectangle is quickly touched with the 
point of the rilled red or white blood pipette, permitting the diluted blood to 

* The Newton's interference rings are not readily obtainable in the Levy construction 
as in the older type because of the mat or ground surface of the slide upon which the 
cover glass rests. Because of this mat surface accurate approximation of the surface of 
the cover glass and slide is readily obtained. 

The original Burker instrument and Gorgajew-Pappenheim modification of it carry 
clamps which aid in obtaining and maintaining accurate contact. {Author.) 



THE EXAMINATION OF THE BLOOD 135 



flow under the cover glass to just the extent sufficient to cover completely 
the ruled rectangle but not flow over into the moat on either side. No 
bubbles should form in this process. 

4. After allowing three minutes for settling, the evenness of distribution 
is determined either by low-power examination with the microscope or by 
placing the counter upon the stage of the microscope, which is illumi- 
nated by a mirror with the diaphragm open as wide as possible. If now 
the counting surface is viewed obliquely with the unaided eye, any 
irregularity in the distribution of the cells is easily recognized by variations 
in the density of the blood film. If such irregularities are observed, the 
cover glass should be removed, the chamber carefully cleaned, and the 
procedure repeated. 

The Thoma-Metz Hemocytometer. — The counting plate is mounted 
in the plane of the ocular diaphragm of eyepiece No. n. The Leitz ob- 
jective No. 6, is used in connection with it. The dilution of the blood 
is carried out with the aid of two Thoma pipettes of regular type, fol- 
lowing the known method. 

The large square in the center of the counting plate (Fig. 48), is divided 
into four smaller squares and serves for the counting of the red blood cor- 
puscles. The large square is surrounded by a circle which is divided 
also into four parts of equal area, serving for the counting of white blood 
corpuscles. 

Figure 48 represents a diagram of the counting plate itself. The regular 
chamber of 0.1 mm. depth is used for the counting by this method. 

Directions for the Counting in a Solution of 1 Cu. Mm. — (A) For Red 
Blood Corpuscles. — The dimensions of the large square of the counting plates 
are so calculated that one side of same covers 0.1 mm. of the object. The 
area, therefore, is equal to 0.1 X 0.1 = 0.01 sq. mm., and the cubic contents 
of that area of the object as covered by the entire square is equal to 0.01 X 
0.1 = 0.001 cu. mm. The number of red corpuscles in the solution — diluted 
1:100 — amounts therefore, to 100 X 1000 = 100,000 times the corpuscles 
found in the square counted. 

Example. — 52 red corpuscles found in the square. 52 X 100,000 = 
5,200,000 red corpuscles in one cu. mm., solution. 

In order to achieve a reliable average count it is advisable to move the 
slide and count in various zones of the solution. 

(B) For White Blood Corpuscles. — The circle established for the counting 
of white corpuscles covers ten times as much area as does the square 
for the counting of red corpuscles. This circle, therefore, covers an area 
of 10 X 0.01 =0.1 sq. mm. of the counting chamber of a depth of 0.1 mm. 
and the cubic contents amounts to 0.1 X 0.1 = 0.01 cu. mm. The 
actual number of white corpuscles as contained in the solution — diluted 
1:10 — will therefore amount to 10 X 100 = 1000 times the number as 
found in the circle. 

Example. — 8 white blood corpuscles found in the circle. 8 X 1000 = 
8000 white corpuscles in 1 cu. mm., solution. 



136 



MEDICAL DIAGNOSIS 



In order to achieve a reliable average count, it is advisable to move the 
slide and count in various zones of the solution. 

The two factors: 100 X 1000 for red blood corpuscles are engraved in 
"red." 10 X 100 for white blood corpuscles are engraved in "white" 
on the counting slide. 

Advantages. — The counting plate is produced in a photographic way and 
can be focused sharply for every eye by means of the adjustable eye lens, and 
therefore, the ruling appears in sharp lines in the counting field. 

For the counting of red as well as white blood corpuscles, separate fields 
are used. These fields are, in their area, so adjusted that a unit for multi- 
plication is established. This factor allows quick counting. 

The apparatus is adjusted for an optical equipment of objective No. 6 
(4 mm. focal length) and ocular No. 11 (5 X), as these are the lenses mostly 
used for blood-counting work. Small variations, as far as lenses of other 
makes are concerned, can be overcome through the adjustment of the tube 
length. On the bottom of the slide, a square is drawn and the proper 
I optical relation is established when this square covers the large square of the 
counting plate. 

(The author has had no experience with the instrument and has been 
unable to secure one for test purposes.) 

Oliver's Hemocytometer. — This ingenious instrument is shown in Fig. 
49, and save in the severer types of anemia and in leukemia where the 
excess of leucocytes vitiates any optical method, is fairly 
accurate in skilled hands. 

Method. — A small amount of Hayem's solution is 
placed in the glass tube and into it is stirred the blood 
taken up by the capillary pipette. In a dark room it is 
then diluted gradually with the Hayem's mixture until 
a bright horizontal line becomes visible as the observer 
looks through the mixture at a candle flame beyond. 
Each point on the scale represents 50,000 red cells. 

Precautions. — (a) One looks at the edge of the tube, 
not its flat face, (b) The pipette should be thoroughly 
clean before using, (c) The tube should be inverted to 
secure proper admixture each time that the diluent is 
added, (d) An imperfect marginal line forecasts the 
appearance of the complete transverse line and warns 
one . to go slowly with the dilution, (e) A small Christmas candle should 
be used in a dark room. (/) The tube should be close to the eye and the 
observer fully 10 feet from the candle. 

The procedure is seldom employed at the present time. It has too 
limited a range and the personal equation is too great a factor. 

The Hematocrit (Hedin-D aland). — This consists of a graduated capillary 
tube, each degree of which represents 100,000 erythrocytes. The tube is 
filled with blood and placed (with a similar tube opposite) in the centrifuge 
which should be revolved at high speed for at least two minutes when the 




Fig. 49. — Method 
of holding Oliver's 
hemocytometer. 



THE EXAMINATION OF THE BLOOD 



137 



Volume index. 



red column will represent the erythrocytes present as indicated by the scale. 
The tube when filled by suction is dried and closed at its other end by the 
vaseline coated finger which is kept in place while the rubber suction tube 
is withdrawn. The results obtained are rapid but only approximate when 
used in the severer types of anemia. As pointed out by Capps, it affords 
a means of obtaining information relating to cell volume. 

It is a simple matter to calculate the normal height of the red blood cell 
column in the hematocrit tube as compared with the height of the total 
blood column. This is usually 50 on the scale tube and this figure is reckoned 
as 100 per cent, normal. 

The figure so obtained is divided by the figure representing, in percentage, 
the number of red cells per cubic millimeter counted in the blood of the same 
individual, as compared with the normal, 5,000,000 cells per cubic millimeter 
The quotient is the red cell "volume index" and parallels in a considerable 
degree the "color index" heretofore described, both as regards its variations 
and their clinical significance. 

The normal red cell "volume index" is 1. In primary pernicious anemia 
it is high; in secondary anemias, reduced; in chlorosis, distinctly low. 

These variations, if marked, are usually obvious to the trained observer in an 
examination of the simple well-made blood smear. 

The method may find its wider usefulness in the detection and measure- 
ment of blood changes other than those of anemia. 

LEUCOCYTOSIS AND LYMPHOCYTOSIS.— Assuming that the term 
leucocytosis covers an increase of the polymorphonuclear neutrophilic cells, 
both relative and absolute, it is evident that one must know first what con- 
stitutes a normal leucocyte count; second, what conditions other than disease 
may increase the number. 

The Normal Average. — This varies from 6,500 to 10,000 to the cubic 
millimeter of peripheral blood, the average being 7500. 

Physiologic Leucocytosis. — The most important is the so-called digestive 
leucocytosis which represents on the average an increase over normal of about 
one-third. The variation is greater after a heavy proteid meal than on a 
vegetable diet and reaches its maximum usually within from two to four 
hours after a meal. The increase itself may be purely polymorphonuclear 
or, more rarely, is common to all normal forms. It may be delayed in cases 
of subacid dyspepsia and is very marked in nursing infants and diabetics. 

The so-called preagonal leucocytosis may be observed immediately before 
death, the counts occasionally reaching 20,000 or even 30,000 cells. Cabot 
states that in pernicious anemia this may take the form of so decided a 
lymphocyte increase as to simulate lymphatic leukemia; nevertheless, as 
a rule, it is a polymorphonuclear increase due probably to the stasis of a 
failing circulation and a prof ound toxemia such as that which may be employed 
in the experimental production of a leucocytosis. In such instances the 
primary increase is lymphocytic, the polymorphonuclear increase following 
later on. It is important to remember that both in the later months of 
pregnancy in primiparae and during the first week following delivery a Pregnancy. 



Digestion 

leucocytosis. 



Misleading. 



138 



MEDICAL DIAGNOSIS 



New-born 
babes. 



Crucial point. 



Various 

associated 

conditions. 



Sepsis. 



Basis. 



Highly 
important. 



moderate leucocytosis is the rule. So also in new-born babes the count 
usually ranges from 18,000 to 20,000 during the first two days of life and 
after the second week and during the first year it remains at 10,000 to 15,000 
per cubic millimeter. The type of physiologic leucocytosis is almost in- 
variably polymorphonuclear though there may be a coincident lymphocyte 
increase in the new-born, in malignant disease, or in hemorrhage. See 
"lymphocytosis" on following page. 

Differentiation of Leucocytosis from Leukemia. — The number of white 
cells present does not suffice to differentiate the one, a mere transitory 
symptom, from the other, a peculiarly intractable and fatal chronic disease. 

77 is rather the type of white cell which dominates the clinical picture, or 
the blood findings as a wliole combined with other signs and symptoms of known 
character and association that sets leukemia apart so clearly and definitely 
as to leave little opportunity or excuse for error. With rare exceptions leucocy- 
tosis means a polymorphonuclear increase alone or, more rarely, a mere gener- 
al increase of leucocytes of the normal types. 

The Leucocytosis of Disease. — So many diseases are associated with a 
more or less marked leucocytosis that it is only necessary to enumerate some of 
the more striking instances, and more useful to remember the exceptions, or, 
more particidarly, the diseases in which a diminution (leucopenia) occurs. 

Practically all inflammations, particularly of serous membrane, and any 
suppurative process attended by toxemia, would ordinarily produce leucocytosis, 
yet we may have these, lacking such a phenomenon (a) because the infiammatioji 
or toxemia may be too slight to excite a reactive change; (b) because the toxin 
overwhelms the organism, thus preventing leucocytic reaction; (c) because the 
organism is primarily too feeble to respond. 

In illustration one may cite lobar pneumonia as representing a disease 
in which leucocytosis is ordinarily marked, and typhoid fever in which a 
leucopenia is ordinarily found. 

These diseases stand at opposite poles, one being sthenic and the other 
asthenic; one of brief duration, the other prolonged and tedious; one showing 
early and profound toxemia, the other allowing most of its victims to escape 
by resolution before the system is overwhelmed by toxins. 

The case of lobar pneumonia which slwws a leucopenia is practically hope- 
less. The case of genuine typhoid fever carrying a leucocytosis is one with 
complications. 

Acute appendicitis offers another illustration. In this disease one may 
have an inflammation and toxemia so slight as to produce no leucocytosis; 
an overwhelming toxemia with the same result; or, as it is the rule, a well- 
defined leucocytic reaction representing a good defensive mechanism opposed 
to sharp infection. 

It is useless to attempt to name or even tabulate all the conditions giving 
rise to leucocytosis. In abscess it is practically constant, but in malignant 
disease a high count may be found only in rapidly growing tumors of the kidney, 
lungs or liver, and in the author's experience especially in metastatic hepatic 
invasion from gastric carcinoma. In ptomain poisoning, uremia, cholemia, 



THE EXAMINATION OF THE BLOOD 



139 



and gas poisoning the leucocytosis may be marked. So also in cases of 
acute delirium, convulsions, after surgical operations or indeed after general 
anesthesia. A polymorphonuclear percentage above 85 strongly suggests 
the presence of actual suppuration or gangrene. The blood findings of the 
various diseases are discussed under the individual headings.* 

Leucopenia. — This covers any leucocyte count running below 5000 cells, 
excluding, of course, tJiose cases of reduction associated with profound anemia. 

As might be expected, this condition may be present as a result of mal- 
nutrition or starvation, but its chief importance is its occurrence in certain 
diseases of the infectious and toxemic type. 

Among these are typhoid, paratyphoid, malaria, Malta fever, influenza, 
measles and rotheln, tuberculosis {in the absence of septic symptoms), leprosy, 
trypanosomiasis, and less commonly in chlorosis, chronic infantile gastro- 
enteritis, and, following the use of agaricin, atropin, camphoric acid, ergot, 
picrotoxin, sulphonal and tannic acid. 

Lymphocytosis. — This may be either relative or absolute, the former without 
any necessary increase in the total white cell count, the latter covering both an 
increase in percentage and in the total lymphocytes. The latter is almost always 
a lymphatic leukemia. 

It should be remembered in this connection that in infancy the lympho- 
cytes and transitional cells may constitute 55 or 60 per cent, of the total 
white cells, gradually dropping to the normal figure at the age of four or 
five with a corresponding increase in the polymorphonuclear forms. There- 
fore, the increased percentage has little significance at early ages. 

Either the large, small or transitional mononuclear forms may predominate 
in any case, and the condition is invariably pathologic when occurring in older 
children or in adults. It is usually associated with profound malnutrition, 
and especially marked in the terminal stages of diseases of that type as well 
as in marked anemia and in several of the acute and chronic infections 
characterized by leucopenia, notably malaria, typhoid, Malta fever, scarlet 
fever, diphtheria, measles, tuberculosis and trypanosomiasis. So also we find 
the condition marked in ailments involving the lymphatic glands or spleen or 
the invasion of lymph channels by malignant growths. As regards drugs, 
it is said to follow the administration of thyroid, quinin and pilocarpin. 
Its occurrence in syphilis in which it is combined with eosinophilia is of some 
diagnostic importance. 

Eosinophilia. — The determination of this condition is made by a differ- 
ential count establishing their proportion, associated with a formal count 
of the total leucocytes, the latter multiplied by the former giving the total 
number of eosinophiles in a cubic millimeter. 

77 is of lessened importance as a clinical sign because of its presence in a 
great number of diseases, but its constancy in trichiniasis , hydatid disease and 
in the victims of the more important intestinal parasites is of considerable value. 

* It is affirmed by some authorities that the percentage increase of polymorphonuclears 
(relative preponderance) represents the degree of toxic absorption and the total numerical 
increase of leucocytes measures the resisting power of the organism. 



Confusing 
factors. 



List of 
diseases. 



Normal in 
infancy. 



Abnormal. 



Syphilis. 



Value. 



140 



MEDICAL DIAGNOSIS 



Diseases 
yielding 
reactions. 



A double 
process. 



Use erythrocyte 
counter. 



Caution. 



Appearance of 
platelets. 



Normal count. 



Rationale. 



The attempt made by some of the foreign hematologists to create a 
group of which eosinophilia should be diagnostic has not proven successful. 

77 is, as stated, of some clinical value in syphilis when combined with lympho- 
cytosis and its constant presence in spasmodic asthma is of interest. In scarlet 
fever there is at first a low white count but after a few days a marked leucocytosis 
and decided eosinophilia are present. Both are said to be absent in measles. 

Counting the Blood Plates. — Indirect Method. — This requires a diluting 
fluid* through a drop of which placed upon the finger the puncture is made. 
After mixing, a differential count is made to determine the ratio of plaques 
to erythrocytes. It is then only necessary to count the erythrocytes by 
means of a counting chamber to know the number of plaques present in 
the given specimen. 

Direct Method. — The direct method of Wright and Kinnicutt is prefer- 
able. One employs as diluting fluid solutions of brilliant cresyl blue (1:300, 
aqueous) and potassium cyanide (1:1400, aqueous). 

The solutions are mixed just before use in the proportion of two parts 
of the former to three parts of the latter. 

The original solutions must be freshly prepared, or, refrigerated if kept 
as stock solutions. 

v The blood platelets appear clearly defined as oval, round, or somewhat 
elongated bodies stained lilac and sharply contrasted with the leucocytes, 
which show a deep blue nucleus and light blue protoplasm. The red cells 
are decolorized. 

The size of the platelets is variable, being larger when few are present, 
smaller when occurring in increased numbers, but they average about 3 
microns in diameter. 

Normally, their numbers vary from 150,000 to 300,000 per c.mm., and 
the count is made exactly as in the case of the erythrocytes. 

Determination of Hemolytic Resistance. — If blood is added to water it 
immediately "lakes," i. e., gives up the hemoglobin of its erythrocytes to the 
liquid. If the osmotic pressure is equalized by the addition of some suitable 
substance such as sodium chloride (0.9 per cent.) the solution becomes iso- 
tonic and no "laking" occurs. 

By using properly graduated solutions of sodium chloride or other sub- 
stances the resistance of any given blood to hemolysis may be determined. 

The same process is applied in determining the proper donor of blood 
for transfusion for both donor and patient must belong to the same group 
with respect to cell resistance whether to iso-hemolysins or iso-agglutinins. 

Total Blood Volume. — It is wholly probable that the ingenious and rela- 
tively simple procedure of Keith, Rowntree and Geraghty, will supplant the 
methods of Haldane and Smith, Morawitz, Zuntz and Plesch, Abderhalden 
and Smith, and von Behring. 

The principal feature of this latest procedure is the introduction into the 
blood of a rapidly diffusible, slowly absorbable dye, known as " vital red" 

* Aqueous solution of sodium chloride 1 per cent, and potassium bichromate 5 per 
cent. (Determann). 



Till: IX VMIXATION OF T1IK Hl.ooi) 



141 



(disodium-disulphonaphthol-azotetramethyl triphenyl methane), and colori- 
metric comparison with a properly standardized mixture of the dye and the 
unstained plasma of the patient. Its slow absorption and elimination and 
relative non-toxicity (3 c.c. per kilo of body weight being wholly without 
poisonous effects) insures the possibility of sufficient time retention to insure 
thorough mixing with the plasma, without appreciable loss of the dye, un- 
less to some slight extent through fixation by the tissues. 

The results obtained agree more closely with the older ideas than with 
the modern views as to the relation of total blood volume to body weight. Normal 
Keith and his co-workers find that the average blood volume is 85 c.c. per ; average - 
kilo of body weight, equal to one-eleventh of the body weight, and varying 
between that figure and one-thirteenth. 

As regards the partition of the blood components 57 per cent, was found Normal ra 
to represent plasma, and 43 per cent, erythrocytes and leucocytes. 

The plasma content as determined by the hematocrit varies from 42 to 
56 c.c. per kilo of body weight. 

One of the interesting results reported bears upon blood volume in arterial 

hypertension, or hypotension. In the chronic hypertension of renal cases, 

it was found normal or even decidedly reduced. In obesity the blood (and 

plasma) volume is reduced, in anemia often increased as to total plasma. 

The actual technic while relatively simple is too extended to receive 

detailed description in a work of this type and too time con- Time 
suming and exacting in its demands to make it of general c 
availability to the practitioner in the comparatively infre- 
quent instances in which its employment might be of especial 
(clinical interest.* 
Coagulation Time. — It is sometimes important to estimate 
the coagulation period in hemophilia, purpura and in "ob-, 
struction of the biliary tract with or without jaundice" 
(Cabot), as in these conditions clot formation may be greatly 
retarded. 

For accurate work the method and instrument of Russell 
and Brodie as modified by Boggs may be used; or for rough 
determinations, in the absence of better appliances, the simple 
method represented by Fig. 50. In the former coagulation 
should occur within from three to six minutes; by the simpler 
method, in from two and one-half to five minutes. The latter p 
merely involves the placing of several drops of the suspected blood upon 
slightly warmed microscope slides which are tilted upward at varying inter- 
vals until they appear as in B of the plate, the elapsed time representing the 
coagulation period. Another rough but useful method consists in placing 
the drop of blood upon a perfectly clean glass slide and passing a needle 
through it every twenty or thirty seconds until the needle drags the clot. 
The Boggs coagulometer consists of : (a) a round glass-bottomed " moist 

* Reference to the extended original article is necessary. Keith, Rowntree and Ger- 
aghty, Archiv. Int. Med., Oct. 15, 1915, Vol. 16, No. 4, pp. 547-576. 



Often 
important. 



A B 

Fig. 50.— 
Delayed co- 
agulation of 
blood, a sim- 
ple test. 
(After Da- 
Costa.) 



Normal 



142 MEDICAL DIAGNOSIS 




Courtesy of A. H. Thomas Co. 



chamber"; (b) a cover fitting into and closing the chamber and carrying in 
the center a cone of glass the truncate apex of which lies within the " moist 
chamber"; (c) a capillary tube opening into the side of the chamber through 
which a jet of air can be pumped with a hand bulb so as to impinge upon the 
drop of blood taken upon the tip of the glass cone for examination; (d) a 
small opening in the upper surface of the cover of the chamber, which serves 
as an air outlet. 

Procedure. — The lobe of the ear is punctured and the time of appearance 
of the blood accurately noted. The tip of the glass cone receives a blood drop, 
the cell is at once covered, the 
chamber is placed upon the 
stage of a microscope, and at 
intervals of 30 seconds a soft 
current of air is played upon 

the blood drop. Three essential FlG 5I> _ The Brodie-Ri^eU co^d^teT « 

stages of movement are seen to en- modified by Boggs. 

sue as affecting the blood corpus- 
cles: (1) Independent. (2) Clumped. (3) Mere "radial" mass response 
to the air current, denoting complete coagulation.* 

Wassermann Test. — The discovery of the spirochceta pallida was closely 
followed by this reaction for syphilis which combines the phenomenon of 
hemolysis with that of complement fixation (Bordet-Gengou). 

The test departs from the strict and definite "fixation of complement" 
reaction in permitting the use of antigen derived from certain normal tissues 
(Noguchi) as a substitute for the specific antigen hitherto deemed necessary 
to such tests. (See "Wassermann Test".) 

The reader is referred to the works devoted to serology for a full discussion 
of the test which is so delicate and so beset by confusing factors as to be of little 
value in the hands of anyone save the trained and up-to-date serologist. 

The value of positive reactions is undoubted, when these represent the work 
of the specially trained expert. 

Negative reports should not greatly influence the question of test treatment 
or be permitted to greatly influence an opinion based upon a strongly suggestive 
history or clinically significant symptom-group. 

The Determination of Alkalinity. — Personal experience with this method 
has convinced the author that it does not merit attention as a clinical 
procedure. 

Exudates and Transudates. — In general a transudate does not coagulate 
spontaneously unless there be much blood admixed, the specific gravity is 
1015 or less and it contains not more than 2.5 per cent, albumin. An exudate 
coagulates promptly, contains 4 per cent, or more of albumin, and shows a 
specific gravity of 1018+. 

* The mass is fixed and recovers its outline when the gentle air current ceases, much 
as an indented rubber ball recovers its outline after indentation. Just preceding this 
terminal stage the clot has become so far fixed as to promptly correct the slight dis- 
location produced by the air current. 



THK EXAMINATION OF THE BLOOJ 143 



CYTODIAGNOSIS.— Widal has given this name to the differential 
study of the leucocyte content of pleural, peritoneal and cerebro-spinal 
fluids as they are obtained in operative or diagnostic aspiration. It is a 
valuable procedure within narrow limits. 

The fluid must be centrifugalized, and if immediate attention cannot be 
given it, any clot may be broken up by shaking in a flask with small glass 
beads or the fluid may be drawn into a syringe or aspirator flask half full of a 
solution consisting of calcium oxalate (2 parts) and normal saline solution 
(1000 parts, Sahli). From 10 to 20 c.c. should be obtained if possible. The 
centrifuge must be run from five to ten minutes according to the speed obtain- 
able and the fluid kept on ice and examined within twenty-four hours. Exami- 
nations are best made by staining smear preparations as in the case of the 
blood. The triacid stain is satisfactory, or Wright's stain, plus one-third its 
volume of pure methyl alcohol, may be used, to save heating the specimens, 
though its methylene blue may overstain in the sharply alkaline serum. 

Under the microscope we consider erythrocytes, endothelium and tumor 
cells as well as leucocytes, and the following reasonably dependable conclu- 
sions may be drawn: 

(a) The presence of large amounts of blood suggests carcinoma, tuberculosis, 
and the hemorrhagic diseases, but may be present in cardiac, scorbutic, and 
nephritic cases, though usually accidental. 

(b) In general the predominance of polymorphonuclear forms indicates 
marked and relatively recent infection. 

(c) A large number of mononuclear cells indicates a less acute process, its 
later or chronic stages, or the chronic stage of a non-specific exudate. A combina- 
tion of a considerable quantity of red blood cells and an excess of lymphocytes 
strongly suggests tuberculosis. 

(d) A large number of endothelial cells unassociated with any considerable 
number of leucocytes speaks for a transudate. 

(e) Specific tumor cells may, if typically grouped, prove the presence of a 
malignant growth, but ordinarily can with no certainty be distinguished from 
endothelial cells. The combination of an excess of endothelial cells and red 
blood cells strongly suggests tuberculosis. 

Primary Tuberculosis is indicated by a predominance of lymphocytes 
after a week or ten days; acute infection, by polymorphonuclear preponderance. 
Predominance of endothelial cells in tesselate arrangement indicates a transu- 
date. Secondary tuberculous pleurisies may show polymorphonuclear pre- 
dominance or a sediment of necrotic cells and debris. An exudate showing 
bacteria and 90 per cent or more of polymorphonuclears means that empyema 
is imminent (Musgrave).* 

INOSCOPY. — Jossuet's method of predigesting the coagulum of sus- 
pected exudates as preliminary to the examination for tubercle bacilli has 

* Musgrave highly recommends Wright's stain, 3 parts, methyl alcohol, 1 part. Stain 
twenty to forty-five minutes, treat with 8 or 10 drops of water, let it stand two or three 
minutes and wash gently by flooding with water several times, allowing it to stand a few 
seconds with each washing. 



144 



MEDICAL DIAGNOSIS 



Hemoglobin- 

erythrocyte 

ratios. 



proven of much value in pleuritic cases but is now largely superseded by the 
"antiformin method." Its findings have less accuracy, however, than 
animal inoculation and possibly than cytodiagnosis, so that it is the positive 
factor that should be considered, the failure of the test being no adequate 
proof of the absence of tuberculosis. 

Technic. — The fluid is collected in sterilized flasks and the clot, when 
formed, thoroughly washed on sterile gauze spread over the mouth of a funnel 
or other receptacle. The clot is then placed in a flask or flasks in each of 
which is poured from 20 to 30 c.c. of the solution (pepsin 2 grams, glycerin and 
strong HC1 of each 10 c.c, sodium fluoride 3 grams, distilled water 2000). 
Digestion will be complete in about two or three hours at body temperature. 
Centrifugation of the mixture for ten minutes is followed by decantation and 
the staining of cover-slip preparations to which a bit of egg albumin may be 
added. Gabbett's method and stain should be used, but the preparation 
must not be as vigorously decolorized as is usual in sputum mounts, thirty 
to forty-five seconds being sufficient. 

THE ANEMIAS 

TYPES OF ANEMIA. — There are three principal clinical types of anemia : 
(1) simple anemia or chlorosis; (2) secondary anemia, which as its name 
implies is that which follows or is associated with other diseases; (3) pernicious 
anemia. 

Sim. Anemia. Chlorosis. 
Hemoglobin low. Cells rela- 
tively high. (Low index.) 




Secondary Anemia. 
More or less uniform reduc- 
tion in cells and hemoglobin. 



Hemoglobin relatively high 

Cells low. High index. 
Pernicious Anemia. 



Fig. 52. 



Chlorosis is characterized by a predominant hemoglobin loss and a rela- 
tively slight diminution in the number of red cells present. That is to say, 
the individual cell is poor in hemoglobin. 

Secondary anemia shows, as a rule, a more even reduction in both 
elements. 



IHE AN KM IAS 



145 



Pernicious anemia is the exact reverse of simple anemia in that the 
cell decrease predominates and, therefore, the hemoglobin value of the 
individual cell is high. 

GENERAL CONSIDERATIONS.— Color.— In the anemias pallor as M.sieading. 
affecting the skin and mucous membranes is the rule, but is subject to fre- 
quent exceptions. 

Perso)i$ may be pale, yet not anemic, or ruddy and profoundly anemic. 

The author recalls many cases of advanced leukemia in which the color 
was most deceptive. The student and the indoor worker is often pallid, 
yet not anemic. 

The outward signs of anemia should be sought in the face, the conjunctiva, 
the lips, the mucous membrane, the lobes of the ear, the finger nails, tongue 
and pharynx. 

Wide Variations.— In chlorosis there is usually marked pallor and the skin 
is likely to show a greenish-yellow tint. 

In pernicious anemia there is ordinarily very marked pallor and the skin 
is of a lemon-yellow tint. 

In secondary anemia aside from pallor one meets with many variations 
in color. 

In Bright J s disease with anemia the skin may be pasty white; or show 
the peculiar sallowness, brown or fawn color, more or less characteristic of 
the advanced chronic parenchymatous or "mixed" type of the disease. 

Interstitial nephritis, even when well established, often yields no such 
evidence, being found in men of normal complexion or in those who have the 
ruddy countenance of the high liver. 

Syphilis. — Certain cases of congenital and tertiary syphilis with secondary 
anemia show a peculiar sallowness impossible to describe, but easily recog- 
nized by those who have been shown it. 

Malignant disease, especially advanced carcinoma of the stomach, is 
sometimes associated with a somewhat characteristic earthy pallor and in 
some instances the anemia may be extreme and closely resemble that of 
the pernicious type. 

In diseases of the mitral valve one frequently finds an anemia masked by 
high color due to chronic congestion. 

Muscular Weakness. — In all pronounced anemias one meets with lassi- 
tude and muscular weakness, varying, as a rule, with the severity of the 
disease. It is least marked in mild anemias of the secondary type and most 
evident in pernicious anemia. 

Temperature. — Three-fourths of all cases of pernicious anemia are ac- 
companied by fever, usually of the intermittent type, with an evening 
exacerbation. It is by no means an infrequent symptom in severe cases of 
chlorosis* or secondary anemia. 

Gastrointestinal Disturbances. — Symptoms referable to disturbed di- 
gestion, gastric or intestinal, are encountered chiefly in the chlorotic and per- 

* It nevertheless should always suggest an active or smouldering tuberculosis in these 
latter cases and hence a thorough examination of the lungs. 
10 



146 



MEDICAL DIAGNOSIS 



" Bruit de 
diable." 



Pseudo- 

"Corrigan 

pulse." 



Capillary 
pulse. 



Misleading 
headache. 



nicious forms of anemia and in the leukemias. Anorexia, bulimia, nausea, 
vomiting, constipation and diarrhea are the common symptoms. Established 
and advanced pernicious anemia is usually associated with exhausting at- 
tacks of diarrhea and intercurrent vomiting. Paroxysmal abdominal pain 
occurs in about 50 per cent, of the cases. 

Respiratory System. — Exertion dyspnea is more or less pronounced in all 
severe anemias, but particularly so in marked chlorosis and pernicious anemia. 

Circulatory System. — Palpitation, syncope and precordial oppression 
are common. Edema of the extremeties is not infrequent in chlorosis 
and is invariably present in advanced leukemia and pernicious anemia. 
The pulse is of low tension (60 to 80 mm. systolic pressure is not uncommon 
in pernicious anemia) ; a curious humming may be heard in the vessels of the 
neck, and various murmurs are audible over the heart and the great vessels. 

Myocardial weakness is likely to be pronounced and the heart is often dilated 
or markedly dilatable if the anemia is decided. 

Anemic Murmurs. — The general characteristics of the murmurs associated 
with anemia are: (a) Their systolic time, (b) Softness of quality, (c) Predilection 
for the pulmonary area, (d) Absence of marked and sequential cardiac outline 
changes, (e) Tendency to disappear as anemia is improved by treatment. 

These murmurs may be heard over any of the valvular areas, but are 
most frequent by far in the pulmonary and mitral regions. A systolic murmur 
in the subclavian and carotid is a very common feature in extreme instances. 

In certain cases combining anemia and chronic congenital asthenia, and in 
hyperthyroidism, one may find outward symptoms suggesting aortic regurgita- 
tion, viz.: throbbing peripheral vessels, water-hammer pulse, and even a capillary 
pulse. This condition need not mislead one in the absence of a diastolic 
murmur* and modified aortic second sound. 

The flow of blood is remarkably accelerated in severe anemia and this 
fact together with the lowered specific gravity of the blood and the weakened 
myocardium would seem adequate causes for the associated murmurs. 

Nervous System. — The symptoms under this head are many and various, 
being chiefly those in varying degree common to all conditions characterized by 
impairment or perversion of the blood supply of the tissues. 

Insomnia, drowsiness, vertigo, mental dulness and apathy, extreme irri- 
tability, perverted sensation, neuralgia, psychasthenia, hysteria, headache, 
and even delirium may be encountered, though delirium is not often seen save 
in pernicious anemia or the last stage of leukemia. 

Headache may be found in all degrees of severity in simple cases of chlorosis, 
and one form is peculiarly interesting by reason of its close resemblance to the 
headache of meningitis.^ Such headaches are so severe as to require most 

* The author has reported one (terminal stage) case of pernicious anemia in which all 
these symptoms, together with a loud diastolic aortic bruit were present without aortic valve 
changes adequate to explain the murmur, and a few other such clinical curiosities are to be 
found in the literature. 

t Two cases have come under the author's notice in which a mistaken diagnosis of cere- 
bral meningitis had resulted from this curious condition. 



THE ANEMIAS 



147 



radical measures for their relief, and often tend to recur until the general 
therapeutic indication, namely, the administration of iron, is fulfilled. 

General Nutrition. — In simple anemia the fat is usually well preserved, 
giving the patient a plump appearance. 

In secondary anemia the state of nutrition is dependent upon the primary 
lesion. 

In pernicious anemia, even in its later stage, there is often a wholly misleading 
appearance of fairly good nutritipn, due to the presence of overlying fat, but the 
skin in these cases has a peculiar velvety feel, and the muscles are sometimes of 
the consistency of jelly to the touch. 

The Eye. — Muscular insufficiencies are common, retinal hemorrhage fre- 
quently occurs in pernicious anemia and in all severe forms the ophthalmo- 
scope shows a pale fundus. 

GENERAL ETIOLOGIC FACTORS.— Age.— Secondary and pernicious 
anemias occur for the most part in those at or above middle age. Chlorosis 
is essentially a disease of the earlier years, most often commencing at or 
about the age of puberty. 

Sex. — Ninety per cent, of all cases of chlorosis (simple anemia) occur 
in young women. 

Pernicious anemia is more frequent in the male, secondary anemia follows 
the laws of incidence of the primary lesion. 

Specific Causes of Anemia. — Little is positively known of the specific 
pathogenesis of the anemias and the scope and purpose of this volume for- 
bids a discussion of the theories. 

General Causes. — In connection with simple anemia one is likely to find 
defects in food, environment, habits and general sanitation. Boarding- 
school girls and working girls may suffer alike from insufficient or improperly 
prepared food or from lack of variety, no less than from poor ventilation, over- 
work, or lack of fresh air or sunshine. Depressing emotions, such as grief, 
homesickness or disappointment in love often play their part, and the effect 
of nearly all of these general factors is shown in Arctic explorers who have in 
many instances suffered from severe forms of anemia during the Arctic 
night, when nostalgia, darkness, fatigue, poor ventilation and improper diet 
all were present. 

Secondary Anemia. — This may be associated with the following condi- 
tions: (a) Repeated hemorrhages (hemorrhoids, nose-bleed, uterine hemor- 
rhage, gastric ulcer, hepatic cirrhosis), (b) Malignant disease, especially 
carcinoma of the stomach, (c) Syphilis, leprosy and tuberculosis, (d) 
Mineral poisoning, arsenic and lead especially, (e) Malaria. (/) Bright' s 
disease in its various forms, (g) Intestinal parasites, (h) Auto-intoxication, 
(i) Any acute infectious disease, acute rheumatism being the chief. 

The foregoing statements as to general symptomatology are applicable to all 
forms of anemia in varying degree. Considered as arbitrary types, chlorosis 
stands at one pole, pernicious anemia at the opposite, while secondary anemias of 
exceptional severity are ordinarily overshadowed and dominated by the symptoms 
of the causal lesion and may assume varying and at times misleading forms. 



Varies with 
type of 
anemia. 



Pale disc. 



Bad hygiene. 



Lovesickness 
and nostalgia. 



148 



MEDICAL DIAGNOSIS 



A Cause of Chief Importance. — Many cases of chlorotic and secondary 
anemia lacking any easily demonstrable primary cause results from hidden 
foci of chronic intermittent or remittent infection such as are fully discussed 
elsewhere in this volume. 

CHLOROSIS 



Cause 
unknown. 



Lessened 
incidence. 



Developmental 
period. 



Recurrent 
cases. 



Type chiefly 
arected. 



Peculiar 
vulnerability. 



Leading char- 
acteristics. 



Characteristic Feature. — Hemoglobin deficit first reported by Johann 
Duncan in 1867 (Osier). 

Etiology. — Although known and recognized before the days of Hippo- 
crates, the specific etiology is unknown. Its onset is associated with the 
period of sexual development in the female and it would seem that some 
fault of function in the glands of internal secretion is the chief factor in 
causation. Its incidence in our own country has decreased strikingly dur- 
ing the past twenty years — a period characterized by greatly improved 
living conditions, a better understanding of concealed septic foci, and the 
free exhibition of Blaud's mass in the department stores. 

Age and Sex. — It occurs rarely in young males but is almost exclusively 
limited to the female sex. Of primary attacks, 99 per cent, occur between the 
ages of 14 and 25, and chiefly between the 14th and 18th years. Obviously, 
this latter period corresponds suggestively to that immediately preceding, 
accompanying, or following the establishment of menstruation. It repre- 
sents also the age of maximal susceptibility to focal infections. Inasmuch 
as the disease shows a peculiar tendency to chronicity and recurrence under 
the usual casual and unsystematic management on the part of patient and 
physician alike, one encounters frequently cases of chronic or recurrent 
anemia of the chlorotic type at later ages and occasionally even in middle age. 

The Congenital Asthenic. — According to the author's experience nearly 
all of the cases of pronounced chlorosis occur in individuals of the con- 
genitally asthenic (universally visceroptotic) type. The characteristics 
of this peculiar type of constitutional inadequacy or inferiority are such as 
would favor or predispose to the development of chlorosis, whether this be 
considered as fundamentally the result of disturbance of endocrine func- 
tion, nutritional deficit, or the result of infections. 

In such individuals there is a peculiar nutritional instability and an 
unfortunate dependence upon nutritional reserve for the maintenance of 
health and normal function. The larger number of cases of endocrine dis- 
turbance, of gastric neurosis, of cardiovascular abnormalities of the func- 
tional type, are associated with the presence of the "drop heart," abdominal 
visceroptosis, flabby abdominal muscles, a narrow costal angle and the 
slender bony and muscular structure characteristic of this type. They 
may be fat or lean. 

In these congenital asthenics, particularly, one finds with especial fre- 
quency not only focal infections of the usual type but radiographic evidence 
of larval or obsolete tuberculosis of pulmonary site. It has long been known 
that this is true also of cases of chlorosis. 

The readiness with which disturbance of function occurs in connection 



THE ANEM1 \S 



149 



with this constitutional state makes it easy to understand that deficient 
bone-marrow activity might occur readily in connection with it and indeed 
both the symptomatology and the etiologic indications accord with the 
assumption that in the greater number of instances one is dealing with 
this peculiarly vulnerable and unstable type. 

Older Theories of Causation. — Among the numerous and diverse theories 
which have been advanced in the past, one may note the following: 

Love-sickness is given as a cause. Of course, this may be and often 
is encountered in a disease affecting almost exclusively young girls and 
young women of the age which peculiarly predisposes to this state of mind 
and body. 

(b) Hypoplasia of the generative organs has also been advanced as a 
cause and is present no doubt in a certain proportion of the chlorotic cases. 
However, it would be improper in the light of present knowledge to consider 
this in itself a direct cause or a constant associated etiologic factor. 

(c) Tuberculosis, cardiovascular defects, heredity, psychoneurasthenic 
states, constipation and autointoxication, for the most part represent effects 
rather than causes and defects peculiarly likely to be encountered in connec- 
tion with the congenitally asthenic type. 

(d) Over-work, bad food, unhygienic environment, worry and mental 
depression, and even certain specific occupations have been advanced as 
casuative factors. Doubtless each and every one may be considered a 
potential contributory element, but certainly no one of them can be put 
down as a specific factor in etiology. 

(e) Much stress has been laid by certain writers upon the potency of 
homesickness as a factor in chlorosis and it is quite true that one encounters 
a large number of chlorotics amongst the recently arrived immigrants, 
especially such as come from northern countries as those of Scandinavia. 
Usually, however, it is unlikely that homesickness plays a part more import- 
ant in itself than any other state of mental depression and worry; and 
furthermore, in the class of individuals just mentioned, many other factors 
favorable to the development of the chlorotic state are present. The larger 
number of these young female immigrants have come from the farms, 
from an open country life with coarse wholesome food and abundance of 
out-door work, and have exchanged these favorable conditions of environ- 
ment for city living, domestic service, work in public laundries, and other 
occupations of a relatively unfavorable nature. 

(/) There can be little doubt that chronic concealed septic foci may 
play a part in the production and more especially in the persistance and 
recurrence of chlorosis, yet the greater number of anemias for which chronic 
infections of the tonsils, teeth, and other organs are responsible are of the 
secondary type to be described later and not of the chlorotic type. 

Unfavorable Environment. — The betterment of conditions of living and 
working has undoubtedly resulted in a marked diminution in the incidence 
of cases of chlorosis as might be expected when one considers the large number 
of contributory factors in etiology involved in bad housing, whether related 



Bone-marro\ 
deficiency. 



Dubious 
etiologic 
factors. 



Potential 

contributory 

factors. 



Nostalgia. 



Focal 
infections. 



150 



MEDICAL DIAGNOSIS 



Occupation. 



Low color 
index. 



Erythrocytes. 



Achromia 
marked. 



"Blasts." 



to dwellings or shops, insufficient and improperly prepared food, excessively 
long working hours with resulting tendency to extreme fatigue, and depriva- 
tion of fresh air and sunshine for the indoor dweller or worker. Each and 
every one of these factors is of vital importance to health in general and 
especially to the maintenance of good health on the part of those of the 
congenitally asthenic type of constitution. 

Cardinal Symptoms. — The most striking symptoms are lassitude, breath- 
lessness, the characteristic color, and a blood picture characterized by a low 
color index and the predominance of the small erythrocyte. 

Color. — Simple pallor or less frequently a peculiar " greenish-yellow " 
skin are usually, though not always, prominent signs. Indeed the term 
"chlorosis," "green sickness," is a misnomer. 

The patients appear, as a rule, relatively plump and well nourished, though 
pale, and their occupation is likely to be that of laundress, shopgirl, factory 
worker or school girl. The developmental period is the one of commonest 
incidence. 

The heart is often dilated moderately and edema of the ankles is a common 
symptom in severe cases. Vasomotor instability is marked and flushing may 
be associated with cold extremities, numbness and other symptoms of a like 
sort. A great many of the severe cases show the "drop heart" fully 
described elsewhere. Nearly all chlorotics are congenital asthenics. 

The lungs are sluggish and the breathing is superficial. 

Systolic murmurs are commonly encountered over the left base, at the 
apex or even in the aortic area. Both cardiac murmurs and dilatation 
respond promptly to effective treatment. 

A venous hum {"bruit de diable") is often heard over the jugular and a 
similar sound may at times be heard at the occiput or over the eyeball. 

Preservation of fat is the rule, high color not uncommon ("chlorosis 
rubra"), puffiness of the face may be decided and the eyes may be peculiarly 
brilliant and show a bluish sclera. 

The general symptoms are those described in the preceding pages but are 
usually moderate in degree. 

The therapeutic test for chlorosis is found in the prompt response of its 
symptoms to the proper administration of iron and relapses are common if pa- 
tients are not kept under observation for long periods. 

Blood Findings. — The blood macroscopically appears pale and thity and 
the color index is low. The hemoglobin percentage varies widely in the different 
cases (12 to 75 per cent.), its average being about 45 per cent. Total blood is 
increased and a certain grade of hydremia is present. 

The red cells are not proportionately decreased, the average being 4,000,000 per 
cubic millimeter. A count under 2,000,000 is rare, and the average size of the 
cell is less than normal. Stained specimens show marked achromia and old 
cases may show polychromasia and marked variation in the size of the cells (aniso- 
cytosis). Marked cell deformity (poikilocytosis) , is rare but in some recurrent 
cases extreme. 

Nucleated red cells are seldom found and when present are normoblasts. 



THE ANEMIAS 



<5' 



The leucocytes may be normal, slightly or markedly decreased* or increased 

and relative lymphocytosis is not uncommon. Myelocytes are rarely found, 
the eosinophils are decreased and the "coagulation time" is shortened. 
Blood platelets are slightly markedly increased. 

THE ADDISONIAN PERNICIOUS ANEMIA. 

("Plastic Pernicious Anemia") 

Age. — It occurs usually in middle age and is excessively rare in childhood 
and in old age. 

Sex. — In the United States and England males are oftenest attacked. 
In Germany females are chiefly affected. The world owes to Addison of 
England its first knowledge of this remarkable and mysterious disease.! 

Etiology. — The actual causes of pernicious anemia are unknown, but its 
dominant and invariable characteristic is an excessive, intractable, and ulti- 
mately fatal hemolysis due doubtless to an unknown toxin. 

The blood picture is suggestively like that of the bothrioceph- 
alus and pyridin anemias in which known hemolysins are causative. It 
follows, oftentimes, shock, mental strain, prolonged exposure and fatigue, 
syphilis, malaria, alcoholism, and in women repeated and excessive child- 
bearing, but any or all of these factors seem to be only- contributory. 

The present view would seem to be that certain toxins acting in small 
but potent doses over long periods abnormally stimulate the hemolytic 
activities of the bone marrow, spleen and lymph glands. 

As a result of the continued overstimulation and the persistent hemolysis 
the erythrogenetic centers themselves become overactive and enlarged 
and cause that ultimate dominance of the large immature vulnerable 
erythrocytes and erythroblasts which dominate the blood picture of the 
disease. 

Grawitz lays especial stress upon the well-known shortage of free HC1 
in the stomach contents of these cases as favoring excessive albuminous putre- 
faction and diminishing the defenses against bacterial activity. 

It would seem possible that the ultimate cause may be found in the 
selective activity of peculiarly virulent hemolytic streptococci. 

The disease is peculiarly insidious in onset and in public clinics the great 
majority of cases show an erythrocyte count under 2,000,000 at the first 
examination. 

Symptoms. — These are as described under "General Symptomatology" 
of the anemias, but patients present as special features or striking signs a 
more or less characteristic lemon-yellow color, together with insidious and 
slowly developed failure of strength, attaining gradually a most extreme type 
of muscular weakness in the established case. 

* Osier reports a series with an average white count of 8,467 per cu. mm., and Gulland 
and Goodall a series with average under 5000. 

f Addison's first report appeared in the London Med. Gazette, March, 1849. Biermer 
wrote of the same ailment in 1868, and in Germany it is termed quite wrongly "die Biermer- 
sche anaemie." 



Coagulation 
time. 



A mystery. 



Insidious 
onset. 



152 



MEDICAL DIAGNOSIS 



Striking 
symptoms 



Macroscopic 



"Coagulation 
time." 



High color ii 
dex, and low 
erythrocyte 
count. 



Hemoglobin. 

Poikilocytosis. 

Anisocytosis. 



Predominance 

of 

megaloblasts. 



Polychromasia. 



Impaired nutrition, intermittent gastrointestinal disturbance often of 
great severity and persistence, vertigo, submucous and subcutaneous hemor- 
rhages, extreme pallor of mucous membranes, retinal hemorrhage, severe 
headaches, tinnitus aurium, dyspnea, optical disturbances, fainting attacks, 
and slight edema of the extremities are among the prominent manifestations 
of this obscure ailment, as usually encountered. 

The asthenia is strikingly progressive in untreated cases, yet temporary 
recovery is common and may endure for several years, though the ultimate progno- 
sis is fatal. 

Heart. — The heart is weak and dilatable, the pulse rapid 'and labile in 
action and anemic murmurs are pronounced. 

Fever of the hectic type is a feature of the advanced cases or of the terminal 
stage. 

Hemorrhages in the spinal cord and meninges are not uncommon and mis- 
leading pictures may be produced through "patchy" involvement of the 
posterior or lateral column's singly or combined. 

Blood Findings. — The blood is pale, thin, slips quickly off the ear or 
finger following puncture, and if dropped on a piece of white bibulous paper 
the red is surrounded by a ring at first almost colorless but later showing a 
faint gray tint. 

The ''coagulation time" is increased and bleeding from the puncture of 
the ear may continue sluggishly for a considerable period, but is seldom or 
never excessive. 

The " total blood volume" -is diminished in these cases, the " volume index" 
is high, the specific gravity decreased. Blood plates and fibrin alike are strik- 
ingly diminished. 

The color index is high, the red cells are reduced on the average to 
1,500,000 per cubic millimeter and 1,000,000 is a common finding. 

Nageli has reported a count of 138,000 and Zeigler one of 110,000 per 
cubic millimeter in a case of the ''aplastic" type, described further on as a 
separate form. The lowest observed by the author was 348,000. 

The hemoglobin usually is reduced greatly and may be as low as, or even 
below, 15 per cent., but in most instances is relatively in excess. 

The average diameter of the red cell usually is increased, poikilocytosis (cell 
deformity) is marked and the "pear-shaped" and " anvil " forms are pecu- 
liarly plentiful. The red cells show great variation in size (anisocytosis) and 
giant non-nucleated and nucleated red cells are invariably present, though 
often found only after careful search and only rarely in great numbers, save in 
the so-called "blood crises." 

In this so-called "plastic" form, the megaloblasts must be found to out- 
number he normoblasts or a positive diagnosis is not then justified. A relative 
excess of microblasts or of normoblasts usually indicates a severe secondary 
anemia. 

Polychromato philia . i.e., irregularity in staining and consequent lack of 
uniform color in certain of the stained cells in a blood smear is a marked 
characteristic of this disease though not peculiar to it. 



nil'. ANEMIAS 



153 



'Die leucocytes are diminished in three-fourths of all cases and this leuco- 
penia may be extreme, the average being less than one-half the normal count.* 

Myelocytes and erythrocytes showing basophile granules with Wright's 
stain are nearly always present, though in small numbers. 

It is usually possible to make an accurate diagnosis of pernicious anemia 
by the blood findings alone, but now and then cases occur in which the clinical 
history and physical signs must be invoked. 

BotJiriocephalus infection and nitro-benzol poisoning present a blood 
picture almost identical with pernicious anemia or actually indistinguishable 
from it. 

Advanced cases of malignant disease of the stomach may present quite as 
extreme an anemia, but in this the small cell type usually predominates, both as 
to nucleated and non-nucleated red cells, the polymorphonuclear leucocytes are 
normal in number or increased and the lymphocytes relatively or actually dimin- 
ished in number. 

The urine in advanced pernicious anemia is usually dark and shows a con- j 
siderable increase of urobilin. 

The frequency with which pyorrhea alveolaris , dental abscesses and the chronic 
tonsillar and sinus infections occur in certain intractable anemias may prove 
ultimately of the first importance in establishing the identity of the specific causa- 
tive agent. 

Autopsy Findings in Addisonian Pernicious Anemia. — The autopsy 
findings throw little light upon the cause of the disease but disclose certain 
striking pathologic changes more or less peculiar to it. 

Fatty degeneration is the dominant process in the parenchymatous 
viscera and is especially marked in the liver, heart and kidneys. The heart 
is usually dilated and flabby and contains little or no blood. Its color is a 
pale yellow. 

The red bone marrow is strikingly deepened in color and the yellow marrow 
of the long bones appears to be transformed into a deep red gelatinous sub- 
stance often likened to currant jelly. This appearance is usually more 
striking than that seen in even the severest forms of secondary anemia. 

An extraordinarily large deposit of iron in the liver and to a lesser 
degree in the spleen and kidneys attends the continued destruction of 
red cells. 

A section of the liver thoroughly treated with a weak solution of ferro- 
cyanide of iron and then washed in a weak aqueous solution of hydrochloric 
acid assumes a strikingly beautiful blue color. 

The entire general picture presented by the victim on post-mortem sec- 
tion is one of extreme anemia and deficient blood volume. Even the imper- 
fectly formed blood clots show a pallid red. 

* This leucopenia usually affects chiefly the polymorphonuclears both neutrophile 
and eosinophile and to a lesser degree the large lymphocytes. A relative lymphocyte 
increase is, therefore, usually present. 



Leucopenia. 



Myelocytes 
and basophiles. 



Its simulators. 



A confusing 

secondary 

form. 



Urobilin 
increase. 



Focal 
infections. 



154 



MEDICAL DIAGNOSIS 



Sex 
predominance. 



Cause 
unknown. 



Progressive 
and resistant. 



Low erythro- 
cyte count. 



Low or normal 
index. 



Absence of 
poikilocytosis. 



Only a 
syndrome. 



APLASTIC PERNICIOUS ANEMIA 

Definition. — This term is applied to a relatively uncommon pernicious form 
of anemia, occurring usually, but by no means exclusively, in females between 
the ages of twenty and forty, in which the blood findings suggest a failure of 
hyperplastic response on the part of the bone marrow. 

Etiology. — The cause of the disease is wholly unknown. It is held, with- 
out much substantial justification, that in some instances it represents a termi- 
nal transformation of the hyperplastic Addisonian anemia. It may be 
treated properly as a distinct type, however, for bone-marrow insufficiency 
and aplasia are the dominating features in its pathogenesis. 

The disease is usually progressively fatal, lacks the clinical signs of excessive 
hemolysis, is resistant to all therapeutic measures, and is distinctly more hemor- 
rhagic in type than the ordinary form. 

Blood. — The erythrocyte count is seldom much above 2,000,000 and one 
count as low as 110,000 is reported. 

The color index is usually low or about normal. All forms of nucleated 
reds are absent or extremely scant. Poikilocytosis and anisocytosis are slight 
or wholly absent and polychromatophilia is not marked. Leucopenia and 
relative lymphocytosis are present as in true pernicious anemia but of higher 
grade. The blood platelets are decreased markedly. 

The skin seldom shows the pale lemon tint so common in advanced Addi- 
sonian anemia. The urine is relatively fight in color and free from urobilin. 
The liver, spleen and lymphatic glands are not markedly enlarged and even 
though nucleated cells are originally present they tend to disappear as the 
disease advances. 

Autopsy reveals an entire absence of hyperplastic changes in the bone 
marrow and a greater or less degree of actual aplasia, the bone marrow in 
some instances consisting of yellowish fat. 

SPLENIC ANEMIA 

Not a Clinical Entity. — This condition has not yet made itself a place in 
medicine as a clinical entity and its features do not seem to be sufficiently 
characteristic to constitute a separate disease but rather to stimulate us to 
seek a more accurate terminology. 

Anemia with splenic enlargement would seem to be the more correct term. 
So far as the actual blood picture is concerned, any form of anemia may be 
simulated, the marked secondary type being that commonly shown. 

We must regard the condition for the present as an interesting symptom- 
complex, lacking the glandular enlargement of Hodgkin's disease or the peculiar 
blood changes of leukemia, and adding to the ordinary symptoms of anemia that 
of splenic hypertrophy, commonly associated with hepatic enlargement. A 
large number of cases of this general description prove to be due to syphilis or 
to malignant growth. 

Three syndromes under this general heading are worthy of discussion. 



THE ANEMIAS 



155 



SPLENOMEGALY WITH HEPATIC CIRRHOSIS AND ANEMIA.— 
This symptom-complex unites anemia, hepatic cirrhosis and splenomegaly. 

This disease was long ago known by the reasonably accurate and descrip- 
tive name "splenomegaly with hepatic cirrhosis." We owe to Banti an ex- 
cellent and orderly description of the condition. 

First Stage. — At any age, but most frequently between thirty and fifty 
a painless splenic tumor develops and gradually increases in size, until in form, 
area, and consistence it may closely resemble the spleen of a myelogenous 
leukemia. Coincidently there develops an anemia of the simple chlorotic 
or mild secondary type with low "color index" and more or less enlargement 
and induration of the liver. 

Second Stage. — Icterus appears and dyspeptic symptoms may become 
prominent. 

Third Stage. — After a few months the icterus and anemia become inten- 
sified but show no decided departure from the picture of severe chlorosis or 
of a secondary anemia of the ordinary type; epistaxis, hematemesis, purpura 
or other hemorrhages may appear, cachexia is marked and, later, ascites is 
evident. A fatal issue may result from progressive inanition or from gastric 
or intestinal hemorrhage. 

Nearly all of the cases observed by the author, whether at home or abroad, 
have proven ultimately to be either syphilitic or due to malignant growth, and 
those proven luetic have presented, for the -greater part, the typical picture as 
drawn by Banti. 

SPLENOMEGALY OF THE GAUCHER TYPE.— This extremely chronic 
and excessively rare disease of infancy and early childhood combines in itself 
the peculiar pigmentation of Addison's disease with splenomegaly, subsequent 
enlargement of the liver, and anemia. 

It is familial but probably not hereditary, occurring usually in several 
members of the same generation (females are chiefly affected), and is char- 
acterized anatomically by the presence of masses of peculiar hyaline cells 
of large size and probable endothelial or reticular origin, (40/z) in the spleen, 
liver, bone marrow and lymph glands. 

The blood picture is neither characteristic nor consistent. It may be 
that of mild chlorotic anemia (the usual form) with leucopenia, or present 
the blood findings of mild secondary anemia or those of a severe but atypical 
pernicious form with megaloblasts and myelocytes. 

A tendency to hemorrhages may be present. 

By some authorities it is stated that leucopenia is constant throughout 
and a chlorotic blood picture invariably present. 

The course of the disease is extremely protracted, the general health is 
but very gradually affected and death occurs after several or many years 
through some intercurrent disease. 

Though a disease of childhood and early youth, it often escapes diagnosis 
for many years. 

CONGENITAL HEMOLYTIC JAUNDICE.— This is an extremely 
chronic, strikingly hereditary, familial disease, of great interest and rarity, 



So-called 

"Banti's 

disease." 



Primary stage. 
Splenomegaly. 



"Transition 
stage." 



"Ascitic 
stage." 



Peculiar 
pigmentation. 



Familial. 



Bastard blood 
picture. 



Familial. 



i56 



MEDICAL DIAGNOSIS 



characterized by extraordinary vulnerability of the red blood cells, decided 
anemia, splenomegaly, moderate hepatic enlargement, pronounced icterus 
and urobilinurea. All symptoms of an actual obstructive jaundice are lack- 
ing in the stools and urine. 
Hemolysis. The destruction of red corpuscles is extraordinary in many cases, the blood 

picture being in the rarer instances that of a pernicious anemia. Their re- 
sistance to hypotonic sodium chloride solution is so greatly diminished as to 
constitute an important factor in diagnosis. 

An interesting case was reported recently from the author's former clinic 
by Richards and Johnston.* 



LEUKEMIA ("White Blood") 



Historic Note. — Until 1841 this disease was regarded as a purulent inflam- 
mation of the blood. John Hughes Bennett gave the first account of the 
disease in the year 1845. 

Pathogenesis. — The latest investigations strengthen the theory that we 
shall find ultimately that an infection plays the chief role. Leukemia is 
undoubtedly a primary affection of the bone marrow and the lymphoid 
structures, the essential change being one of excessive and wholly unregulated 
myelocytic or lymphocytic hyperplasia, leading ultimately to the dominance 
in the blood picture of types of white cells which normally are wholly absent 
or appear only in small numbers in the blood stream. We know practically 
nothing of the early stages of the disease. 

Varieties. — There are two forms of leukemia, the myeloid and the lymphatic. 
In the first form the blood assumes the so-called myeloid type, in the second, the 
lymphoid. 

Although several cases of acute myelogenous leukemia have been reported, 
we may for the present regard it as essentially a chronic disease. 

Lymphatic leukemia, on the other hand, may be either acute, subacute or 
chronic. Transmutation may occur in rare instances. 

Important Distinction. — It should be clearly understood that the existence 
or non-existence of leukemia is not determined merely by the number of white 
cells present in the given blood. 

A count of 90,000 leucocytes may be but a leucocytosis and a count of 
25,000 might represent a leukemia. The difference between the two is dis- 
tinctly qualitative, not quantitative. It is true nevertheless that in most 
cases of leukemia the leucocyte count is very high at the time of first 
recognition. 

* Cases showing an apparently clearly denned blood picture of pernicious anemia, but 
showing decided splenic enlargement and slight jaundice, should always be specially in- 
vestigated as to familial tendency and the osmotic resistance of the red cells should be tested. 



THE ANEMIAS 1 57 

MYELOID LEUKEMIA 

Definition. — . 1 chronic, progressive and fatal disease characterized by a 
combination of profound anemia of the pernicious type with an extraordinary 
increase of leucocytes of both the common and the unusual types, which findings, 
together with splenomegaly, dominate the clinical picture. 

Etiology. — Age. — It may occur at any period, but for the most part is 
encountered in middle age. 

— Males are chiefly affected, predominantly so, in the author's 
experience. 

Other etiologic factors are not well understood. Certain rare cases of 
streptococcic sepsis have presented a picture suggestively similar but there 
remains no definite etiologic factor up to the present time. 

SYMPTOMS. — The general symptoms are those of severe anemia as 
already described at the beginning of this section. The disease is not likely 
to be detected until well advanced,* and the general symptoms are then those insidious in 
of a profound anemia with an especial tendency to hemorrhage and serous 
effusions. 

Dyspnea is marked; ultimate loss of flesh usually extreme, and both liver 
and spleen are enlarged, the latter to an enormous degree in certain cases, Enormous 
and always to a marked degree. f It is astonishing that so great an enlarge- 
ment frequently may be unattended by serious discomfort. 

In certain cases there is pain and tenderness over the long bones and 
disorders of sight and hearing are not uncommon. 

Blood Findings. — The red cell count is markedly reduced and the white striking 

picture. 

cells are greatly increased in number, the average count being 400,000 in estab- 
lished and well-advanced cases, the maximum sometimes exceeding 1,000,000 
cells. The characteristically important white cell of leukemia is the myelocyte characteristic 

- e e , myelocytic 

and from 20 to 50 per cent, of the leucocytes present are of the myelocytic dominance, 
type. 

The eosinophiles are also present in unusual numbers, showing both 
an actual and relative increase. Both the lymphocytes and polymorpho- 
nuclear cells, though absolutely increased, are relatively diminished. 

Megaloblasts, normoblasts and microblasts are present in quantity and 
their nuclei frequently show mitotic changes. 

One of the most striking though not invariable symptoms of the later stages 
of the disease is the tendency to hemorrhage from mucous membranes. Hemorrhagic 

These are often large, persistently recurrent, and demand that every 
patient should be duly warned and instructed concerning measures for their 
relief or control. They often prove a terminal event, or death may result 
from asthenia or from either gradual or sudden cardiac failure, often associ- 
ated with general dropsy. Severe recurrent unexplained hemorrhages demand 
an examination of the blood. 

* Not only may strength be well preserved over long periods, but the outward appear- 
ance of health as well. Even a gigantic spleen may be wholly unnoticed by the victim. 

t In one case shown by the author to the Minnesota State Medical Society in 1903, the 
splenic margin actually rested against the anterior-superior spine of the right side. 



tendency. 



i58 



MEDICAL DIAGNOSIS 



Lymphocytosis 
absolute. 



LYMPHATIC LEUKEMIA 

Essential Features. — The essential features of lymphatic leukemia are 
two in number: (a) Enlargement of the lymphatic glands, (b) An absolute 
monocytosis in which either the large or small cell type may predominate. 

The cause is unknown; chronic cases endure for years, but acute cases may 
terminate in a month or six weeks. 

SYMPTOMS. — Any or all groups of lymphatic glands may be enlarged. 
The tumors are, as a rule, separate and movable, free from active inflammatory 
changes and show little or no tendency to suppuration. They vary greatly in 
size but seldom exceed the dimensions of an egg. Usually all accessible glands 
are affected in some degree. 



Lymphomata. 



Predominant 
localization. 



Consistent 
picture. 



A terrible 
complication. 




Fig. 



53.— Lower section shows a lymphatic leukemia. Upper section normal blood 
showing leucocytosis. These types of cells should be carefully noted. 



The cervical chains are ordinarily most prominent, but predominance of 
enlargement may be found in the axillary or inguinal groups and nodes 
normally inconspicuous may form large masses. 

In the rarer cases the glandular chains affected are not accessible, yet decided 
involvement of the retroperitoneal or bronchial groups may exist. 

The spleen is moderately or decidedly enlarged, but the glandular symptoms 
dominate the picture. 

Fever is present in variable degree in all acute cases and the later stages 
of the chronic form. 

Pressure symptoms may be marked and in three of the author's cases death 
occurred horribly from actual slow suffocation due to the pressure of 
mediastinal growths. 



THE ANEMIAS 



159 



Insidious Onset. — In this form of leukemia, as in the myeloid form, the 
condition is usually well advanced before the patient seeks his physician, 
complaining of progressive weakness, easily induced fatigue and, perhaps, of 
glandular swellings. 

Some pallor is usually manifest and these patients often carry a peculiarly 
harassed expression. 

The spleen is usually easily palpable but seldom descends more than one 
or two finger-breadths below the costal margin. 

The liver may be greatly enlarged and markedly indurated but usually 
the increase in size is moderate. 

Fever. — A moderate daily rise of temperature is not uncommon even in 
the chronic cases. 

BLOOD FINDINGS. — The blood picture contrasts strikingly with that of 
myeloid leukemia in the comparative lack of diversity of form and type in the 
blood cells. 

Save in the rarest instances, the lymphocyte absolutely dominates the 
leucocytic field. 

Nucleated red cells are rare as compared with the myelogenous leukemias, 
though in the acute type of the disease they may be present in considerable numbers 
and the same is true of certain of the leukemias of children. If nucleated reds 
are present, the normoblast predominates in most instances. 

Very rarely an extreme degree of anemia proper co-exists with the 
leukemia and the blood picture more nearly approaches that of pernicious 
anemia so far as the erythrocytes are concerned. 

The leucocyte increase, while striking, is seldom as large as in leukemia of 
the myelogenous type. 

The average lies between 200,000 and 250,000 cells, the maximum being 
about 1,000,000, but in a case observed by the author the count reached a remarkable 

77 . J case. 

2,133,000 for the single examination possible and w r as probably a preagonal 
increase, as it occurred but twenty-four hours before death. As before stated, 
the remarkable predominance of the lymphocytic type (average 90 per cent.) 
is striking and the cells show many atypical forms. The myelocytes are 
relatively rare, eosinophiles are diminished and neither the mast cell nor the 
basophile are common. 

ACUTE LYMPHATIC LEUKEMIA.— This rare ailment is sufficiently 
definite in its clinical characteristics to merit a special description. 

As in the case of the chronic form, post-mortem section reveals general 
proliferation of lymphoid tissues of somewhat less extent and degree, as w r ould 
be expected in a lymphatic leukemia of short duration. 

Suggests An Acute Infection. — The onset is usually abrupt and well- 
defined, rarely insidious. A chill may or may not initiate the febrile stage. 
Very often an antecedent or existing severe stomatitis, tonsillitis, or pharyn- 
gitis occurs and may prove most misleading, though in the future we may 
find the fact helpful in determining the true etiology of the leukemic 
states. 

A Misleading Occurrence. — When, as occasionally happens, there is no 



Onset usually 
abrupt. 



Suggestive 
coincidences. 



i6o 



MEDICAL DIAGNOSIS 



Depends 
upon blood - 
findings. 



Relatively 
common. 



change from the normal in the blood count for a period of several days error 
is very likely to occur. 

Fever is persistent and may assume a distinctly septic type late in the 
course of the disease. Indeed a definite streptococcic infection may occur 
in certain cases. This has been regarded as secondary but recent work 
with the hemolytic streptococci would suggest that such a conclusion may be 
erroneous. 

Hemorrhage from the nose or gums may initiate the attack and con- 
stitutes an important complication of the disease. It may be most persistent 
and intractable and even prove the terminal event. The condition of the 
mouth and teeth may closely simulate scurvy. 

Enlargement of accessible glands may be wholly lacking or very 
decided. 

Splenic enlargement is present but only of slight degree in cases of short 
duration and symptoms of profound anemia rapidly develop with progressive 
cardiac weakness. 

The blood picture is identical with that of the chronic form, the small 
lymphocyte usually, but by no means always, predominating. Early counts 
may prove negative. 

It is asserted that many of the cases termed acute lymphatic leukemia are 
actually instances of acute myeloid leukemia, the mononuclears representing 
NaegeWs myeloblasts. 

The differentiation of these cells from the lymphocyte offers great diffi- 
culties, even to the expert hematologist, and is of slight clinical importance. 

Prognosis. — The disease is invariably fatal and may terminate within a 
few days or be prolonged for two or three months. 

DIFFERENTIAL DIAGNOSIS OF THE ANEMIAS.— The enormous 
value of blood examinations is evident if one considers the insuperable difficulties 
surrounding the purely clinical differentiation of the conditions described, 
as compared with the ease with which each disease may be identified, usually, 
by hematologic methods. 

As regards anemia in any of its three chief forms, no confusion is 
possible save in rare instances, and the two chief varieties of chronic leuke- 
mia are quite as sharply contrasted. 

The glandular enlargements of Hodgkin's disease, tuberculosis and syphilis 
seldom offer the slightest difficulty if the blood findings are invoked, nor can the 
various enlargements of the spleen be confused with the splenomegaly of mye- 
logenous or lymphatic leukemia. 

Sources of Confusion. — Certain cases of profound secondary anemia, 
particularly those associated with carcinoma of the stomach or primary 
atrophy of the gastric tubules {not merely the simple achylia gastrica) 
may at times present a picture almost indistinguishable from that of per- 
nicious anemia though the small red cell, both nucleated and non-nucleated, 
is the predominant form in almost every instance. To this may be added 
bothriocephalus anemias, which symptomatically, and in the blood changes, 
may be identical with pernicious anemia proper, and separable only through 



THE ANEMIAS 



161 



the discovery of the true etiologic factor. A careful examination of the 
stools is indicated in all anemias. 

It is probable that in the anemias of true gastric atrophy of the type 
mentioned, the blood findings are always those of the profound secondary 
type. 

Subdivisions and Transition Forms. — It is quite possible that further 
subdivisions of leukemia may be made in the future, and indeed many cases 
of variation in the relative predominance of cell types and apparent transi- 
tion are constantly being placed on record.* 

Von Jaksch has reported a " multiple periostitis with splenomegaly and 
myelocytic anemia, multiple arthritis, profuse sweats and a like and even 
greater tendency to the hemorrhages such as so frequently complicate the later 
stages of myelogenous leukemia." 

CHLOROMA. — In this rare disease the blood findings may be indistinguish- 
able from those of lymphatic leukemia, but the clinical symptoms are strikingly 
different save that its course closely parallels lymphatic leukemia of the acute 
type. 

Tumors. — The curious greenish tumors of chloroma are strikingly unlike 
anything occurring in connection with lymphatic leukemia. 

At autopsy they are found widely disseminated throughout the body, 
but their tendency to appear at points of prominence on its surface makes the 
diagnosis simple if the existence of such a rare disease is recalled to memory. 
Indeed they are especially numerous over the bones of the skull and face. 

This curious ailment is invariably fatal and attacks, almost exclusively, 
male children and adolescents. 

STILL'S SYNDROME. — Still has reported a syndrome, the main feature 
of which is an anemia associated with infantile arthritis with enlargement of 
the lymph glands and spleen, but lacking the blood -findings of leukemia and 
presenting usually the history of rachitis. 

MYELOMA. — In this rare and obscure ailment a period of neuralgia-like 
bone pain may be followed by painful metastatic swellings usually affecting 
chiefly the ribs or bones of the cranium and sometimes producing spontaneous 
fractures. 

Diagnosis depends upon the presence of the Bence- Jones proteid in the 
urine and the result of roentgenographic studies. 

LEUKANEMIA. — This term has been widely and loosely used to cover a 
clinical picture in which the symptoms of leukemia and of pernicious anemia 
are confusingly blended. 

It has been wrongly used also to cover cases which were undoubtedly 
myeloid leukemias or clearly pernicious anemias in which unimportant 
departures from the type had occurred.! 

* The author has observed a case of apparently typical Hodgkin's disease become in all 
respects lymphatic leukemia and many reports of myeloid leukemias under X-ray treat- 
ment have shown an apparent transition to the lymphatic type. 

t As Cabot says, "most reported cases are clearly leukemic and nearly all of the re- 
mainder are pernicious anemias." 
ll 



"Green 
cancer." 



A useless term. 



l62 



MEDICAL DIAGNOSIS 



Not 
uncommon. 



High altitudes. 



Multiple 
causes. 



Stasis 
polycythemia. 



If the term is to be retained it should be confined to cases of the type 
originally reported under it by Leube and Arneth. The original case pur- 
sued the course and had all the attributes of a rapidly progressive and fatal acute 
injection. 

The blood picture was that of a pernicious anemia of the Addisonian type 
to which was added a large increase of leucocytes with many neutrophile 
myelocytes. 

PROGNOSIS IN THE ANEMIAS.— In anemia of the chlorotic type 
the prognosis is always good unless it be a part of the clinical picture of gastric 
ulcer or incipient tuberculosis, or attributable to recurrent septic infection arising 
from obscure foci. 

Secondary anemias are wholly dependent as to cure upon the possibility 
of removing the primary cause. 

Pernicious anemia is almost invariably fatal, though long periods of 
apparent recovery may be noted in cases of the plastic type.* 

Leukemia offers a bad prognosis, though of late apparent cures have 
been common. It is probable that these cases will also prove fatal after a 
period of apparent arrest. 

THE POLYCYTHEMIAS 

POLYCYTHEMIA. — (Erythrocytosis) . — A more or less marked increase 
of erythrocytes above the normal count is observed in a great variety of 
conditions, some important, others trivial, and, curiously enough the perma- 
nency of such a condition still remains unproven. 

It usually represents nothing more than blood concentration or stasis, 
and in high altitudes is perfectly accounted for by the assumption that nature 
meets an actual need associated with the rare air and the dyspnea first pro- 
duced in a non-habituated person. f This assumption is borne out by the 
secondary partial reduction noticed in those who take up permanent 
residence. 

A similar slight increase may follow baths, hot or cold, massage, violent 
exercise and the administration of certain drugs or may be associated with 
the process of digestion, blood regeneration, vomiting, profuse sweating, the 
removal of exudates, profuse diarrheas and, it is said, with myxedema and 
acute yellow atrophy. 

Its presence in connection with circulatory stasis, such as may occur in 
organic heart disease, emphysema, stenotic dyspnea and similar conditions 
affecting the circulation is readily understood and in extreme cases the 
count may reach 7,000,000 per cubic millimeter. In congenital heart disease 

* The longest duration of such a period of false cure personally observed was five years, 
a second period of about one year followed a second stay in the hospital, succeeded by a 
rapidly fatal relapse. One case of complete cure has occured in the author's practice. 
The blood being wholly normal ten years after apparent recovery. 

t An immediate primary apparent increase such as occured in the military observers 
and fighters of the aviation corps during the "Great War" is caused probably by car- 
diovascular embarrassment and irregularities of distribution, violent and abrupt transi- 
tions from sea level to 14,000 ft. altitude being common events of the day's work. 



THE POLYCYTHEMIAS 



i6j 



Polycythemia 
rubra. 



A recent 
discovery. 



of extreme cyanotic types the erythrocyte count may exceed 9,000,000 per 
cubic millimeter of blood and hyperplasia of the red marrow is found in such 
eases. 

In the dyspneic states due to acquired heart disease there is probably no 
excessive formation of red cells, but rather an irregular distribution through- 
out the circulation. 

ERYTHROCYTOSIS MEGALOSPLENICA.— (Erythremia).— This pe- 
culiar disease or syndrome of unknown etiology comprises: {a) Marked 
increase of the red cells, (b) A pecidiar l( red cyanosis." (c) Enlargement 
of the spleen, (d) Frequently, hepatic enlargement, (e) Commonly, albumi- 
nuria, (f) Hyperviscosity of the blood, (g) Rapid coagulation, (h) Great 
increase in the total blood volume. 

The disease was first noted by Vaquez in 1892, again reported by Saundby 
and Russell* and by McKeenf in 1901, and in 1903 Osier's report of cases and 
masterly description brought the condition into prominence. 

It is rare, but not to the extent formerly assumed. The author has 
encountered four cases in his private consulting practice during the past 
few years. 

Hemoglobin values of 165, and even 220 (by Palmer's method), have 
been reported, but in one of Cabot's cases it was but 85 with a count of 
8,484,000 reds and 15,000 whites, and in another 105 w T ith a count of 11,352,- 
000 reds. Moderate or absent leucocytosis is the rule. The highest erythro- 
cyte count reported is 14,800,000 per cubic millimeter. 

The color index is low, the coagulation time variable, and the behavior 
of the erythrocytes to salt solution is normal. 

The specific gravity of the blood is high; that of the serum, normal; 
and the freezing point shows no abnormal variation. 

Symptoms. — The diagnosis can be made at sight with reasonable accuracy 
by one who has carefully observed a typical case previously. 

The face and ears exhibit a peculiar dusky redness seen in no other disease. Dusky red 
77 is furthermore quite distinct from ordinary cyanosis, however intensive, in 
that the red dominates the color field as far as the face is concerned. 

The extremities are markedly cyanotic and its depth and degree is greatly 
intensified by exposure to cold and the dependent position. 

Decided enlargement of the spleen is present almost invariably and 
may attain large proportions. It is smooth, indurated and seldom or never 
fixed by adhesions. { All of the author's cases showed marked enlargement. 

The liver is usually decidedly enlarged. 

Albumin and casts have been present in four of the six cases occurring in 
the author's practice and in all the blood pressure was distinctly high. In all 
cardiac hypertrophy and dilatation were manifest. 

* Lancet, 1901, Vol. 1. 

t Boston Medical and Surgical Journal, June 20, 1901. 

% In a case hereafter referred to as under observation for eight years past the primarily 
gigantic spleen is greatly shrunken and the liver has assumed almost a normal outline. 
The last blood count showed 'over eight million erythrocytes. 



Sight 
diagnosis. 



Splenomegaly. 



Arterial 

hypertension 

common. 



164 



MEDICAL DIAGNOSIS 



Many cases are reported which have lacked circulatory disturbances 
of this nature; and, doubtless, a large number of the cases on record are 
unworthy of inclusion. It is certain, however, that the typical cyanosis with 
splenomegaly and erythrocytosis may exist without high blood pressure. 
Internal hemorrhages and thromboses are common terminal events. 

Prognosis. — No well-authenticated cases of cure have been placed upon 
record. But one of the four cases of the author is living after eight years of 
observation and his improvement has been maintained only by repeated free 
phlebotomy and the use of benzol:* 

In reporting cases the chief clinical factors must be demanded inasmuch as 
a polycythemia of marked degree may co-exist with cyanosis under other 
conditions. The peculiar cyanosis with its accompanying brick-red, mottled 
facial color is most striking. 

CERTAIN OBSCURE DISEASES ASSOCIATED WITH ANEMIA 

HODGKIN'S DISEASE. — ("Pseudo-leukemia" "lymphomatosis granulo- 
matosa," ' ' lympho-sarcomatosis" "lymphadenosis" "anemia lymphatica," 
" adenie," u lymphadenie ," "malignant granuloma" "infectious granuloma") 

Definition.- — An infectious granulomatous process of uncertain etiology, 
chronic, progressive and fatal, chiefly affecting male adults under forty years of 
age; characterized by peculiar histologic changes in and marked enlargement of 
the lymph glands; associated with splenic enlargement and anemia of varying 
degree, but lacking the blood changes of lymphatic leukemia. 

The number of names given above indicate the dubious nature of the 
ailment and the diverse pathologic processes with which it has been confused. 

Historic Note. — The disease was first reported by Malpighi in 1669, 
who did not recognize it as a distinct disease. Craigie, in 1828, differentiated 
the anatomical character of the glands from those of carcinoma and tubercu- 
losis, but to Dr. Hodgkin (1832) we owe our first definite description of the 
disease as a clinical entity. It did not, however, attain general recognition 
until the sixth decade of the last century. 

Etiology.— C. H. Bunting has recently isolated and cultivated a Gram-posi- 
tive diphtheroid bacillus, corynebacierium granulomaiis maligni, which, when 
grown in pure culture and injected into apes, produces an enlargement' of 
glands and histologic changes similar to, if not identical with, those of 
Hodgkin's disease in man. 

Fraenkel and Much have reported Gram-positive granular non-acid-fast 
bacilli, and some observers have considered these as degenerated tubercle 
bacilli, but on the whole, little evidence has been adduced to support the 
older supposition of Sternburg that the disease is of tuberculous origin. 

The etiology therefore remains unknown. 

Glandular Enlargement. — Dorothy M. Reed reports the following his- 
tologic picture as characteristic of Hodgkin's disease: '(a) Swollen endothelial 

* No knowledge of the actual duration of this disease is available for the reason that 
none have been seen in the early stages and watched throughout the course of the disease. 



HODGKIN S UISKASE 



165 



cells lying upon the fibrils of the reticulum; (b) Large epithelioid giant cells 
lymphocytes and eosinophiles occupying interstices of the stroma. The 
essential clinical change is one of enlargement of the lymph glands involving 
primarily limited areas, but tending to extend widely. The cervical and in- 




Fig. 54. — Hodgkin's disease, enlarged glands filling the mediastinum. (Dr. Frank 

S. Bisscll.) 

guinal glands are usually the first affected, the former giving to the disease 
its most marked characteristic. The tissues of the neck may entirely lose 
their normal contour, and the glands there and elsewhere tend to steadily 
enlarge without marked tenderness or symptoms of inflammatory change. 
They tend to maintain their individual outline until late in the disease, 



i66 



MEDICAL DIAGNOSIS 



A source 
of error. 



Debated point. 



Important 
data. 



The Hodgkin's 
Collar. 



and the skin usually remains unaffected and unattached to the subjacent 
tumors. When periadenitis occurs in the later stages lobulate tumors are 
formed which may lose the firmness characteristic of the earlier period, 
become softened and, rarely, may undergo ulceration. The deep glands 
above the trachea, those of the larger bronchi, of the mediastinum and 
retroperitoneal area become involved and in some instances form large 
tumors and greatly complicate the case. The spleen is enlarged in 75 per 
cent, of the cases. In some cases the internal lymphadenoid tissues alone 
are involved, rendering positive diagnosis extremely difficult. 

The Blood. — There are no changes in the blood peculiar to this disease, 
the picture being one of secondary or of chlorotic anemia. The blood index 
is in fact usually low as in the chlorotic type and the number of red cells 
seldom falls far below 2,000,000 per cubic millimeter. In cases which de- 
velop marked mediastinal involvement and cyanosis a stasis-polycythemia 
may obscure the blood picture. In most cases a moderate or decided leuco- 
cyte increase is observed, especially during periods of increased fever when 
it may reach a high figure (50,000 or more). 

A more or less decided eosinophilic, is usually demonstrable. 

Pseudopodia-like elements representing megalokaryocytic protoplasmic 
masses are also reported by Bunting as appearing in the blood. 

In certain profoundly cachectic and asthenic cases the polymorphonu- 
clears are decreased and a relative lymphocytosis results. 

Whether an actual lymphocytosis is at all common is a contested point. 
Morawitz asserts its frequency and its value as a differential point in the 
separation of true Hodgkin's from the other granulomata. It is probable 
that such an increase is usually only apparent and is actual 1 y relative. 

Bunting believes that an increase in blood plates and transitional leucocytes 
constitutes a constant feature and it is true certainly that these features are 
encountered with sufficient regularity to make them diagnostically suggestive. 

Acute Hodgkin's Disease. — Certain cases develop so rapidly as to be 
properly called acute, and may run their course to a fatal termination in a 
few weeks. The symptoms are, however, not different from those of the 
chronic type, save that there is a certain concentration of all clinical 
phenomena. 

Symptoms of the Ordinary Form. — The onset is insidious, save in acute 
cases, and the enlarged glands, usually in the cervical region, but sometimes 
in the groin and axilla, may first attract attention. 

The glandular enlargement may primarily be either unilateral or bilateral, 
but extends and tends to become general. The changes in the neck and 
the peculiar outline produced have given rise to the descriptive term, "the 
Hodgkin's collar." 

As the disease progresses, though often only after several months, a 
considerable or high degree of secondary anemia and more or less progres- 
sive emaciation appear. 

If, as is not infrequent, the mediastinal glands take on a rapid growth, the 
pressure symptoms may be extreme and will precisely resemble those seen 



HODGKIX'S D1S1 VS1 



167 



in any other mediastinal tumors, pain, cough and dyspnea, paroxysmal or 
continuous, being the chief symptoms. 

Fever is present in the advanced cases and shows a decided tendency to 
the relapsing form. Indeed its behaviour may constitute a point of differential 
value. 

Splenic enlargement is readily made out in three-fourths of all cases and 
occasionally becomes excessive. The liver is less frequently affected* 

Differential Diagnosis. — From tuberculous adenitis it is usually readily 
differentiated by the age of the patient (which is generally above thirty and 
almost invariably above twenty); by the absence of decided inflammatory 
symptoms in and around the glands during the earlier periods; by the 
absence of a history of tuberculosis past or present; by the excision, if 
necessary, of a small gland and its examination; together with the fact that 
tuberculosis is more generally localized and unilateral, and that its tumors 
never attain a large size without marked evidence of inflammation and 
caseation. 

From leukemia it is absolutely differentiated in most instances by the 
blood examination. 

Aleukemic lymphadenosis lacks the blood picture of Hodgkin's disease. 

Syphilis must be differentiated by the history, the presence or absence of 
scars, the result of a Wassermann or luetin test, and the difference in the 
character and extent of the glandular swelling, which in this disease, though 
more or less general, does not often attain the large size found in Hodgkin's 
disease. Tentative antiluetic treatment is often advisable in clinically 
atypical cases. 

Lymphosarcomatosis spreads rapidly to all other glands in the area affected 
but does not invade the other adjacent organs. 

True sarcoma tends to spread to other tissues. 

Simple lymphoma is localized and lacks the predominating symptoms of 
Hodgkin's disease. 

In all the conditions named the blood picture described above is lacking. 

It must be admitted that certain of the generalized granulomata of tuberculous 
or syphilitic origin cannot always be differentiated clinically from Hodgkin's 
disease. 

Unusual Symptoms. — An enormous number of symptoms might be named 
in connection with the development of glandular masses in the abdomen, 
among these being bronzing which results probably from pressure upon the 
solar plexus. One has only to bear in mind that in this disease large tumors 
may develop in remote regions producing exactly the same effects as would 
any other tumors in the same location. 

Prognosis. — The disease is almost invariably fatal, its course occupying 
usually one or two years. Misleading periods of improvement followed by 
relapse are extremely common and this applies to both the general and local 
manifestations of the disease. 

* Marked splenic enlargement is due usually to secondary growths: that of the liver 
to the same cause or to fatty degeneration. 



Bronzing 
possible. 



Progressively 
fatal. 



i68 



MEDICAL DIAGNOSIS 



Significance 



"Hysterical' 
purpura. 



PURPURA 

Definition. — A morbid state characterized in its graver forms by a low 
blood-platelet count, prolonged bleeding time, deficient contractility of the 
blood clot, usually without delayed coagulation time, by hemorrhages, 
subcutaneous, submucous, or, in rare instances, an outpouring of blood 
into the serous cavities, with or without fever and other constitutional 
symptoms. 

Deficiency of blood platelets, and the consequent deficiency or lack of 
platelet thrombi, may account for the persistent or unduly prolonged 
bleeding noted, in the severer forms of purpura, following slight wounds. 

The cause of the platelet deficiency is wholly unknown, nor can we 
determine whether in any given case the unknown etiologic factor operates 
to destroy them when formed, inhibit their production from the megacaryo- 
cytes or destroy the parent cell in the bone marrow. 

The platelet count has a practical value in this ailment inasmuch 
as a count below 60,000 per cmm. predisposes to or initiates hemorrhage 
(Minot) and with a decided rise in the count the danger of hemorrhage 
disappears. 

In severe purpura the platelets may almost wholly disappear (5000 or 
less per cmm. of blood). 

Comment. — So little understood is this disease that an arbitrary classi- 
fication serves the purpose of clinical convenience and little more. It seems 
to bear a close resemblance to certain forms of urticaria, to scurvy and to hemo- 
philia, and possesses but two constant and invariable symptoms, viz.: subcutan- 
eous hemorrhages, and imperfect thrombus formation. 

Cases may be grouped under four general heads. 

1. Complicating purpuras, viz., those occurring in connection with (a) acute 
infections, (b) chronic diseases associated with cachexia. 

When purpura occurs in association with acute infection it ordinarily 
indicates aii exceptionally severe type of the primary disease. One may 
encounter it in typhoid fever, smallpox, malignant endocarditis, septicemia, 
pyemia, whooping cough and measles as well as in the more virulent of the 
tropical diseases. In cerebro-spinal meningitis and typhus fever it re- 
presents the usual exanthem. 

In the chronic diseases it is seen most frequently in connection with 
scurvy, pernicious anemia, idiopathic plastic anemia and leukemia, not 
infrequently in tuberculosis, Bright's disease, Hodgkin's disease, syphilis, 
and various cardiac lesions, particularly those associated with marked 
degeneration of the myocardium. In epilepsy it is not uncommon and 
sometimes points the way to a correct diagnosis in cases of an obscure 
nocturnal type. In such instances it is usually slight and transient, often 
showing only on the face as an indistinct capillary streaking which may 
last for a few hours or a few days. 

In hysteria, the same form may be present, or the rarer forms, among 
which the most curious is the cruciform purpura in which, it is said, the hem- 



THE PURPURAS 



169 



Cruciform 
purpura. 



Differentia- 
tion possible. 



orrhages appear at points corresponding to the wounds of the Saviour on the 
Cross. 77 may be seen at once that in epilepsy and whooping cough mechanical 
strain plays a great part. 

True purpura would seem to be a more or less direct expression of an i 
infection and might better be considered wholly apart from the conditions 
mentioned in the paragraph preceding. 

2. Arthritic Purpuras. — In the three forms of purpura coming under this 
class there is a joint involvement distinctly rheumatic in type. Under this 
we have: (a) Simple purpura, (b) Peliosis rheumatica (Schonlein's disease). 
(c) Henoch's purpura. This classification need not be confusing if the fol- 
lowing points are borne in mind. In all, the essential lesion is hemorrhage; 
all are accompanied by fever and by joint lesions. 

Simple purpura is of a mild type and short duration. 

Peliosis. rheumatica is much more severe, with higher fever, more marked 
joint involvement, sore throat usually at the onset and not only marked purpura, 
but frequently, pemphigoid spots, purpuric edema and marked urticarial mani- 
festations of either the ordinary or giant variety. The distinctive feature, how- 
ever, is the involvement of joints to a marked degree. 

Henoch's purpura differs from the two already named, primarily, in the 
fact that gastrointestinal symptoms, such as nausea, vomiting, diarrhea, and 
hemorrhage from mucous membranes, are the predominating features, while 
the arthritis is usually slight. In all other respects it may closely resemble the 
other forms. 

3. Purpura Hemorrhagica {Morbus Werlhofii). — This terrible disease 
may be rapidly fatal, and is characterized by severe and often intractable hemor- 
rhage from any or all mucous membranes, associated with high fever. 

It will be seen from the foregoing description that though the basic 
symptom is the same in each and every variety, the differences presented 
are such as to permit of clinical differentiation in most instances. 

One cannot but feel that an infection must lie at the root of purpura, 
but nothing of a specific nature has so far been discovered. 

4. Purpura Fulminans. — In this form the disease runs a rapidly fatal 
course and may terminate without the appearance of joint lesions, those of 
the skin being the only striking indications of the nature of the ailment. 

HEMOPHILIA 

Definition. — A morbid state, hereditary and characterized by an extraordi- 
nary tendency to spontaneous or induced hemorrhage, and an especial familial 
tendency to attack the young males and spare the females who, however, are the 
chief sources of its transmission to succeeding generations. 

Etiology. — The actual cause is unknown, but deficiency of fibrin ferment 
(thrombin) or of one of its necessary constituents (thrombokinase, or perhaps, 
prothrombin), is proven. A peculiar thinness and fragility of the vessel 
walls, a neuropathic tendency and abnormal alkalinity of the blood, together 
with many other, presumably baseless, assumptions, have been advanced as 
factors in causation. 



170 



MEDICAL DIAGNOSIS 



Atavism. 



Extraordinary 
features. 



Beware of 
"bleeders." 



"Spontaneous' 
hemorrhage. 



Extraordinary 
delay. 



Age and Sex. — It affects chiefly male children under ten years of age, 
first appearing in early childhood,* cases being rare in the later years of life, 
and usually less severe in their nature. 

In those affected who live to maturity the tendency seems to diminish 
gradually. 

The oft-repeated claims that women of hemophilic stock may themselves 
be bleeders seem to be unsupported by substantial evidence. The claim for 
occasional conduction through the male seems still less valid. 

Heredity. — Although cases occur in which this element apparently is 
lacking, the disease furnishes one of the most interesting known examples of 
atavism in relation to disease. It affects male children through maternal 
heredity, the mother or the girls of a family seldom showing any hemophilic 
tendencies, yet passing it on to their male children. In one family in Switzer- 
land the disease can be traced back over 300 years. It may even skip a 
generation or two only to return later on. 

Symptoms. — Intractable nose-bleed is most common, but hemorrhage may 
occur from the lips, gums, throat, stomach, urethra, lungs, bowels or, in the female, 
from the uterine mucous membrane, though, strangely enough, menstrual flow 
is not always excessive nor is labor extraordinarily perilous, in those rare in- 
stances of hemophilia in the female ordinarily showing extraordinary hemorrhage 
in response to slight wounds, abrasions or even pressure. 

It is fortunate that the disease is relatively rare, as information upon the 
subject is sometimes withheld by members of these foredoomed families, 
and slight wounds or bruises, even the puncture of the ear or finger for blood 
examination, the drawing of a tooth, the application of a leech or a vaccina- 
tion, may bring about a fatal hemorrhage. 

More extraordinary still is the fact that the slightest traumatism or even 
light and unconscious pressure or friction may excite what apparently may be 
spontaneous hemorrhage from mucous membranes or even the free skin (lobe of 
ear, tip ■ of finger) . 

Coagulation Time. — This is greatly prolonged, a firm clot never forming 
under an hour if blood from a vein, unmixed with the tissue juices, is used. 
Blood from a mere skin wound or puncture gives unreliable and misleading 
results because of the unavoidable admixture of such tissue juices which 
contain cephalin. 

The mortality is extremely heavy, and pseudo-rheumatic affections are 
common, as are ecchymoses and hematomata, these showing its close resem- 
blance to purpura and scorbutus. 

Prognosis. — A majority of male children of affected families die under 
ten years of age, though light cases occur in which, after the age of puberty, 
the tendency is largely or wholly lost. 

* Infants are usually free from its manifestations even though they may be profoundly 
affected later. Nevertheless Nacke of Kirchheim, the physician of the famous Mampe 
family which has been under medical observation since 1827, states that he could tell from 
the hemorrhage following the cutting and tying of the cord whether or not that child would 
prove a " bleeder." 



SCORBUTUS 



I 7 I 



SCORBUTUS ("Scurvy") 

Definition. A morbid state peculiarly dependent in most instances 
upon the diet* (vitamin deficiency), characterized by profound weakness, 
anemia, apathy, and a marked tendency to sponginess of, hemorrhage from, 
and severe inflammation and ulceration of, the gums. 

Etiology. — The actual cause is unknown, but the conditions of its develop- 
ment are well understood. They are: (1) A diet from which fresh vegetables, 
fruits and meats arc excluded. (2) Bad air, overcrowding, overwork, deficient 
light. 

Its occasional presence in children even in our own country must not be 
forgotten. 

Up to within the last century scurvy was the scourge of seamen and 
armies. During the Crimean war there were 23,000 cases in the French army 
alone. Military and naval expeditions had sometimes to be abandoned on 
account of outbreaks of the disease and East Indian ships frequently lost 
half of their crews in one voyage. In one of the early Arctic expeditions 50 
per cent, of the members died of the disease. In a recent Antarctic expedi- 
tion the effects of the factors mentioned above were clearly shown, though a 
better food supply prevented a general epidemic. 

A considerable number of cases occurred in the Russian troops during 
their war with Japan; it was present to some extent in the Allied Armies 
during the last great war, and exists at the present writing in famine stricken 
Russia and doubtless in some of the lesser Balkan States. Essentially, 
however, scurvy belongs to generations past.f 

Symptoms. — The leading symptoms are spongy, bleeding, and often ulcer- 
ating gums, purpuric symptoms, areas of brawny induration especially in the 
lower extremities, progressive circulatory weakness often with right heart dilata- 
tion, and subperiosteal hemorrhages especially in children. 

In children the swelling is commonly over the outer aspect of the femur; 
and in every marked case is hard, tense, and exquisitely tender (see " Barlow's 
Disease," following). Epiphyseal suppuration may occur and hemorrhages 
into the joints and retina are not uncommon. Retinal hemorrhages are not 
uncommon. Physical weakness is extreme and there is pronounced and 
progressive mental depression and usually edema of the ankles. 

BARLOW'S DISEASE. — Occurring in infants, scurvy is known as 
Barlow's disease, having been described by Dr. Thomas Barlow in 18784 Up 
to that time it had been regarded wrongly as "acute rachitis" and was so 

* In an absolutely typical and remarkably complete adult case recently observed by the 
author absolutely no connection with diet could be traced nor could the man's condition be 
materially improved by the usual therapeutic measures. 

It may have represented one of the rare examples of atypical purpura exactly simulating 
scorbutus. Many cases of purpura strongly resemble scurvy and the latter sometimes lacks 
the most striking features of the disease. 

t The theories asserted as causative factors: (a) sodium excess, (b) potassium deficit, 
(c) ptomain activity, (d) acidosis, (e) deficient phosphorus compounds, and (/) specific 
infection, have one and all failed to stand. 

X Dr. Cheadle, a colleague, had previously suggested that scurvy played a part. 



An 
avitamjnosis. 



Known 
factors. 



Once a 
scourge. 



Peculiar 
syndrome. 



172 



MEDICAL DIAGNOSIS 



Age 
incidence. 



The gums. 



Posture. 



Misleading 
appearance 



named by Moeller in 1857. As before stated, the most aggressive symptom in 
children is the subperiosteal extravasation. The child lies motionless, 
shrinks from the touch, and presents what is really a characteristic swelling, 
the author having seen, as a student, in Dr. Barlow's and Mr. Edmund 
Owen's wards an immediate diagnosis on sight and touch in many instances. 
The disease is rarely seen in breast-fed children and occurs usually from the 
sixth to the sixteenth month. 

It. derives its general interest from the fact that the other symptoms of 
scurvy as seen in the adult may be entirely lacking. 

In children possessing teeth, mild scorbutic changes in the gums may be 
manifest but in very young babes these are wholly absent. 

The usual symptoms of the hemorrhagic diathesis may be marked and in 
a considerable proportion hematuria may be an early symptom. 

Suggestive Symptoms. — Unwillingness to move the legs though the 
reflexes are wholly normal and the attitude of the babe, which lies with the 
thighs drawn up, cries out if handled and, manifestly, is comfortable only 
when in this position. 

It may be shown usually that the lower end of the femur is exquisitely 
tender or this may be absent primarily and extreme pain on movement at 
the hip or knee be the chief symptom. This is followed by a firm, tense, ex- 
tremely tender swelling which becomes bilateral and involves primarily 
and chiefly the upper and lower portions of the femur and upper third of the 
tibia but does not extend to the epiphyseal junctions. Other bones may be 
affected and even actual epiphyseal separation may result. 

Similar subperiosteal blood extravasations may affect the ribs anteriorly 
and cause what appears to be a marked recession of the sternum and costal 
cartilages. 

The diagnosis should be possible before such extreme symptoms appear. 



DISEASES OF THE GLANDS OF INTERNAL SECRETION I 7 J 



DISEASES OF THE GLANDS OF INTERNAL SECRETION 

ADDISON'S DISEASE ("Morbus Addisonii") 

Historic Note. — This was first reported by Dr. Addison, of Guy's Hospital, 
in 1855, and in his monograph he attributed the ailment to a disease of the 
suprarenal capsules. 

Definition. — A disease characterized by progressive weakness and apathy, 
marked gastrointestinal disorders in the later stages, and a peculiar pigmentation 
of the skin and mucous membrane. 

Etiology. — The exact nature of the primary causative factors remains as 
yet undetermined. An antecedent tuberculosis seems the most important. 
Various diseases may precede it, but their direct connection in causation is 
unproven. Poor food, insanitation, and excessive mental or physical labor, 
are often associated factors, but may be only coincident. 

Congenital Eypoadrenia. — Of late the impression that in cases of Addison's 
disease the chromaffin system is both anatomically and functionally inade- 
quate from birth, has been strengthened. It would appear probable that 
in such cases the glands are peculiarly vulnerable to certain infections and 
especially to tuberculosis. 

Males are affected much more frequently than females (60 to 70 per cent.). 
It is most common in middle age, yet cases have been reported in infants. 

Nearly 90 per cent, of these cases show demonstrable lesions of the suprarenal 
cap side, and in 80 per cent, of these instances the lesion is said to be clearly Etioiogic 

, . paradox. 

tuberculous. In a relatively small percentage a-4esion of the capsule is not 
evident, and, furthermore, the suprarenals may be removed by operation or be 
congenitally absent without of necessity producing the disease* 

Morbid Anatomy and Pathology. — Any one of several conditions may be 
found at autopsy. These are, atrophy, simple or due to chronic interstitial 
inflammation, malignant disease of the capsule, extravasation of blood, 
inflammation or pressure affecting the semilunar ganglia and in a vast 
majority of cases tuberculous infection of the suprarenal itself. 77 seems impaired 
probable that Addison's original theory, that the disease was due to a loss or function 
impairment of adrenal function , is correct. 

The involvement of the semilunar ganglia may materially affect the secre- 
tions of these glands and contribute to the symptom-complex. This view 
seems on the whole much more rational than that advanced by some observers, 
which holds the nervous system entirely responsible for the disease. 

The Chromaffin System. — In the medullary substance of the suprarenals 
nests of cells occur which stain brown with chromic acid. These, the 
chromaffin cells, may be found in the solar plexus, in the ganglia of the sympa- 
thetic trunks and along the sympathetic nerves. Furthermore, such cells 
exist at the hilus of the kidney itself, at the point of origin of the left coronary 
artery, at the root of the mesenteric artery and in the left stellate ganglion. 

* It is true, nevertheless, that experimental epinephrectomy in animals produces some of 
the most important symptoms of Addison's disease. 



174 



MEDICAL DIAGNOSIS 






Blood. 



Pigment 
distribution. 



Mucous 
membranes. 



In the suprarenal gland the chromaffin cells constitute physiologically a 
em largely independent of its "inter-renal" fellow — a distinction which 
nphasized in certain lower animals by an entire and permanent anatomic 
separation. 

Adrenalin is the active constituent secretion of chromaffin tissue and it 
is probable that impaired function of the chromaffin system may account for 
at least many of the symptoms of Addison's disr 

Among the:- xplainable are low blood pressure, subnormal body- 

temperature, progressive muscular weakness, the tendency to lymphocytic 
predominance in the blood picture, the lowered sugar content of the blood 
and the pigmentation itself, though the cortical system may play a part in 
the production of the cardinal symptom last named.* 

SYMPTOMS. — The disease is characteristically insidious in its approach 
and is rarely suspected until pigmentation ; ±- ell-marked. The gastro- 

intestinal disturbance as well as the loss of strength tends to increase and may 
assume the form of crises, yet there are cases showing long periods of lot-: 
and relative immunity from vomiting, nausea and diarrhea. 

A slight secondary anemia is usually present, but is not an important 
factor. LympJtocyiosis is now held to be an almost constant rinding and the 
polymorphonuclear neutrophil leucocytes are both relatively and absolutely 
diminished. The total leucocyte count, however, does not often exceed normal 

res. An eosinophilic increase may often be demonstrated but is not 
constant. 

The body-temperature is subnormal and the blood pressure is invariably 
low, dropping in some :;-ses bo 50 mm. v systolic). 

As the disease progresses, atfacks of syncope, vertigo and palpitation may be 
troublesome and sight and hearing may be impaired. Vomiting may become 
persistent, and indeed uncontrollable, sometimes ending fatally, but usually 
subsiding after several days. A history of active tuberculosis, past or pres 
in some other part of the body is often obtainable. 

The pigmentation of the skin :'; :cr\ ::?:::'■: .::. . the typical 

case showing a deep bronze color that is quite unmistakable, though tlie early 
pigmentation may be little more than a brownish-yellow or definite brown, and, 
rardy 1 the vase may :>. before this deepens to the typical shade. 

It sr:c-us rtain interesting 2nd important characteristics as regards dis- 
tribution, in that it is most marked in the portions of the body exposed to light, 
such as the face and I md to (hoi :: pressure or friction from 

clothing, being emphasized in the axilla, groin, under the breasts, or at the 
waist line and knees. Areas oi pigment atrophy often appear, making a 
sharp contrast and the mucous membranes of the lip and buccal surfaces 
especially are likely to show patchy pigmentation. 

The heart invariably shows atrophy at autopsy. 



* The interested reader should refer to Falta's masterly description :: Addison's disease 
for an adequate description. •"The Ductiess Glandular Diseases.'' BIakis:on, 1915. 

An extended discussion of hyper- and hypo-adrenia is to be found in Tice's "' Practice 
of Medicine."' vol. viii. 1921. p. 131. and Oxford Medicine, vol iii. p. -$3. 



DISEASES OF THE GLANDS OF INTERNAL SECRETI<»\ 



175 



Misleading 
variations. 



"Vagabond's 
disease." 



Diagnosis.— The diagnosis is ordinarily easy in view of the grouping of 
low blood pressure, progressive loss of strength, marked gastrointestinal 
disorders and the peculiar pigmentation as above described. In those rare 
cases in which all characteristic skin discoloration is lacking, the autopsy 
alone suffices to positively confirm a tentative diagnosis. 

Differential Diagnosis. — Verminous bronzing is rarely seen except in the 
clinics of the great medical centers, being due to the constant presence of 
vermin, attended by scratching, which results in a more or less profuse pig- 
mentation; in most instances the attending signs would be lacking as would 
certainly be the patchy mucous membrane pigmentation.* 

Cirrhosis of the Liver. — In a few instances hepatic cirrhosis in its last 
stages may produce a very dark pigmentation, but in such instances there is j 
almost always abundant evidence that the color is due to an actual jaundice. 
In no such case in the author's experience has any doubt arisen. 

Argyria (chronic silver poisoning) is excessively rare at the present day, 
and the color is quite different from the pigmentation of Addison's disease, 
being more distinctly gray, and when excessive, showing a distinct bluish- 
black tint; moreover, it is ordinarily limited to the face and hands, and the 
associated symptoms of the latter disease are absent. 

Parry's disease^ and many other conditions are accompanied by pigmenta- 
tion and peculiar patchy discoloration of the skin, i.e., malignant disease 
involving the abdominal organs, certain cases of tuberculosis, of chronic 
nephritis, etc., but it does not seem that the difficulties in diagnosis are so 
great as to permit us to accept the dictum of Leube, to the effect that one 
"should forego any diagnosis of affections of the adrenal bodies." 

The tuberculin reactions whether positive or negative are of slight value in 
view of the deceptive frequency of the former and the uncertainty of response in 
any such profound cachexia as is characteristic of the disease. 

The strongest emphasis should be placed upon the absence of patchy pig- 
mentation of the mucous membranes in the many simulators of Addison's disease. 

Status Lymphaticus. — Certain evidences of this condition are not in- 
frequently encountered and thymus hypertrophy has been reported. 

Prognosis. — The disease is almost invariably fatal, usually within one or 
two years, and the last case observed by the author died after an illness of 
only a few months' duration. In rare instances life is prolonged for more 
than a decade and a few cures have been reported in cases where syphilis 
was possibly the primary factor. 

STATUS THYMICOLYMPHATICUS, ^Lymphatism" a Status Lymph- 
aticus,'' ; ' Constitutio Lymphatic -a") . 

Definition. — A morbid state characterized by coincident hyperplasia of the 
lymph nodes, spleen, thymus, red bone marrow and, in certain instances, hypo- 
plasia of the heart and arteries. A decided tendency to sudden death exists in 
this condition. 

* In such cases as have been observed by the author, the likeness was only sufficient 
to draw a passing reference, 
t Exophthalmic goitre. 



Tuberculin 
test. 



Variable. 



176 



MEDICAL DIAGNOSIS 



Probable 
cause. 



Important 
complex. 



Disease of 
youth. 



"Thymus 
death." 



Historical Note. — The discussion of this curious condition is really a 
revival of ancient knowledge. Nearly three centuries ago the association of 
an enlarged thymus with sudden death is said to have been noticed by Plater, 
and thymic asthma was described by Kopp in 1830. This he regarded as 
a pressure asthma. Later discussions occurred, but the subject was again 
dropped to be renewed during the past few years. 

Etiology. — Little is known of the etiological factorsj but the disease is 
one of youth and early childhood. It is probably associated with functional 
inadequacy of the chromaffin system and this belief receives clinical support 
in its not infrequent appearance in cases of Addison's disease and the fact 
that the blood picture is practically identical in these two conditions. 

As to the functions of the thymus itself little of importance is known 
although many theories have been advanced and much conflicting testimony 
adduced. 

Symptoms. — The symptoms upon which, as a whole or in part, a diag- 
nosis must be based are essentially the following: a pale, pasty, rachitic or 
tuberculous aspect, enlargement of the spleen and of the superficial glands, 
usually associated with tonsillar hypertrophy, adenoids and dulness over the 
upper sternum. 

The thyroid may be slightly enlarged, and there may be evidence of in- 
volvement of the mesenteric glands. 

The chief clinical importance of the disease lies in its relationship to 
early and sudden deaths in the young or even the adult, both as occurring 
without apparent cause and in connection with operative or therapeutic pro- 
cedures, the so-called "thymus death." 

This assumes considerable importance to both the physician and surgeon, 
cases having been reported as following adenoid operations, anesthesia, adminis- 
tration of antitoxin, convalescence from various infections, and croup. 

Paltauf ascribes to this condition many of the cases of otherwise inex- 
plicable sudden death in children. The condition merits further study and 
observation, and its symptomatology should be kept clearly in mind. 

Attacks of causeless suffocative dyspnea and cyanosis occurring in babes or 
young children shoidd always suggest the condition as a possibility and demand 
a most careful investigation including roentgenography and careful percussion. 

A dull area over the manubrium whose lower border rises with extension of 
the head and falls with flexion is particularly suggestive and any dyspnea in- 
duced by throwing the head back may be regarded as a suspicious symptom. 



'Athyrea. 



Sporadic or 
endemic. 



MYXEDEMA AND CRETINISM 

^Definition. — A chronic depressive disorder of cellular metabolism associated 
with more or less marked functional insufficiency affecting alike vegetative, 
psychic, circidatory and trophic spheres, associated with and resulting from 
structural changes and impaired function on the part of the thyroid gland. 

Cretinism is the term applied to athyrea in the immature organism and 
may be either sporadic or endemic, the latter form appearing chiefly in regions 
where goiter is prevalent. 



DISEASES OF THE GLANDS OF INTERNAL SECRETION 1 77 



Signs of the disease usually appear at or about the fifth or sixth month Age 
but may develop earlier or much later. Some authorities attempt to dis- 
tinguish two forms, the "infantile" and "juvenile." 

Classification.— Although lacking in fundamental differences, three clinical 
groups may be distinguished: 

First. — Cretinism or myxedematous changes in the infant or young 
child. 

Second. — Myxedema adultorum, i.e., as it appears in the adult. 

Third. — Operative myxedema, which covers the changes attending the 
complete removal of the thyroid gland. 

Etiology. — That the loss of function which is usually but not invariably Gland atrophy 
associated with atrophy of the thyroid gland is directly responsible for myxe- 
dematous changes has been well established by both clinical and experimental 
observations. 

The disease attacks women five times more often than men, is peculiarly Heredity 

- . . . , ,. , . , ... marked. 

frequent in certain countries and districts, and in the case 01 cretinism seems 
to be markedly hereditary; the offspring of people who have removed from 
regions where cretinism is endemic showing a marked tendency to the disease 
whatever the nature of their new environment. 

Congenital syphilis, a tubercular taint and rachitis seem to favor the Predisposing 
development of the disease in children and infants. In these the disease is 
ordinarD y directly due to congenital atrophy or deficient function, but does 
not make its appearance for several months after birth, as a rule, and some- 
times not for many years. 

SYMPTOMS OF SPORADIC CRETINISM.— The appearance of the The cretin, 
affected child is characteristic and unmistakable. 

The face is senile, coarse and stupid, the lips and eyelids thickened and Characteristic 
overgrown, the tongue is large and thick and often protrudes from the mouth, 
the root of the broad, flattened nose is depressed, the head is large, clumsy and 
rests upon a thick, short neck. 

The stature is dwarfed, and a child of fourteen or fifteen appears often to Arrested 

. t tl .{ ' J J JJ rr J development. 

be two or three years old. 

The legs are bowed, the abdomen prominent, the joints thick and clumsy, 

the gait awkward, dragging, laborious, and marked lordosis is often present. 

The skin is sallow, the hair often thin and brittle, the skin usually dry, though it Depressed 

may be greasy, and signs of arrested mental development are as striking as the 

physical appearance. 

The fontanels remain open and muscular weakness is usually marked. open 

In infants the dentition is markedly delayed and, in all children affected, 

there is likely to be a great delay in the epiphyseal closure. Delayed 

t . . ., . ,. «.«.,., i* • • dentition. 

It is impossible to discuss fully in this volume a condition concerning 
which so little is positively known or to deal with the many conditions which 
may or may not represent mere variants. Certain cases seem to represent 
a form of infantilism. 

The head enlarges but the growth of the facial bones is retarded, and 
myxedematous changes in the skin are usually marked. 



physiognomy. 



1 7 8 



MEDICAL DIAGNOSIS 



Sexual organs. 



Test 
medication. 



Striking when 
typical. 



Acute 
myxedema. 



Sexual development is distinctly retarded and imperfect, and the sexual 
instinct is almost wholly lacking in the female and but slight in the male. 

Respiration is slowed, the temperature lowered and such patients do not 
sweat under the usual test doses of pilocarpin or show glycosuria following the 
administration of adrenalin. 

ENDEMIC CRETINISM.— This form of athyrea or hypothyrea occurs 
chiefly in regions where goiter is prevalent among the adults of the population 
and differs materially from sporadic 
cretinism not only in the frequent ab- 
sence of some of the extreme features 
(half-cretins) but also in its less marked 
and constant response to thyroid medi- 
cation. 

Typical Symptoms of Myxedema in 
the Adult. — The skin is dry, harsh and 
pasty, the hair lusterless and brittle, the 
face peculiarly moon-shaped and lacking 
in expression. 

The features are clumsy and coarse, the 
nostrils broad, the lips thickened and the 
tongue enlarged. Thought, motion and 
speech are slow and clumsy. The whole 
body is increased in bulk, and the superfi- 
cial tissues have an appearance like edema, 
yet show no pitting on pressure. Large pads 
of firm inelastic tissue usually appear above 
the clavicles and on the extensor surface of 
the forearm and wrist, and the hands and 
feet are "pudgy" and clumsy. 

Headache may or may not be present. 
Irritability is usually marked and actual 
delirium, hallucination and even true in- 
sanity may develop. 

A bluish red color in the lips, nose and cheeks may be present and the 
palpebral fissures are often narrowed. Low blood pressure, readily excited 
exertion-dyspnea, low body temperature with more or less persistent or easily 
induced chilliness, are usually manifest. 

Duration. — The course of the disease may extend over a period of from ten 
to twenty years, the patient dying of intercurrent disease. 

Osier reports what is apparently a case of acute myxedema and in 
some instances it seems to have been associated with the development of 
exophthalmic goiter. 

The author has reported in 1905 a case in which very decided symptoms 
of myxedema coexisted with those of acromegaly.* 

* See Transactions of the Association of American Physicians, 1905 (see also reference 
under "Acromegaly"). 




Fig. 55. — Cretinism. {Courtesy 
of Dr. Henry Jackson.) 



DISEASES OF THE GLANDS OF INTERNAL SECRETI<>\ i; 



Operative myxedema does not differ materially from that described above. 
This condition is rare because it necessitates for its development the complete 
or almost complete removal of the thyroid gland. 

Diagnosis of Myxedema. — /;/ the adult this must depend upon the peculiar 
physiognomy, the dry skin, marked edematous aspect of the body, and the failure 
of the bulky pads of tissue to pit on pressure, combined with the speech and mental 
state of the patient. 

Carbohydrate tolerance is greatly increased, although, in general, metabolism 
is distinctly depressed; 250-300 grams of glucose producing no alimentary gly- 
cosuria, a fact of considerable importance in certain doubtful, illy-developed 
cases. 

The improvement of all symptoms under the administration of thyroid gland Therapeutic 
offers conclusive proof of the nature of the disease, but loss of bulk alone is not 
sufficient evidence. 

Masked Myxedema. — Where one case of myxedema is recognized, a hundred 
cases of thyroid insufficiency escape our notice and it should be clearly under- Extremely 
stood that fragmentary clinical pictures fully justify and indeed demand test 
doses of the specific remedy. 

Some of the ?nost striking cases of improvement observed by the author have 
represented patients whose obscure symptoms barely suggested dysthyroidism 
as a possibility. 

It is impossible to formulate any clean-cut group of symptoms which 
would lead us to a correct diagnosis in these cases of masked hypothyroid- 
ism. In many, one's suspicion is excited by the occurrence of a fragmentary 
myxedema picture made up of any one or several of the following symptoms: 
dryness of the skin, the presence of the so-called myxedema pads particularly 
at the back of the wrists or in the supraclavicular region, inactivity of the 
sweat glands, a slowing up of the mental processes, and the like. 

Osier properly warns the clinician against laying undue stress upon 
the supraclavicular pads alone. As a matter of fact, this condition is very insufficient 
commonly seen in any stout person otherwise in perfect health and may be 
absent in decided thyroid insufficiencies. 

But in many instances the therapeutic test, namely, the administration 
of thyroid gland, is productive of the happiest results even when no clinical 
picture is discernible. If the administration of this remedy is carefully and 
intelligently handled one need not fear the results, but every patient should 
be carefully watched least some larval hyperthyroidism be roused into 
activity. 

HYPERTHYROIDISM 

(" Exophthalmic Goiter " "Parry's Disease" 

Definition. — A disease which, when fully and typically developed, is char- 
acterized by abnormally increased metabolism, prominence of the eyeballs, rapid 
pulse, enlargement of the thyroid gland and fine tremor associated with marked 
nenous manifestations. ' 



i8o 



MEDICAL DIAGNOSIS 



Neither 

Basedow's nor 
Graves' 
disease. 



Hyperthyrea. 



Ndt a "nervous 
disease." 



Types of 
extreme 
importance. 



Atypical Forms. — 77 may be, and often is, but imperfectly developed as a 
clinical picture, even when assuming an extreme and rapidly fatal form and 
may present an acute, subacute, chronic, or larval type, the last two being the 
forms oftenest encountered. 

The names of Basedow and Graves have apparently been improperly 
used in connection with this disease, and it should be called Parry's disease, 
as he described it quite fully in 1825, indeed having made notes of a case as 
early as. 1786, half a century before the description of the two former 
appeared (Osier). 

ETIOLOGY. — The disease is due chiefly to hyper thy rosis (increased thy- 
roid activity), the exact cause of which is unknown. 

It is the exact opposite of myxedema with respect to the vegetative functions, 
which are exalted to a marked degree. 

It is probable, as suggested by Falta, that the symptomatic expressions 
of hyperthyrosis vary with and are dependent upon the participation and 
response of other sources of internal secretions in the individual case. 

Age and Sex. — It is rare in men, quite common in women, and appears 
usually between the ages of twenty and forty, though rarely under the age 
of fifteen. 

Emotional Crises. — It seems to be well established that violent or depress- 
ing emotion, even though transient, may produce it and in some instances 
it has seemed to the author that there was a marked sexual element. It can 
no longer be regarded as a disease of the nervous system. 

SYMPTOMS.— Acute cases occur which, with or without marked exoph- 
thalmos or excessive or even marked tremor, may terminate fatally after a few days 
of violent and intractable gastrointestinal crises and profound and progressive 
cardiac weakness, i.e., precisely the same phenomena that -may bring a chronic 
case to a fatal end* Curious abortive or incomplete transient acute attacks 
also occur with or without the complete, classical, clinical picture. 

Ordinarily, the onset of the disease is gradual and its progress slow, its 
tendency being toward increase in the severity of all symptoms, but with 
marked periods of improvement if under observation and treatment. 

Thyroid Enlargement. — It usually involves both lobes, but not equally, 
and may be unilateral or, at first, almost wholly absent. Venous bruit and 
loud systolic or double murmurs are commonly heard, there is usually a 
palpable thrill and often a visible expansile pulsation. 

Exophthalmos. — This protrusion of the eyeballs varies greatly in degree, 
and it is said may become so great as to actually dislocate the eye.f The 
change is almost invariably bilateral, the vision is seldom affected, but 

* A rapidly fatal case of this type seen recently by the author showed a relatively slight 
unilateral enlargement of the thyroid of sudden onset, following by several days an accident 
which resulted in a broken thigh. 

Tachycardia was marked, vasomotor relaxation extreme, intractable vomiting domin- 
ated the clinical picture and the heart rapidly weakened, dilated enormously, and yielded 
no response to stimulation. 

f No such extreme cases have ever been observed by the author. 



DISEASES OF THE GLANDS OF INTERNAL SECRETION 



181 



much stress has been laid upon three so-called signs in connection with 
exophthalmos. 

These are: (i) The failure of the lid to follow promptly the downward 
movement of the eyeball ("Graefe's sign"). (2) Great lengthening of the 
time intervals of involuntary winking. These ordinarily represent but fifteen 
or twenty seconds but in this disease may be minutes apart if exophthalmos is 
marked ( %i Stelwags sign"). (3) Deficient convergence of the eyes ("Moebius's 
sign"). {4) A tremor of the lids may be noted when the eyes are slowly and 
softly closed which has been dignified of late by the name of Rosenbach's phe- 
nomenon, but is neither limited to exophthalmic goiter nor new to medicine. (5) 
A lifting of the upper lids when the patient's gaze is fixed intently upon some 
object ("Kocher's sign"). 

All are somewhat superfluous clinically. The characteristic associated 
appearances, in any considerable grade of exophthalmos, are the peculiar 
stare and the rim of white which appears between the corneal margin and 
both lower and upper lids ("Dalrymple's sign"), but these are not necessarily 
due to either palpebral spasm or lid retraction. 

Tests of Importance. — Of late several tests have been proposed for the 
detection of larval hyperthyroidism. It is well known that the basal metabo- 
lism is greatly increased, but the special apparatus needed and the time 
necessary for the completion of the tests and the special delicacy of the 
technic employed, render it quite unavailable for the average practitioner. 

Hence, simpler tests are greatly to be desired. Of these, several have 
appeared during the last few years, the most readily applied being those of 
Goetsch and Loewi. 

It must be remembered that neither of these have proven infallible, yet 
both may be considered useful, justifiable, and of considerable value. 

Goetsch's Tests. — Goetsch has devised two tests; one, a skin reaction; 
the other, a general one. 

The Skin Test. — Goetsch states that if 1 minim of a 1:4000 solution of 
adrenalin is injected intradermically "the central large area of blanching" 
results, this being "surrounded by a peripheral zone of reddening due to 
neighboring secondary vasodilation. In the blanched area a characteristic 
'goose flesh' is often seen due to the contraction of the 'erector pili ' muscles, 
which are of the smooth variety and under sympathetic control. The 
reaction lasts for one and one-half to two and one-quarter hours as compared 
with one-half to three-quarters of an hour in a normal individual, in whom, 
furthermore, the area of blanching is much less definite and the peripheral 
zone of red is usually entirely absent." 

In practically all cases of hyperthyroidism, Goetsch states that the reac- 
tion is more marked and of longer duration than in a normal individual. 

It should be added that of late much stress is laid on the behavior of the 
color of the areola produced in this test, which, in victims of hyperthyroidism, 
though fading to a lavender color remains for nearly or quite four hours 
after the time of the original injection. 

The Hypodermic Test (Goetsch). — Seven and one-half minims (0.5 c.c.) 



Over-rated 
signs. 



lS2 



MEDICAL DIAGNOSIS 



May for a time 
exist alone. 



Cardiac dilata- 
tion common. 




of a 1:1000 solution of adrenalin chloride is injected hypodermically in the 
deltoid region. If hyperthyroidism is present there is an " early rise of blood 
pressure, and pulse variation of from 10 to 50, and normally proportional to 
the degree of toxicity present." Among the associated symptoms produced 
are " asthenia, tremor, throbbing, vasomotor changes, apprehension and 
nervousness." 

Note. — It is obvious that the second of these tests should be used with 
some discretion and that both must contain possibilities of error. 

With respect to the hypodermic test, it would appear that the condi- 
tions under which it is performed should be controlled carefully, this being 
especially true if we are to draw fnimtinr i mmmum 
any conclusions of importance 
from the rise in blood pressure of 
the lesser grades. Every practis- 
ing physician knows how readily 
decided increases in systolic 
pressure occur and there would 
seem to be a considerable oppor- 
tunity for error with respect to 
this manifestation. 

Loewi's Test.— This consists 
in the instillation of a 1:1000 
solution of adrenalin into the eye; 
dilatation of the pupil following 
if hyperthyroidism is present. 

Rapid Pulse. — This is often the first symptom to attract attention 
frequency is greatly affected by exertion and psychic excitation alike (labile 
pulse); regularity or irregularity may be present and the frequency may 
vary from 90 to an uncountable rate, as is frequently seen in fatal cases. 
Peripheral pulsation is marked, the abdominal aorta may throb violently and 
a capillary pulse or even a venous pulse is often present. High " pulse 
pressure" is common in well-marked cases. 

Bruits. — All sorts of bruits may be heard at the base and over the gland 
or the vessels of the neck, usually associated with palpable thrill in well- 
marked cases, together with visible pulsation of the gland itself. A systolic 
murmur is seldom lacking in the mitral area and the heart is not only readily 
dilatable, but often dilated.* 

* Some of the most rapid and extreme dilatations observed by the author have been 
associated with acute hyperthyroidism and several have been post-operative complications. 
Residual' post-operative dilatation of a decided degree is common and, too often, disre- 
garded and far more rapid and satisfactory post-operative results would be obtained if the 
cases showing marked cardiac involvement were treated medically for a short period before 
surgery is attempted. At present, even in successfully operated cases, a period of several 
months (6-12) is usually necessary to the development of maximal improvement follow- 
ing surgical procedure. 

Such cases usually are perfectly responsive to rest and digitalis, though in some, but not 
all, of the extremely acute forms the drug seems impotent. 



Fig. 56. — Tachycardia as frequently seen in 
exophthalmic goiter. Upper tracing,, jugular; 
lower, radial. Pulse rate 132. Time 3^ sec. 
Note respiratory curve in jugular tracing, and 
resemblance of pulse to that of aortic regurgi- 
tation. (Tracing by Dr. R. E. Morris, made 
with his modification of Mackenzie's ink- 
polygraph.) 



Pulse 



DISEASES OF THE GLANDS OF INTERNAL SECRETION 



I S3 



"Formes 
frustes" 
important. 



Nervous 

symptoms 

marked. 



Goiter heart may sometimes be due to pressure on the vagus, ("Rose's 
dyspneic form"). 

The glandular bruits are sometimes auto-audible, or to be heard at a 
distance. The subjective sensation of throbbing is often most harassing. 
The heart action may be violent, often tumultuous, and its area of visible 
pulsation greatly extended. 

Tremor. — A fine involuntary tremor usually attacks the head and 
extremities, rarely the eyelids, lips or tongue, and is of great importance, as 
constituting one of the earliest and most constant symptoms of the 
disease. 

Tremor and rapid heart action may be present, separately or in combination, 
without exophthalmos or demonstrable goiter. 

Decided exophthalmos is absent in at least 60 per cent, of the cases. 

Blood Picture. — Aside from a decided tendency to a relative lymphocytosis 
or, more correctly, a mononucleosis the blood shows nothing of interest. 
This is increased during exacerbations and may be experimentally produced 
by thyroid feeding. 

Subsidiary and Complicating Symptoms. — A vast number of symptoms 
may be encountered in connection with the course of the disease. Ordinarily 
extreme nervousness, insomnia, subjective sensations of throbbing, flashes 
of heat, excessive perspiration, general or local, excessive flow of saliva or, 
more rarely, dryness of the mouth, cardiac distress and mental irritability 
are those most marked. Less common are the marked gastrointestinal 
disturbances, complicating myxedemas, angio-neurotic edema, pigmentation 
or leukoderma of the skin. 

Serious mental depression may occur or instability in the psychic sphere 
may manifest itself in ways most diverse and capricious. Irritability or 
actual choler may rapidly alternate with gaiety and exaltation. * Melancholia 
has been the common form observed, -though acute mania sometimes 
occurs. 

Emaciation is often extreme in advanced cases; yet on the other hand, 
one frequently meets with those of the well-nourished type. 

The disease is ordinarily chronic, lasting for several years; it is, moreover, 
frequently curable under medical treatment or may disappear and reappear 

The author has thrice seen an acute firm enlargement of the thyroid gland 
associated with marked nervous symptoms, tremor and tachycardia, which lasted 
but three or four days.f 

Mere swelling of the thyroid gland, whether inflammatory or non-inflam- May be trivial, 
matory, suppurative or non-suppurative, is not unusual, and moderate en- 
largement of the thyroid is so common in young girls at the age of puberty and 
in young women at the time of their first pregnancy as hardly to deserve 
notice. The surgical conditions of the thyroid cannot be considered here. 



Mental 
disturbances. 



Usually 
unimportant. 



* In one case coming under the author's observation an insanity developed temporarily, 
in an ancient virgin, with delusions of so unfortunate a nature as to involve wholly innocent 
parties in a serious scandal, the later development of the case making all clear. 

f The last case two weeks. 



184 



MEDICAL DIAGNOSIS 



Pituitary gland 
affected. 



ACROMEGALY ("Acromegalia, Marie's Disease") 

Definition. — A chronic nutritional disease, supposedly attributable to 
overactivity of the anterior lobe (glandular) of the hypophysis, and charac- 
terized by progressive enlargement or overgrowth of certain portions of the 
body, chiefly and primarily affecting the bones of the hands, feet and 
face, essentially chronic and progressive in its course and tending to a 
fatal issue after the lapse of 
many years. 

Historical Note. — It was 
first described by Marie in 
1886, having existed for 
thousands * of years without 
recognition as a clinical 
entity, though presenting one 
of the most striking pictures 
known to medicine. 

Etiology. — The cause of 
the disease is unknown, 
though the fact that in nearly 
every case that has come to 
autopsy the pituitary gland 
has shown definite changes, 
usually adenomatous or adeno-- 
carcinomatous, points to that 
curious structure as the prob- 
able source of the disease. 

The pituitary gland is a 
secreting organ as regards its 
anterior portion, whereas its posterior lobe has evidently a nervous func- 
tion. As its duct has become atrophied in the process of structural de- 
velopment, the secretion has become an internal one taken up by lymphatic 
absorption. But little is definitely known with respect to its functions 
despite the excellent work of many workers during the past few years. 

There is much to support the belief that it is the main center for body 
growth and that it bears some curious but little understood relation to the 
thyroid and suprarenal glands. 

A relation between gigantism and acromegaly has been suggested and is 
probable. It would seem possible that as suggested by Brissaud and 
Meige, if the hyperpituitarism occurs in childhood, gigantism results, but 
if delayed until ossification of the epiphysis is complete, acromegalic 
changes occur.* The disease occurs more frequently in women than in 
men, usually begins in early adult life, almost never after the age of forty, 
and no recognized preexisting disease has been definitely connected with it. 

* This is denied by Falta and others who insist that hyperpituitarism alone does not 
produce gigantism and that acromegaly may occur while the epiphyseal junctures are still 
open. 




Fig. 57. — Acromegaly showing enlarged and 
clumsy bones (case of L. G.). 



DISEASES OF THE GLANDS OF INTERNAL SECRETION 



■l«5 



SYMPTOMS. — If well- developed, it is essentially a case for street- 
car diagnosis, being easily recognized by its outward signs. The face is 
elliptical in form, the superciliary ridges being prominent, the head often 
large and massive, the lower jaw prognathic, the features enlarged and 
coarse also by reason of the marked thickening of the greasy integument, 
in which appear deep creases, especially marked across the forehead. 

In many cases even the 
lids are thick and coarse, the 
hands and feet are enormously 
enlarged, the ringers are spatu- 
late and clumsy, and upon ex- 
amination the increase is 
found to depend upon the 
bony overgrowth, a rinding 
easily verified by the X-ray. 
This growth may extend for a 
considerable distance upward 
along the bones of the fore- 
arm and leg, and sooner or 
later tends to involve the 
clavicles, scapulae, ribs and 
spinal column, at which time 
the patient is likely to assume 
a peculiar stoop, due to 
kyphosis of the spine. The 
X-ray may reveal an enlarge- 
ment of the sella turcica. 

There are no constant 
symptoms, as far as the in- 
ternal organs are concerned, 
and decided subjective symp- 
toms, such as headache, 
mental irritability, malaise, 
joint pains, disturbance of 
vision or drowsiness, may be 
absent until the later periods 
of the disease. 

The tendency is toward a fatal termination after a long term of years, in 
some cases covering two decades, and the symptoms are subject to many 
variations and exceptions. 

In one case which, fortunately, has been under the author's close ob- 
servation for nearly twenty years, most interesting variations have been 
observed.* In this case the predominant facial hypertrophy in the bones 
of the face appeared in the upper jaw; the bones of the feet were but 
slightly hypertrophied as compared with those of the hand, yet after a 
* Transactions of the Association of American Physicians, 1905. 




Fig. 58 Acromegaly. — Showing predominant 
hypertrophy of great toe (case of L.G.) 



Street-car 
diagnosis. 



Striking 
symptoms. 



Sella turcica. 



Prognosis. 



An unusual 
case 



l86 MEDICAL DIAGNOSIS 




term of years marked localized overgrowth appeared in both great toes. 
Another, then rare, phenomenon was a very marked co-existing myxedema, 
which promptly vanished each time that a course of thyroid medication 
was applied, finally disappearing altogether at a time when a previously 
existing marked enlargement of the thyroid gland slowly subsided. In 
this case also there was from the beginning a chronic synovitis of the knee- 
joints, persisting and so weakening the ligaments as to permit displacement 
of the patella and render the patient liable to dangerous falls. At the 
present writing this individual still lives, but grows gradually weaker and 
is subject to attacks of vertigo and occasional syncope. 

Differential Diagnosis.— The difficulties attending the diagnosis of 
acromegaly relate almost wholly to its early or relatively early recognition, 
and this must usually depend upon the testimony of the patient, or those in 
daily contact with him, relative to 
changes in physiognomy, often best 
revealed by a comparison of photo- 
graphs taken at different ages, and to 
a definite enlargement of the head, 
hands or feet necessitating changes in 
the size of the hat, gloves or shoes, 
respectively. 

The marked enlargement of the 

sella turcica, readily demonstrated in _^, n . . 

7 J . Fig. 59. — Hand. Case of pulmonary 

most of the advanced and decided cases osteoarthropathy. 

with actual tumor, may be lacking 

in certain cases. Acromegaly, it is said, may be mistaken for myxedema, 

leontiasis ossea, osteitis deformans, arthritis deformans, and pulmonary 

hypertrophic osteoarthropathy. There is hardly a shadow of an excuse for 

any error along these lines. 

Osteitis deformans is rather a matter of deformity than overgrowth, and 
in it the cranial bones are chiefly affected rather than the facial bones as in 
acromegaly. Furthermore, the shape of the head in osteitis deformans is 
characteristic, its broadened cranial portions contrasted with the narrower 
maxillary region, a condition usually reversed in acromegaly. 

Leontiasis ossea shows merely bony prominences on the skull and face, and 
lacks every characteristic of acromegaly. 

In pulmonary hypertrophic osteoarthropathy enlargement of the hands 
and feet exists, but is confined chiefly to the^articulations. The face is 
not affected, and chronic pulmonary disturbance of some sort, primary or 
secondary, is an invariable accompaniment. 

Syringomyelia causes enlargement of the extremities but is readily differ- 
entiated by the associated symptoms. 

Arthritis deformans certainly could not be mistaken for acromegaly under 
any conditions. 

The demonstration of an enlarged sella turcica by the X-ray, a procedure 
already mentioned, is a valuable and sometimes crucial test. 



DISEASES OF THE GLANDS OF INTERNAL SECRETION 



l8 7 



Gigantism. — There are two chief divisions of giants, viz., the acromegalic 
and the eunuchoid. In the latter the genitals are distinctly of the infantile 
type and the bones long and slender. 

It is assumed to be the result of hyperpituitarism existing prior to uniting 
of the epiphyses. 

Hypopituitarism. — The evidences of this condition vary with the age 
period at which the pituitary insufficiency occurs. 

Its chief effects express themselves in the retardation or actual limita- 
tion of growth, underdevelopment and, in adults, impairment of sexual 
function, obesity and in the female amenorrhea. 

Dwarfism in some forms is probably an expression of the condition and 
in young children a syndrome embodying adiposity and arrested sexual 
development may be associated with pituitary tremor. 

INFANTILISM. — Closely related to myxedema and cretinism is the 
curious condition termed infantilism of the Lorain type or those described 
by Gilford as ateliosis and progeria. 

The former type (Lorain) represents merely man or woman in miniature. 
In the latter (Gilford) there is an asexual type representing delayed develop- 
ment and a sexual form represented by the ordinary traveling showman's 
dwarf, the delayed development in this case yielding along sexual lines 
at puberty. 

Progeria covers cases of infantilism associated with premature senility, 
outward and structural. „ 

PANCREATIC INFANTILISM.— This condition, characterized by a 
marked amelioration under the administration of pancreatic extract, is 
described by Byrom Bramwell. * In this case the developmental arrest was 
complete for seven or eight years, but in the course of nine months' treat- 
ment there was a gain of 8% pounds in weight, and nearly 2 inches in 
growth. The patient was eighteen years of age, his developmental arrest 
occurring at eleven or twelve. The various classifications of infantilism 
are unsatisfactory and probably do not rest as yet upon a very substantial 
basis. 

EXOGENOUS OBESITY.— Obesity may be general or local, and its 
cause may be excessive food consumption, or defective employment of 
normal oxidation or elimination. 

In view of the discomfort caused by the excessive accumulation of fat, its 
tendency to limit proper exercise and cause impairment of the functions of 
vital organs, such as the heart, one may fairly consider the condition as a 
morbid state tending directly to shorten life. The general conformation of 
the body should be given consideration, and large bones, unusual muscular 
development and a relatively small waist measurement are factors that 
materially modify the estimation of individual longevity. This means that 
excessive fat is the condition most feared. 

There are two distinct types of the obese, namely, the anemic and the 
plethoric, with little to choose between them, so far as life expectancy is 
* Clinical Studies, Vol. 1, part 2, Jan., 1903. . 



Shortens life. 



Lines to be 
drawn. 



i88 



MEDICAL DIAGNOSIS 



concerned. The excessively obese are peculiarly liable to disturbances of 
the secretory organs, heart disease, asthma, diabetes, gall-stones, gout, 
apoplexy. Furthermore, they succumb readily to severe acute infections, 
and are bad subjects for major operations. 

ENDOGENOUS OBESITY.— In certain cases of obesity the combustive 
capacity of the individual is subnormal. 

General Comment. — As is well known, certain races or tribes deliberately 
cultivate obesity in their women, making the pudgy outlines of the Hottentot 
Venus their ideal of feminine beauty. In all races 90 per cent, of the cases 
of excessive obesity occur in women; furthermore, the condition is often 
congenital. Cases are reported in which a baby thirteen months old weighed 
75 pounds, a child four years old weighed 256 pounds. In some of these less 
pronounced cases the excessive fat of childhood disappeared largely in adult 
years. Cases of excessive weight have been reported that tax one's credulity 
to the utmost. Daniel Lambert is said to have weighed 730 pounds. A case 
was reported in Baltimore in which the weight was 850 pounds, and one from 
North California is said to have reached 1000 pounds. These cases are 
ordinarily short-lived, and the fact that few excessively fat people attain 
advanced age cannot fail to strike even the lay observer. 

In a rare and curious disease known as "adiposis dolorosa," more 
likely to affect women than men and falling almost wholly between the 
age periods of forty-five and sixty, the excessive accumulation of fat is 
associated with asthenia, headache, pain, tenderness of tissues, and mental 
disturbances. 

The accumulation of fat in this disease ordinarily occurs in the form of 
bunches or nodules, though later becoming widely distributed in most in- 
stances. Its cause is possibly a disturbance of internal secretion but nothing 
certain is known.. Degeneration of the ultimate nerve filaments has been 
reported and inthe absence of the typical findings with respect to fat deposit 
its differentiation from an alcoholic polyneuritis may be difficult or impossible. 

It is wholly probable that "adiposis dolorosa" as an entity will disappear 
soon from medical literature. 

CERTAIN DISEASES OF UNKNOWN CAUSATION 

OSTEITIS DEFORMANS. ("Paget's Disease").— Definition.— A rare 
disease characterized by kyphosis of the upper spine, a broad-based thorax, 
lozenge-shaped abdomen, marked enlargement of the cranial portion of 
the head and enlargement and deformity of the long bones, due to a rarefying 
osteitis. The disease is extremely rare and of unknown etiology and needs no 
further description. 

LEONTIASIS OSSEA. — A disease characterized by hyperostosis of 
the bones of the cranium, rarely those of the face, in some instances com- 
bined with localized hypertrophy of the soft tissues. 

MICROMEGALY. — This disease is the opposite of acromegaly, is ex- 
cessively rare, and of unknown causation. 



THE EXAMINATION OF THE URINE 



189 



PULMONARY HYPERTROPHIC OSTEOARTHROPATHY.— {Bam- 
berger's Disease). — This ailment, associated almost invariably with chronic 
pulmonary disease, is characterized by an enlargement of the hands and feet, 
the distal portions of the long bones, joints, and terminal phalanges chiefly 
being affected. The finger-nails become brittle and show longitudinal 
striation. 

Achondroplasia.— Victims of this curious developmental abnormality are 
seen frequently on our streets active, intelligent, wearing a facial aspect 
reasonably well suited to their actual age, but seldom exceeding in height that 
of a well developed child of ten, and almost invariably wearing a "pug" nose 
as evidence of precocious ossification. 

The genitals develop normally to full adult proportions. 

The skull is so enlarged as to suggest hydrocephalus, the four fingers of the 
hand are of nearly equal length, and if, as happens often, the mid- and ring- 
fingers stand apart, the two pairs of fingers with the thumb form the "trident 
hand." The trunk is nearly or quite of adult proportions but the arms and 
legs are extremely short. These cases are readily distinguishable from the 
cretinic dwarfs on the one hand and' those of pituitary disease (Frohlich's 
syndrome), with their obesity and infantilism, on the other. 

A great variety of cases of excessive fat accumulation may be placed under 
this head, but their exact classification is unsatisfactory and the condition 
may arise from various disturbances of the internal secretions. Among 
these, the obesity of hypothyroidism is especially important, as is that fol- 
lowing castration and the menopause. 

URINALYSIS AND DISEASES OF THE KIDNEY 

General Considerations. — The normal activity of the kidney depends upon 
a proper performance of function on the part of the other related organs, as well 
as upon the structural and functional integrity of the kidney itself. 

Its remarkable intrinsic nervous mechanism makes it difficult to apply 
rigid rules governing its activity, tut it may be said that the quantity of 
urine and inorganic salts depends upon osmotic glomerular filtration as 
affected by blood pressure and volume, whereas the output of urea and its 
congeners is determined by the peculiar selective action of the cells of the 
convoluted tubules. 

Therefore, anything affecting the renal structure or circulation, directly or 
indirectly, must alter the amount and constitution of the urine. 

Value of Urinary Examination. — No other secretion or excretion of the body 
furnishes greater or more varied information. Any substances which are taken 
into the blood stream are excreted ultimately in large measure by the kidneys, 
and through a critical chemic and microscopic examination of the urine we can 
measure variations in nutrition and waste, and obtain positive, suggestive or 
corroborative data with relation to many diseases, both local and general. 

Poisoning (coal-tar products, morphia, lead, mercury, chloral, etc.), 
Bright's disease, diabetes, spermatorrhea, cystitis, pyelitis, gonorrhea, 



Active and 
intelligent 



Pug-nosed 
dwarfs. 



Relationships 
marked. 



Filtration. 



Selective 
cell action. 



Wide scope. 



190 



MEDICAL DIAGNOSIS 



Obtain 24 
hours' urine. 



Collection and 
preservation. 



Night vs. Day. 



Best. 



Worst. 



Diverse 
factors. 



Women and 
children. 



Transient and 
trivial. 



oxaluria, gout, the presence of fever, a failing heart, typhoid fever, pneumonia, 
septicemia, urinary and general tuberculosis, filaria sanguinis hominis. 
dyspepsia, chronic appendicitis, hysteria and partial or fully established 
obstructive jaundice may be mentioned as some of the conditions, either 
directly diagnosticated, or suggested, by urinary signs. 

The ordinary examination of the urine is largely qualitative, but certain 
necessary quantitative methods involve only a small amount of apparatus and a 
negligible loss of time, and all vital procedures may be carried out by simple 
methods whose margin of error is not so great as to vitiate clinical results. 

The First Step in the Urinary Examination. — The total urine for twenty- 
four hours best represents the functional activity of the kidney as affected by 
changes in its structure or diseases of related organs. 

It should be collected in clean bottles, the night urine separate from that 
of the day, and if it cannot be kept cool, a preservative should be added. 
Chloroform is the best agent readily available and is readily removed by 
heat. Camphor, thymol, chloral and formalin give rise to misleading 
reactions. 

Toluol is an admirable preservative and, as it floats upon the surface^ 
need not be removed, the urine needed for examination being withdrawn by a 
pipette as needed. 

Procedure. — The urine passed on the first morning is disregarded, all 
voided for the remainder of that day saved, thoroughly mixed, and kept in 
a cool place. That passed after retiring and that portion voided upon arising 
the following morning are separately collected.* 

In certain important renal diseases, notably in advanced interstitial 
nephritis and certain cases of cardiac insufficiency, the normal ratio of day to 
night excretion is greatly modified or reversed. 

Ordinarily, the day urine is three or four times greater in volume than that 
of the night, hence any marked departure in the direction of equalization or of 
reversal of preponderance is suggestive. 

Single Specimens. — Of the individual specimens, that passed late in the 
day, preferably after a full meal and exercise, is most likely to contain 
albumin or sugar, and, except in suppurative disease of the kidney or bladder, 
that least likely to show abnormalities is the early morning urine. 

Normal Variation. — The normal amount of urine varies from 750 to 2000 
c.c, and this variation may be temporary or permanent, depending upon 
exercise, the amount of perspiration, the kind and amount of water ingested, 
or the nervous condition of the individual. The smaller amount represents 
usually either diminished ingestion or increased loss of fluid through other 
channels, such as free perspiration during hot weather, or a diarrhea. Women 
drink little water and usually show a small daily total, and children secrete 
relatively more though absolutely less than adults. 

POLYURIA.— Temporary vs. Persistent. — An increased flow may be 
temporary or permanent, purely functional (psychic, emotional), or, due to 

* This insures at least one fresh specimen should decomposition occur in either of the 
others, and a mixing of the three gives the twenty-four hours' total. 



THE EXAMINATION OF THE URINE 



IQI 



local or general organic disease. The ingestion of large quantities of water or 
such diuretic substances as beer or gin, the use of certain diuretic drugs, 
hysteria, migraine, and atmospheric humidity with low temperature, 
markedly, though temporarily, increase the amount. 

Persistent polyuria usually indicates actual disease, and is encountered 
in certain neuroses (urina spastica), as well as in chorea, pyelitis, amyloid 
kidney, interstitial nephritis, convalescence from acute nephritis, absorption 
of exudates, and diabetes mellitus or insipidus. 

Diabetes mellitus and certain rare cases of interstitial nephritis* violate the 
accepted rule that increased flow of urine results in or is associated with a lowered 
specific gravity. In diabetes insipidus the total urine shows increased total 
solids, though the individual voidings yield diametrically opposite findings. 

OLIGURIA. — Pathologic diminution is usually associated with severe 
acute congestion, various forms of acute nephritis, chronic parenchymatous 
nephritis in its active stage, or with circulatory diseases and conditions 
producing passive congestion. Among these are cardiac weakness from any 
source, cirrhosis of the liver, chronic emphysema, or pressure due to ab- 
dominal growths or a pregnant uterus. 

Relation of Oliguria to Color and Specific Gravity. — A marked oliguria 
accompanies acute infections associated with toxemia and high body tem- 
perature, profuse diarrheas or hemorrhages, shock or collapse. 

In nearly all instances a reduction in the total quantity of urine is associated 
with an increase in coloring matter and a heightened specific gravity of the 
individual specimen. . This last may be present from various causes in the 
individual voidings, even though the total excretion of solids is markedly 
diminished. 

ANURIA. — Complete suppression of urine may result from many causes 
and, though always serious, may or may not prove critical. 

It may occur in nephritis, renal tumor, phosphorus poisoning, shock or 
collapse, hysteria, ureteral calculus, cholera, and as a sequel to nephrectomy. 
If but one kidney is functionally potent, pressure upon the ureter of the other 
organ may produce complete anuria. 

It is sometimes directly obstructive and, in cases not due to actual renal dis- 
ease, has been known to exist for two weeks or more without producing uremic 
manifestations. 

Frequency of Micturition and Dysuria. — Increased frequency associated 
with pain usually indicates disturbance of the renal pelvis, bladder, prostate or 
urethra, rather than disease of the kidney itself. 

It maybe due to simple concentration and high acidity or, more frequently, 
urethritis or cystitis. Relatively or absolutely painless increased frequency 
may accompany any increased urinary flow, normal or abnormal, or certain 
stages of active disease, acute or chronic, of either the pelvis or the paren- 
chyma of the kidney. 

* Ogden reports such an instance — "The Clinical Examination of the Urine," 1903. 
The author has never encountered one though the relatively high specific gravity of the 
scant urine of terminal cardiac incompensation in such cases is a common finding. 



Usually 
important. 



Polyuria and 

specific 

gravity. 



Associated 
conditions. 



Etiologic 
factors. 



Unusual 
duration. 



Painful. 



Painless. 



192 



MEDICAL DIAGNOSIS 



An important 
sign. 



Specific 
gravity and 
reaction. 



Black. 



Green-black. 



Claret-color. 
Yellow foam. 



Yellowish- 
green, green- 
ish-brown, 
reddish- 
brown. 

Deep green. 



Of some diag- 
nostic value. 



Habitual rising at night to void urine may be due to urethral stricture, an 
enlarged or inflamed prostate, gravel, renal or cystic stone, diabetes mellitus 
or insipidus, malignant or tuberculous diseases of the genito-urinary tract, 
interstitial nephritis, insomnia, and, rarely, to mere habit. Nearly all patients 
exhibiting the polyuria of interstitial nephritis or the frequent night micturi- 
tion of prostatic disease believe the frequent voiding to be merely the result 
of "habit." 

THE COLOR. — Fresh normal urine varies from pale yellow to yellowish- 
red, and all urines may be classified as pale, normal, high-colored, 
or dark. 

Deep color is usually associated with relatively high specific gravity and 
marked acidity; pallor with low specific gravity and lessened acidity or alkalinity, 
diabetes mellitus furnishing an exception to the ride. 

Indeed, so striking is the heavy weight of diabetic urine in connection 
with its light color, that a provisional diagnosis is often suggested when lifting 
the tube or bottle. 

Fever urines are usually high-colored, scant and of high specific gravity, 
though fever may of course exist in exhausting and wasting diseases with a 
relatively pale color and low specific gravity. 

Brown, Black, Smoky, or Red Urines. — (a) Blood. — Color red, reddish 
brown, smoky, brown, or black. 

(b) Melanemia (Melanotic Sarcoma). — The urine becomes black on standing, 
but does not reduce Fehling's solution. 

(c) Alcaptonuria. — Urine becomes black on standing and reduces Fehling's 
solution. 

(d) Poisoning by Coal-tar Products. — The greenish-black color is due 
to hydroquinon and follows the excessive use of drugs like carbolic acid, 
naphthalin, guaiacol, resorcin, salol, creolin and lysol. 

(e) Hematoporphyrin. — Color of port wine or Bordeaux. 

(/) Bile. — Greenish, yellowish-green, greenish-brown or deep brown urines 
may contain bile pigment, in which event the foam produced by shaking the 
liquid is yellow. Urine containing bile may, when freshly passed, be reddish 
brown, but oxidation of the brown bilirubin converts it into biliverdin and 
produces the greenish tinge. A deep green urine results from the administra- 
tion of methylene blue. 

Blue urine usually indicates a great excess of indoxyl products, as in ileus, 
cholera and typhus, but is rare. Orange and reddish-brown urines suggest 
rhubarb, senna, or chrysophanic acid; yellow urines, santonin. 

INDICAN. — (Indoxyl-potassium-sulphate). — This normal urinary chro- 
mogen and tryptophan derivative results from albuminous putrefaction in the 
presence of bacteria; and, if found in the urine in excess, suggests intestinal stasis 
or obstruction, septic processes or the excessive ingestion of red meat. 

C. E. Simon reports an excess in hypochlorhydria, anachlorhydria and the 
hyperchlorhydria of certain gastric ulcers, and an excess is found in typhoid 
fever, appendicitis (chronic or acute), cancer of the stomach, peritonitis, chronic 
gastritis and similar conditions, reaching its maximum in stasis and ileus. 



THE EXAMINATION OF THE UK INK 



193 



Establish a 

rough 

standard. 



color solution. 



Obstruction in the lower colon or simple constipation does not materially increase 
it.* 

Test (Jafe-Stokvis). — (a) Take equal parts of the urine and strong hydro- 
chloric acid, (b) Add two or three drops of a saturated solution of sodium or 
calcium hypochlorite or of common saltpeter. Shake. Add 1 ex. of chloroform, 
shake thoroughly and repeatedly and set aside. The chloroform then shows a 
depth of color varying with the amount of indican present. Potassium iodide 
if present may yield an intense carmin, and codein a reddish-purple. 

The observer should establish a normal standard by repeated observa- 
tions using always the same quantities of urine and reagents. A more 
accurate test involves the use of a small amount (not an excess) of lead 
acetate sol. (20 per cent.) which removes the urinary pigments in the 
recipitate. 

Quantitative Tests (Strauss' s Method). — This involves the use of a 
standard color solution obtained by dissolving 1 mg. of C. P. indigotin in standardized 
1000 c.c. of chloroform. This should be carefully sealed and kept in the 
rk. 

Take of urine 20 c.c, add 5 c.c. of lead acetate sol. (20 per cent.) which 
recipitates the urochrome, filter. Mix 10 c.c. of Obermayer's reagentf with 
10 c.c. of filtrate (= 8 c.c. urine), add 5 c.c. of chloroform, cork, and shake 
gently for two minutes. Remove chloroform, add another 5 c.c. of same 
and so continue until no color is extracted. Of the chloroform used take 2 
c.c. in test-tube, add chloroform guttatim until the color corresponds with that 
of the standard solution in a control tube of equal caliber, both being held 
against a white background. 

I The total number of cubic centimeters of chloroform used both in ex- 
traction and dilution represents the amount containing 1 mg. of indigotin. 
By multiplying the total amount of chloroform used for extraction by the 
amount used to dilute to a standard color and dividing by two which cor- 
responds to the amount subjected to this dilution we obtain the amount 
necessary for complete standardization of the total chloroform used. 

INDOL (Excreted as indoxyl potassium sulphate). — When found in 
substance in the urine this suggests recto-vesical fistula; otherwise, the same 
statements and tests apply as are given under "Indican." 

Test for Indol in Substance. — Cholera red reaction. Add to the urine a 
few drops of dilute sodium nitrite solution and gently pour it down the side 
of a tube containing sulphuric acid. Indol yields a purple color at the point 
of contact, a diffuse pink on shaking and blue-green on neutralization with 
sodium hydrate.% 



Recto-vesical 
fistula. 



* Winternitz considers the absence of an indican increase in ovarian disease of differential 
value in cases where doubt arises as between this disease and a chronic appendicitis, in the 
presence of symptoms equally explainable by either condition. 

t Obermayer's reagent. C. P. HC1 1000, ferric chloride 2. This forms a permanent 
fuming yellow mixture. Accurate quantitative determination is not essential. 

\ This is simple and sumcientiy delicate, but other tests, such as that of Ehrlich, will 
show 1 part of indol in 400,000 parts of urine. 
13 



194 



MEDICAL DIAGNOSIS 



Diagnostic 
importance. 



Diagnostic 
value trivial. 



Of slight diag- 
nostic value. 



SKATOL (Excreted as skatol-carbonic-acid). — This substance is said 
to be especially abundant in cases of tuberculous ulceration of the intestines, 
gastric or intestinal carcinoma and pneumonia, and is not increased in the 
other diseases showing an excess of indoxyl (F. C. Wood). 

Rosenbach's Test. — Add nitric acid, guttatim, to boiling urine. A 
Burgundy-red color with a bluish-red foam on shaking indicates skatol. A 
reddish or brownish red is usually due to urobilin. 

UROERYTHRIN. — This normal urinary pigment is increased in febrile 
states, gout, in various dyspeptic conditions and after excesses in food or 
alcoholics. It gives an orange color to the urine and a rose tint to uratic sediments. 

Test. — Add C. P. sulphuric acid to the urine guttatim and a carmine- 
red color reaction appears, or some pink urates dried or filtered may yield a 
bright green color with a drop of sodium hydrate solution. 

MELANIN. — This substance produces a brownish-black urine or one 
darkening thus from above downward upon exposure to the air (melanogen) . 
This color is intensified by the addition of nitric acid, bromine water, chromic 
acid or ferric chloride. 

Significance. — It is the pigment of melanotic sarcoma and carcinoma 
(see also "Alcaptone" which also produces dark urines). 

UROBILIN. — This, or rather its chromogen, urobilinogen, in very small 
amounts is a normal constituent of urine, is derived from bilirubin by a process 
of reduction within the intestine and is probably the stercobilin of the feces. 

In excess it suggests an acute infection, such as sepsis, scarlatina, pneu- 
monia, acute rheumatism, malaria, typhoid or erysipelas, as well as lead colic, 
hepatic cirrhosis, hemolytic pernicious anemia, congenital hemolytic jaundice 
or internal hemorrhage. It may accompany passive Congestion, as in a weak 
heart, the ingestion of such substances as antipyrin and antifebrin, chloro- 
form inhalation or the injection of tuberculin (Wood). 

It may be also the forerunner of, or alternate with, jaundice, constituting 
the urobilin icterus, most frequent in atrophic cirrhosis, carcinoma and 
pneumonia. It will readily be seen that it assists but slightly in exact 
clinical diagnosis save in relation to hemolytic processes. 

Chemic Test. — To the reddish or reddish-brown urine, w T hich upon shaking 
usually shows a brownish or even yellow foam, one adds ammonia freely and 
follows with a few drops of a i per cent, solution of zinc chloride. Urobilin 
is indicated by a green. fluorescence. 

Spectroscopic Test. — Dilute urine if necessary, add a few drops of tinc- 
ture of iodine to each 10 c.c. of urine, and the spectroscope will show a broad 
absorption band between the green and blue if urobilin itself, not its. 
chromogen, be present. 

THE OXYACIDS. — These have the same significance as indoxyl and have 
no special clinical importance. 

ALCAPTONE. — This rare substance, a derivative of the amino-acids, has 
no clinical importance aside from the fact that it produces a urine which, like 
that containing melanin, slowly darkens on standing or, rapidly, following the 
addition of an alkali. It reduces Fehling's solution, though not affecting 



THE EXAMINATION OF THE URINE 



195 



the fermentation, phenyl-hydrazin or bismuth sugar tests, and yields a nega- 
tive polariscopic test. See also "Melanin" and "Hematoporphyrin," both 
of which produce dark urine. 

HYDROCHINON AND PYROCATECHIN.— Both of these substances 
produce a urine which darkens on standing, but are of no other clinical 
importance. 

UROCHROME AND HEMATOPORPHYRIN.— These constant normal 
urinary pigments are often associated with urobilin and uroerythrin. The 
first is the chief yellow or amber pigment, the second scant and red. (Uro- 
bilin yields a yellowish brown and uroerythrin a pink color to the urine.) 

Urochrome is readily precipitated by lead acetate solution, leaving a clear 
urine well adapted to spectroscopic examination. 

Urochromogen Test of Weiss. — This simple test consists in dividing a 
small amount of urine into two portions, reserving one for control, and add- 
ing to the test specimen a few (2 or 3) drops of potassium permanganate 
solutions, 1 : 1000. 

A canary-yellow color constitutes a positive reaction and is said to be of 
special importance in relation to prognosis in pulmonary tuberculosis.* 

Hematoporphyrin is an iron- and albumin-free derivative of hemoglobin 
and is often excreted in excess in chronic users of trional, sulphonal, tetronal, 
and the like, the urine being by transmitted light Burgundy red, and, 
by reflected light, dark brown or black. It is probably derived from 
hematin. 

Salkowski's Test. — Treat 30 c.c. of urine with a mixture consisting of 
equal parts of a solution of barium chloride (10 per cent.) and cold saturated 
solution of barium hydrate. Wash the resulting precipitate with water, 
again with absolute alcohol, and shake it up repeatedly with a warm solution 
representing 10 c.c. of alcohol and 6 to 8 drops of HC1. 

If the test be positive, a red- violet color results and the solution yields to 
the spectroscope the characteristic double bands of acid hematoporphyrin, 
viz. — a narrow dark band in the orange and a broader one between the 
yellow and the green in contact with a lighter band in the yellow. 

CREATININ. — This derivative of the ingested meats follows the 
same laws as urea as to the variation in excretion, both in health and 
disease. 

Test. — It is easily recognized by the intense red color produced by adding 
a little saturated solution of picric acid and a few drops of sodium hydrate 
(Jajfe's test) to the urine. 

Various other substances of no clinical importance but related to the 
foregoing organic compounds are omitted. 

* M. E Cowen has recently reported the results of testing 832 cases at the Cresson 
Sanatorium and believes that " only in the presence of an actual destructive process does the 
positive reaction appear. He would apply it, therefore, both in prognosis and in the man- 
agement of the individual case. The author has had no personal experience with the test, 
but if its name is truly descriptive it should have much the same incidence, significance and 
value in this disease as would positive diazo-reactions, i.e., according to the author's ex- 
perience it would indicate active mixed infections. 



A useful 
procedure. 



196 



MEDICAL DIAGNOSIS 



Chylurea, 
pyurea and 
lipurea. , 



The nubecula. 



Physiologic 
sediment. 



Persistent 
opacity. 



Fixed vs. 
volatile alkali. 



MILKY URINE. — Such an appearance is usually due to pus or chyle. 
Pus forms a sediment and its characteristic cells are easily detected by the 
proper chemical and microscopic tests. 

Free fat upon the surface is almost invariably from an unclean bottle, 
the local use of some unguent, or, rarely, to extreme fatty degeneration of the 
kidney. Fat cells are characteristically refractile under a shifting focus and 
stain black with osmic acid and red with Sudan III. It cannot be denied 
that a true lipurea occurs as a rare finding in many diseases or even in an 
alimentary form. 

Chyluria. — This rare condition is almost pathognomonic of the presence 
of Filaria sanguinis hominis. The urine appears usually like skim milk though 
often tinged with pink. The typical large fat globules are absent, blood and 
lymph cells present, and the fat cells appear under the microscope as fine 
mote-like particles. The urine resembles a fine emulsion. A " cream" 
layer may rise on standing and the parasite itself be found in the fluid. 

Tests for Fats. — The microscopic or macroscopic examination suffices 
in many cases. 

Chemic Test. — Add potassium hydrate and ether, shake, decant and 
evaporate the supernatant fluid. The fat is taken up, held in solution and 
remains after evaporation. 

Fibrinuria. — In rare instances, as in some cases of villous growth in the 
bladder, the urine jellies on standing, or, if less fibrin be present, a sticky 
sediment may adhere to the bottom of the glass. 

TRANSPARENCY. — Normal, undecomposed urine is usually perfectly 
clear save for a slight mucous nubecula floating in its upper portion. 

Even in freshly passed urine, however, earthy phosphates or the amor- 
phous urates sometimes cause a physiologic sediment, the phosphates being 
associated with feeble acidity or alkalinity;* the urates with concentration and 
acidity. 

Heating increases the precipitation of phosphates and redis solves urates. 
Persistent opacity or turbidity is pathologic in undecomposed urines and may be 
caused by pus, blood, fat or bacteria. 

ODOR. — The peculiar odor is intensified in sharply acid, concentrated 
urine and distinctly and characteristically modified in alkaline urine; the 
volatile alkali (ammonia) being easily detected if present, as are indol and 
skatol in recto-vesical fistulas, the odor of hydrogen sulphide in hydro thionurea, 
bitter almonds in nitro-benzol poisoning, etc. 

REACTION. — The reaction may be acid, alkaline or amphoteric, i.e., 
doubly reactive, f // alkaline, the physician should determine by repeated 
tests whether the condition is temporary or permanent and the alkali fixe d (potas- 
sium or sodium) , or volatile (ammonia) . Any ammoniacal urine to which a few 



* Many such urines are really neutral, as shown by a phenolphthalein solution, though 
turning red litmus-paper blue, possibly through the release of C0 2 from the bases (F. C. 
Wood). 

f Presumably because of the co-existence of the acid monosodium phosphate and the 
alkaline disodium phosphate. 



THE EXAMINATION OF THE URINE 



IQ7 



drops of potassium or sodium hydrate solution has been added yields when boil- 
ing the odor of ammonia. So also, immersed red litmus-paper resumes its 
original color when dried in the air. 

The "Alkaline Tide." — A physiologic alkaline or neutral reaction often 
appears two or three hours after a meal especially in vegetarians, in which 
case the alkali is fixed, not volatile, and the condition unimportant. 

Persistent, non-dietetic alkalinity is abnormal, and urine ammoniacal when 
passed indicates usually some disease of the bladder or prostate with or without 
renal involvement. 

An exclusive meat diet tends to produce acidity; an exclusive vegetable 
diet, alkalinity; but quantitative determination of the acidity or alkalinity 
is clinically useless. 

Excessive Acidity. — This may be encountered in fevers, in acute rheu- 
matism to a marked degree and in gout, diabetes, leukemia, scurvy, and 
decided cardiac incompensation. As a rule high acidity and scanty urine 
go together. 

SPECIFIC GRAVITY.— For ordinary purposes a clinical urinometer 
of the usual type, properly graduated for definite temperature (usually 
i7.5°C.) is sufficient. In testing freshly passed 
urines, for every 3°C. above the standard temper- 
ature for the individual instrument one point 
should be added to the right-hand figure of the 
specific gravity. If more accurate results are de- 
sired or very small quantities of urine are to be 
dealt with, as in urethral catheterization, the 
hydrometer of Saxe, one of the pycnometers, or the 
Westphal balance may be readily obtained. 

Technic. — In ordinary clinical work the following 
precautions are necessary: (a) The urine must be 
allowed to cool or proper allowance made, (b) All 
air bubbles must be removed with filter-paper, (c) 
The urinometer must be perfectly dry and (d) intro- 
duced with a little spin to prevent it from adhering to 
the side of the receptacle, (e) The specific gravity should be read from the 
meniscus or true surface, the observer's eye being at that level; false readings result 
if one reads from above, because the fluid rises slightly along the urinometer stem, 
if) If the amount of urine is small, approximate results may be obtained by 
diluting sufficiently to float the instrument and multiplying the two right-hand 
figures of the specific gravity by 2, 3 or 4 according to the amount of distilled water 
used. 

Factors Determining Specific Gravity. — The normal figures vary from 
1. 012 to 1.024, the average lying between 1.018 and 1.022. Hysteria and the 
use of diuretic fluids or drugs may reduce it to 1.002 and in disease it varies 
from j. 002 to 1.060. 

In general, high specific gravity points to large hemorrhages, profuse per- 
spiration, diarrhea, fever, and diabetes mellitus. 




i 



Fig. 60. — Urinometer, 
thermometer and specific- 
gravity tube on foot. 



Physiologic 
alkalinity. 



Volatile 
alkali. 



Effect of diet. 



When 
encountered. 



Instrument. 



Temperature. 



Details 
important. 



Wide 
variations. 



198 



MEDICAL DIAGNOSIS 



Exceptions 
to rule. 



Organic vs. 
inorganic. 



Rough 
methods. 



Urinary 
nitrogen. 



Variations. 



Low specific gravity suggests chronic Bright's disease (particularly inter- 
stitial nephritis), diabetes insipidus and hysteria. 

As a rule, a low specific gravity accompanies increased excretion, and a 
high specific gravity, diminished excretion, but there are many exceptions 
to this rule, many grave diseases being associated with scant urine and defi- 
cient elimination of solids, whereas diabetes mellitus may show an enormously 
increased excretion with the highest readings and diabetes insipidus an in- 
creased amount and low specific gravity with an actual excess of solids in the 
twenty-four hours' urine. 

URINARY SOLIDS 

Normal Constituents. — Normal urine in the healthy adult of average weight 
and on a mixed diet should contain about 60 grams of solids. Of these about 
35 grams are organic and 25 grams inorganic. By multiplying the two right- 
hand figures of the specific gravity by 2.2337, one obtains roughly the total 
urinary solids in 1 liter (1000 ex.) of urine. [Example: Sp. Gr. 1020. 
20 X 2.337 ~ 46.74 grams per 1000 c.c] Of this about one-half is urea, 
which should be separately estimated. 

The principal inorganic substances are: HC1 (9.35 grams), phosphoric 
acid (2.5), sulphuric acid (2.5), nitric acid (1.0), oxalic acid (0.0 1 to 0.02), 
sodium (8.0), potassium (3.0), ammonia (0.7), magnesia (0.5), lime (0.3), 
iron (0.001 to 0.002). 

The organic substances are, in grams^ urea (30.0), creatinin (r.o), uric 
acid (0.7), hippuric acid (0.7). Traces of a large number of organic sub- 
stances, including the purin bodies, make up the balance for the organic 
group. 

The pathologic substances are the albumins, blood, bile pigment, bile 
acids, indoxyl, acetone, diacetic acid, cystin, leucin, tyrosin, carbohydrates, 
phenol, creosol, skatol, urobilin, cholesterin, lecithin, diamins, melanin, fats, 
fatty acids, lactic acid, beta-oxybutyric acid. 

Of these, indoxyl, acetone, lactic acid, fatty acids, phenol, creosol, skatol, 
urobilin and even albuminous bodies may be present in clinically unrecognizable 
or negligible traces in normal urine. 

TOTAL NITROGEN.— A Direct Index of Protein Metabolism.— 
Before considering urea and uric acid the derivation and importance of the 
total nitrogen excretion should be considered. 

While the total nitrogenous output of the human body involves a consideration 
of that of the feces, lungs and skin as well as the urinary nitrogen, the fact that 
this last represents, in health and on a mixed diet, from 92 to 93 per cent, of the 
total makes the urinary examination the primary clinical consideration. 

Unfortunately the same ratio does not hold true in disease and in the case 
of special dietaries, for the reason that in pathologic states the total amount 
of nitrogen is divided among other nitrogen-containing compounds in vari- 
ous degrees. 

The healthy adult on a mixed diet secretes 0.2 gram of nitrogen per 



THE EXAMINATION OF THE URINE 



199 



kilo of body weight, viz., from 10 to 15 grams of nitrogen per day and under 
such conditions about 86 per cent, of the urinary nitrogen is urea nitrogen, 
though this ratio is not absolutely constant. Eight per cent, is derived from 
ammonia, creatinin, the purin bodies and the pigments, while 6 per cent, rep- 
resents hippuric acid and unknown substances. 

The total nitrogen excretion measures the variations, not merely of nitrog- 
en us intake, but of body waste and hence the metabolic processes. 

Nitrogen Retention. — Though excretion is increased by nitrogenous diet, 
an excess may nevertheless be retained in part for several days, a fact which 
has not yet been explained. 

Increased Excretion. — This occurs in acute infectious fevers (excepting 
acute yellow atrophy of the liver), malignant growths, chronic infections, 
pernicious anemia, exophthalmic goiter, scorbutus, the leukemias, resorp- 
tion of exudates, diabetes insipidus, phosphorus poisoning and, indeed, in 
practically all diseases associated with marked emaciation, malnutrition or 
excessive toxic metabolism. 

Diminished Excretion. — This occurs in nephritis, diseases of the liver and 
in convalescence from acute diseases, though in the first named, if associated 
with excessive albuminuria, the urine may show an apparent increase if the 
albumin is not removed. In nephritis especially, the stomach, intestines and 
skin may take on vicarious activity and the feces will show increased nitrogen 
content. 

For accurate work, careful measurements of the nitrogen intake and 
that of the feces as well as the urinary nitrogen is necessary, a time- 
consuming process illy-adapted to clinical work. (See "Index of Urea 
Excretion. ") 

Individual specimens of urine are no more than suggestive with respect 
to the nitrogen excretion. It must always be determined from the twenty- 
four hours' total urine. For a full description of all the elaborate chemical 
processes involved, the reader is referred to the special works dealing with 
physiological chemistry, but the most commonly used methocl of quantitative 
" urinary nitrogen" estimation is given briefly in the following paragraphs. 

ESTIMATION OF TOTAL NITROGEN (KjeldahVs Method).— This 
method depends upon: (a) The conversion of urinary nitrogen into ammonia. 
(b) The transformation of ammonia into ammonium sulphate, (c) The 
liberation of the ammonia by sodium hydrate, (d) Distillation into a deci- 
normal sulphuric acid solution, (e) Determination of the amount of com- 
bined ammonia by titration of the decinormal acid solution with a decinormal 
alkaline solution, using some such indicator as rosalic acid, alizarin red, or 
methyl orange. (/) Estimation of total nitrogen on basis of 0.001401 gram of 
nitrogen for each cubic centimeter of combined acid and ammonia as indi- 
cated by the preceding titration. 

Test. — First Step. — Using the apparatus shown in Fig. 61 and placing 
it under a proper fume-conduction hood, one measures into a Kjeldahl 
flask of 800 c.c. capacity, 5 c.c. of urine; 10 c.c. of concentrated sulphuric 
acid and 1 gram of copper sulphate. 



Ratio to body 

weight. 

Urea. 



Not 
practicable. 



Avoid fumes. 



200 



MEDICAL DIAGNOSIS 



Oxidation 
processes. 



Conversion 
into ammonium 
sulphate. 



Prevent 
"bumping." 



Liberate 
ammonia. 



Distil and 
recombine 
ammonia. 



Ammonia 
bound by 
acid. 



Titrate to 
measure 
amount 
combined. 



Second. — Heat over low flame until white fumes indicate the giving off of 
sulphuric acid. 

Third. — Add 5 grams of potassium sulphate and, shaking carefully from 
time to time, boil for from thirty to forty minutes or until the yellow color 
has entirely given place to bluish green. 

Fourth. — Set aside to cool. 

Fifth. — Add distilled water sufficient to make total quantity of liquid in 
flask about 250 c.c. 

Sixth. — Add a few bits of zinc, pumice stone or a little talcum powder to 
prevent "bumping" during the succeeding stages. 




Fig. 61. — Kjeldahl's nitrogen apparatus. {Webster, "Diagnostic Methods") 

Seventh. — Add 50 c.c. of 40 per cent, sodium hydrate, being careful to 
avoid having it touch neck of flask. 

Eighth. — Shake; connect by means of a Fresenius bulb with a Liebig 
condenser. 

Ninth. — Place in an Erlenmeyer flask 50 c.c. of a decinormal sulphuric 
acid solution and rapidly connect the outlet tube with the bulb and condenser. 

Tenth. — Heat slowly and carefully to boiling and maintain slow boil for 
twenty to thirty minutes or until about 150 c.c. of test mixture have passed 
over, or until outlet tube fails to color red litmus-paper blue, i.e., until 
distillation of ammonia is complete. 

Eleventh. — Disconnect distilling flask and rinse both connecting and outlet 
tubes into acid solution. 

Twelfth. — Titrate acid solution with decinormal sodium hydrate, using 
for an indicator rosalic acid, methyl orange, or alizarin red. 

The acid and alkaline solutions being standardized and of equal strength, 



THE EXAMINATION OF THE URINE 



20I 



— * 

— 5 

— va 

— U.QI 



— *02 



003 






the number of cubic centimeters of sodium hydrate solution required indi- 
cates the number of uncombined acid molecules, and by deducting this from 
50 — the number of cubic centimeters of decinormal acid solution originally 
used — one finds the number representing combined ammonia, each cubic 
centimeter of which is equivalent to 0.001401 gram of nitrogen. 

Hence the difference between the number of cubic centimeters of deci- 
normal sodium hydrate solution used in the last titration and the number of 
cubic centimeters decinormal acid solutions originally used, multiplied by 
0.001401 gram gives the amount of nitrogen in 5 
c.c. of the urine, and multiplying by 20 one obtains 
the total nitrogen percentage and readily calculates 
it for the mixed twenty-four hours' output of which 
the original 5 c.c. must be a part.* 

UREA. — In the normal individual on a mixed 
diet the urea output varies from 20 to 35 grams in 
twenty-four hours. Under such conditions it follows 
in nearly every particular the laws of total nitrogen 
excretion already given. 

Women excrete less than men, and in vegeta- 
rians or poorly fed patients, or those on a milk 
diet, the amount may not exceed 15 grams a day. 
Urea nitrogen represents approximately 86 per 
cent, of the total nitrogenf (protein-free diet 60 
per cent., vegetable diet 79 per cent., rich proteid 
diet 87 per cent.). 

Retention Periods. — There are periods of re- 
tention lasting several days, and these may be 
increased by certain drugs, such as salicylic acid, 
caffein, and quinin. Urea excretion is greatly 
increased in many conditions associated with 
marked tissue waste such as fevers, severe ad- 
vanced diabetes, pernicious anemia and leukemia. 
In diseases of the liver the urea excretion is more 
greatly diminished than is the total nitrogen, leucin and tyrosin being coinci- 
dently increased, or, in acute processes, an increased ammonia excretion 
replaces the leucin and tyrosin. 

In view of the recent work of Folin and others, one cannot consider the 
mere estimation of urea a substitute for total nitrogen determinations in 
questions of protein metabolism, but it still remains of value in relation to 
renal disease. 

Urea in Blight's Disease. — In Bright 's disease, save the early stage of 
parenchymatous nephritis, and especially in the interstitial form, urea excretion 
is usually diminished and also shows marked periodic or irregular variations. 

* Synopsis is taken from the full description contained in Webster's excellent book, 
"Diagnostic Methods." 

t And may reach 92 or 93 per cent. 




62. — The Doremus 
ureometer. 



Periodic 
variations. 



202 



MEDICAL DIAGNOSIS 



Sudden drops. 



Early 

chronic 

nephritis. 



Nephritis sine 
albuminuria. 



Estimation 
important. 



Instrument. 



Test. 



It is supposed that retained urea in such instances is responsible for the 
periods of diuresis or diarrhea so commonly seen. A sudden drop in urea is 
often noted in nephritis of all kinds, and is a danger signal that cannot be 
disregarded. 

In many of the author's cases presenting intractable neuralgias the at- 
tacks coincided with periods of low urea excretion. In others indeterminate 
but troublesome gastric symptoms, marked psychasthenia and hypochondria 
and arterial hypertension were found to coincide with the same condition and 
all these cases were promptly relieved by treatment directed to secure the 
better elimination of urinary solids and proper dietetic restrictions. 

In eight such instances no structural disease of the kidney was then clinic- 
ally demonstrable, but all have since shown typical interstitial nephritis. 

The author would strongly differ from, and, indeed, hold the exact reverse 
of, the statement made by certain writers that in renal disease urea determinations 
are less important than the finding of casts and albumin. 

With relation to the functional activity of the kidney even the rough esti- 
mation of urea, under dietetic control, is one of the simplest and most important 
of all clinical tests, and the most convenient method of quantitative testing is that 
of Dor emus which is sufficiently accurate for ordinary clinical purposes * 

Description of the Doremus Ureometer. — The Doremus apparatus is 
much used and consists of a tube carrying a bulb below and so graduated that 
each division corresponds to o.ooi gram of the urea as represented by the 
volume of nitrogen evolved at 65°F. There is also a small, curved, nipple- 
capped pipette holding i c.c. of urine. 

The tube is filled with hypobromite solution f and the pipette, J filled with 
urine {freed from albumin or sugar) up to the cubic centimeter mark, is 
carefully introduced into the bend as far as it will go, while holding the 
measuring tube perpendicularly, and the contained urine slowly and com- 
pletely discharged. After the evolution of gas is complete the number of 
divisions is read off as milligrams per cubic centimeter or the result multi- 
plied by ioo to obtain the percentage. 

A Fascinating and Accurate Procedure. — The method of determination 
of renal function described below should be known to all students and 
practitioners of medicine and the author has felt constrained in this instance 
to give much space to a procedure both time-consuming and exacting. 

It will be noted with satisfaction that the simpler phenolsulphonephtha- 
lein test (see p. 245) has borne the comparison very well and that in renal 
disease the variations from normal are usually violent in the obscurer forms of 

* Of the more elaborate and accurate methods, that of E. K. Marshall is the most recent 
and most useful. It depends upon the use of the Soya bean ferment urease, for the hy- 
drolysis of urea to ammonium carbonate. Though relatively simple, as compared with 
the older methods, it requires special apparatus, and far more time than the practitioner 
can afford. 

f 100 c.c. of caustic soda dissolved in 250 c.c. of distilled water makes a permanent 
solution, to 50 c.c. of which 5 c.c. of bromine is added to make test solution when needed. 

X The instrument can now be obtained with an attached hollow arm with a thumb-screw 
to hold, measure, and release the amount of urine used. 



THE EXAMINATION OF THE URINE 203 



nephritis. It must be borne in mind that a lack of absolute accuracy in the 
rough simple older form nice by no means wholly destroys their clinical value. 

This lies in their simplicity and availability, for this test of precision, 
however fascinating and valuable, is wholly unavailable for the greater num- 
ber of practitioners of medicine. Like the Wassermann test, it must remain 
in the hands of the expert and he will apply it chiefly to groups of patients 
accumulated over several days. 

The Index of Urea Excretion. — Most interesting and accurate results are 
being obtained at present by expert workers in the clinical laboratories, 
through the use of F. C. McLean's " index of urea excretion" which represents 
a marked improvement of Ambard's process based upon his two "laws," 
i.e., (1) when the concentration of the urinary urea is constant the amount 
excreted by the kidneys varies proportionately to the square of the blood- 
urea concentration; (2) when the blood-urea is constant, renal excretion 
varies inversely as the square root of the urinary urea concentration. On 
the basis of these two laws Ambard devised what he calls the u ureo-secretory- 
constant" obtained through a formula known as the "urea-coefficient." 
His formula (the urea coefficient) is the following: 

Ur 

K (constant) = — , — j== 

VDX7oVc_ 

P 25 

Ur = urea per liter of blood. 

D = grams of urea in urine during 24 hours. 

P = weight of patient in kilos. 

C = grams of urea per liter of urine. 

It is asserted by him that the " urea-secretory-constant " ("K") varies 
only from 0.06 to 0.07 in normal individuals, whereas in cases of nephritis 
the value of "K" is enormously raised, by reason of concentration of urea in 
the blood as a result of diminished renal elimination. 

McLean and Selling greatly increased the accuracy of the process by 
replacing the hypobromite method of urea estimation used by Ambard, by 
the exact technic of Folin and of Marshall. 

The tedious recourse to logarithms they avoid by the use of a scale rule 
adapted to the formulas. With relation to the necessity for and value of 
such a method, and after briefly reviewing the various other tests of renal 
permeability and adequacy now in use (lactose, phenolsulphonephthalein, 
etc.) McLean says:* 

" In all these tests it has been the urine alone which has been examined, the assumption 
being made that alterations in the manner or time of elimination are due to kidney factors 
alone. But this assumption is open to serious objection. The time required for the ex- 
cretion of considerable amounts of nitrogen or salt, suddenly added to the diet, may, in- 
deed, give some indication of the degree of kidney insufficiency; but the failure to excrete 
these substances within a specified time is often due to other factors than the ability of 
the kidneys to carry on their excretory functions. Thus a patient with fever may retain 
enormous quantities of salt in the body, even though the kidneys are perfectly capable of 

*Journ. A. M. A., Vol. LXVI, No. 6, p. 415 (abstract). Italics are the author's. 



204 MEDICAL DIAGNOSIS 



excreting it, and retention is due to the fact that the excess salt is removed from the blood 
by the tissues. That, under certain other conditions, a similar retention of nitrogen in 
the tissues occurs, independently of the ability of the kidneys to excrete nitrogenous sub- 
stances, is indicated by the recent studies of Foster and Davis. 

"Study of the daily nitrogen or salt balance between intake and output is of even less 
value than study of suddenly added nitrogen or salt. 

"It has, indeed, long been recognized that determination of the total nitrogen or urea 
output gives no indication as to the state of the function which provides for the excretion 
of nitrogen. An individual may excrete normal amounts of urea in the twenty-four hours, 
and remain in perfect nitrogen equilibrium for weeks or months, and yet be suffering from 
severe nephritis, with advanced functional changes. Except in the case of those patients 
with chronic parenchymatous nephritis, who are scarcely able to excrete any salt at all, 
comparison of the salt output with the intake gives little information. The same objection 
seems to hold with regard to the use of potassium iodid as a test of the ability of the kidney 
to excrete salts, since potassium iodid is influenced by the same extrarenal factors which 
influence sodium chlorid. 

"Studies such as these, of urine alone, can at best give only a general idea of the true renal 
condition, and can be in no sense a quantitative measurement of the renal activity. 

"Determination of the amount of urea nitrogen, or of total non-protein nitrogen in the 
blood, however, is not entirely dependable as a measure of excretory activity. The normal 
concentration of urea in the blood is not fixed, but varies within wide limits in response to 
variations in nitrogen and fluid intake. As a matter of fact, the larger proportion of indi- 
viduals with disturbed urea function have concentrations of urea in their blood which are 
below the upper limits in normal individuals, so that the line of demarcation between 
normal and abnormal subjects is not sharp. 

" Blood urea figures alone, therefore, may call attention only to the more serious instances 
of disturbed function. Furthermore, the concentration of urea in the blood even of nephritic 
individuals is not constant or fixed. On the contrary, Widal and Javal, in 1904, showed 
that the concentration of urea in the blood can be made to fluctuate at will in cases of 
nephritis, by varying the protein intake. 

"Either increased urea formation in the body, or disturbance of urea elimination 
through the kidney, requires a higher level of urea in the blood to provide for a sufficiently 
rapid rate of excretion to keep the organism in nitrogen equilibrium. 

"Changes in the rate of water excretion alter the rate of output of urea, which changes 
as the concentration of urea in the urine changes, though not directly in proportion to these 
changes. The rate of elimination also varies according to the weight of the individual, 
and is constant per kilogram of body weight, when the other conditions remain constant. 
I All of these factors have been considered by Ambard in formulating the laws published by 
him. 

"Data obtained by this method are direct quantitative measurements of one of the 
most important functions of the kidney, that is, the elimination of nitrogen in the form of 
urea. Performance of the test requires a shorter time than the use of any test diet, requires 
fewer analyses, is much more broadly applicable, and may be repeated indefinitely without 
harm or inconvenience to the patient. It requires no knowledge of the nitrogen or fluid 
intake, and is not interfered with by vomiting, refusal o f food, diarrhea, delirium or coma. 
The blood and urine required for the necessary analyses may be secured within the time of 
an ordinary consultation, and the analyses can be carried out in any well-equipped clinical 
laboratory. Also of the value of the results obtained, the method is to be preferred to 
the various modifications of the test diet. 

"The Index of Urea Excretion. — The index of urea excretion is based on an ideal normal 
Ambard's coefficient of 0.080. The extremes of variation of Ambard's coefficient in the 
normal are from about 0.050 to 0.085 or 0.090. Deficiency in urea function results in higher 
values. These higher values are. due to a change in the ratio which exists between the 
concentration of urea in the blood and the rate of its excretion. Such findings indicate 
deviation from the normal, but do not measure the extent of the functional change which 



THE EXAMINATION OF THE URINE 20 



is responsible for such deviation. The significance of the abnormal ratio found in any 
pathologic case, therefore, can be understood only by reference to an arbitrary scale, de- 
termined by experience. 

"Since it is possible to utilize the laws of Ambard in another form to measure functional 
changes directly, we have thought it desirable to use a new formula. In the case of the 
formula as at present used, the ideal normal is determined arbitrarily, by experience, and 
deviations from the normal in the rate of urea excretion are measured directly in terms of 
the ideal normal. Ambard has shown experimentally that the rate of excretion of urea 
under otherwise constant conditions varies directly with the amount of functionating kidney 
tissue. In observations in human subjects it is not possible to keep conditions constant, 
but it is possible, by an application of Ambard's laws, to measure the influence of their 
variations on the rate of excretion of urea. The ideal normal rate of excretion, under the 
conditions found, at any time, is given a value of ioo. The index then expresses, in direct 
percentage, the rate of excretion found, in terms of the rate of excretion that a normal 
individual would develop under the same conditions as to concentration in the blood, con- 
centration in the urine, and body weight. 

"The index is therefore not a substitution of a new formula, with a new scale of arbitrary 
values, in place of the Ambard formula, but is a direct measure of an important excretory 
function. 

"Since, as we have shown, Ambard's coefficient is not in itself a direct indication of the 
state of the function which has to do with the excretion of urea, but is merely the ratio 
between the concentration of urea in the blood and the rate of its excretion, the index 
expresses facts which can be obtained from Ambard's coefficient only by further calculation. 

"Ambard's laws depend on the constant relationship of four variables: (i) the concen- 
tration of urea in the blood; (2) the concentration of urea in the urine; (3) the rate of urinary 
excretion, which together with (2) gives us the rate of urea excretion, and (4) the weight 
of the individual. We have indicated this constant relationship in our present formula as 
follows : 

Rate of urea excretion •%/ Concentration in urine X Constant 



Index of excretion 



Weight of individual X (Blood urea) 2 



"In order to give the index a constant value of 100 for the ideal normal, and in order to 
determine the numerical value for the constant, certain arbitrary methods of expression of 
the various factors must be adopted. We have adopted the same methods as those used 
by Ambard, that is, the expression of rate of urea excretion as grams per twenty-four hours, 
the concentration in the blood and urine as grams per liter, and the weight of the individual 
in kilograms. Urea, and not urea nitrogen, is used throughout. It should be distinctly 
understood that other methods of expression of the various factors would not change their 
constant relationship, or the index, but would change merely the numerical value of the 
constant of the formula. When variables which give an Ambard's coefficient of 0.080, the 
figure chosen as the ideal normal, are substituted in the formula, the constant must have 
a value of 8.96 to give an index of 100. The mathematical derivation of the new formula 
js discussed in detail in our previous papers. It reads: 

T A t TT T7 f m D VCX 8.96 

Index of Urea Excretion (I) = — „., w ., „ — 

Wt X Ur 2 

D = grams urea excreted per 24 hours. 

C = grams urea per liter urine. 

Ur = grams urea per liter blood. 

, Wt = body weight of individual, in kilograms. 

"The rate of excretion is not actually determined for twenty-four hours, but for a 
shorter period, usually seventy-two minutes (one-twentieth of twenty-four hours), the 
calculation being made on a basis of grams per twenty-four hours. It is important to 
remember that it is not the actual twenty-four hour excretion of urea that is essential, but the 
rate of excretion at the time of observation. 



206 



MEDICAL DIAGNOSIS 



"Substitution in the foregoing formula of values obtained by observation in normal 
individuals should give values for the index approximating ioo. The actual variations in 
Ambard's laws in normal individuals are magnified by this formula, the variability appear- 
ing to be much greater than when the same results are expressed in the form of Ambard's 
coefficient. When observations are made under the proper conditions, values for the 
index of jess than 80, corresponding to an Ambard's coefficient of 
0.090, should never be obtained in normal individuals, and no 
normal subject should be repeatedly below 100. Values above 
100 are the rule, and values up to 180 and 200 may occur. Much 
higher values may be obtained under certain pathologic condi- 
tions, associated with an increase in the rate of urea excretion. It 
is perhaps unfortunate that such apparently wide divergence 
occurs among normal persons, and in the same normal individual. 
This is a result of expressing the laws in this form, and it does not 
affect the value of the index as a measure of abnormal variations. 



=:E° 



I 



I ri o 



Example : 

Grams urea excreted per 24 hours, D = 20.0 
Grams urea per liter of urine, C = 11.0 

Grams urea per liter of blood, Vr = 0.330 

Body weight, in kilos, Wt = 55.0 

_ D VCX 8.96 _ 20.0 VITo X 8.96 
Index- mxUr2 ~ 55.0XC0.330) 2 

1. 55.0 on Wt scale is set opposite 20.0 on D scale, first position. 

2. Hair line on runner is moved to 11.0 on C scale, second 
position. 

3. Slide is moved so that 3.30 on TJr scale is at hair line on 
runner, third position. 

Reading is now made at the arrow which points to scale I and 
is at 100. Therefore Index, / = 100. 

"Methods j or Observation. — Observations can be made at any 
time, without regard to diet, since application of the laws is inde- 
pendent of the nitrogen intake. It is preferable, though not 
essential, that the observation should not be made too close to 
the taking of food, since the most rapid changes in the various 
factors occur during the height of digestion and absorption. Since 
observations require neither the introduction of a foreign substance, 
nor the ingestion of weighed amounts of food, they may be made 
without regard to vomiting, coma or delirium, and interfere in no 
way with any plan of treatment that is being carried out. Fre- 
quent observations may thus be made without the necessity of 
interrupting a dietetic treatment with test meals. 

"The essential points in an observation are (1) the collection 

I of urine over a carefully timed period, (2) the collection of blood 
near the middle of that period, and (3) accurate determination of 
the urea content of the samples of blood and urine. 

"Our usual routine is as follows: The patient is given from 150 to 200 c.c. of water, in 
order to insure a free flow of urine. One-half hour later, in order to start with the bladder 

{ empty, he voids. The patient is catheterized if necessary, as in urine retention or in the 
case of coma. The time of voiding is recorded to within one minute. About thirty-six 
minutes later, from 7 to 10 c.c. of blood are withdrawn from an arm vein into a dry tube 
containing a few milligrams of potassium oxalate or citrate to prevent clotting. At the 
end of seventy-two minutes from the first voiding the bladder is again emptied, and the 
urine carefully measured to within 1 c.c. and used for analysis. The patient takes no food 
or water during this period. Otherwise no restrictions are placed on him. 




THE EXAMINATION OF THE URINE 



207 



"The seventy-two minute period is merely for convenience, as being one twentieth of 
twenty-four hours. Any other period, preferably not too long, will serve. Ambard pre- 
ferred a period of thirty-six minutes, but the possibility of error in the collection of the speci- 
men is doubled when the time is halved. If it is desired to carry out a simultaneous phenol- 
sulphonephthalein test, the sixty minute or two hour phthalein period may be used, half 
of the urine being used for the phenolsulphonephthalein reading, and the other half for the 
analyses. 

"Analyses should be made by the most accurate, convenient and rapid method avail- 
able for determination of urea in the blood and urine. The method requires more than the 
usual degree of accuracy in clinical laboratories, as a relatively slight error in analysis may 
introduce a considerable error into the formula. The urease method, introduced by Mar- 
shall, fulfils all of the requirements. This method depends on the breaking down of urea 
into ammonia and carbon dioxid by the specific enzyme found in the soy bean, and the sub- 
sequent determination of the ammonia. We have used the permanent preparation of 
urease described by Van Slyke and Cullen,* and carry out the determinations in the manner 
which they prescribe. With careful technic and control of the reagents, this method gives 
consistently accurate results. It is very simple, very rapid, and requires the minimum of 
manipulation. Three analyses are necessary; blood urea, urine urea and urine ammonia. 
Urine ammonia is determined in order to correct the urea figure for preformed ammonia, 
which is also determined in the urea method. Duplicate determinations on blood are ad- 
visable, as a higher degree of accuracy is thus obtained. The determinations are run 
simultaneously in the same apparatus, and require little attention. 

Table I. — Illustration of Independence of Index and Nitrogen Intake! 








°™» nitrogen in 24 hr. S'SZS&t' 









Output 


c ! S3.S 

— ' « m ki 1 h ffl , 


"0 


1-1 3\2 




Date, 

Weigi 
Intak 




O 

■»-> 

w 


"3 






Nov. 5 65.0 19.2 16. 1 

Nov. 12 ; 64.8 1 9.6 ; 7.92 

Nov. 16 64.8 j 9.6 i 6.6 

Nov. 30 65.4 4.8 3.48 


3.15 

1. 61 

2.92 
1-3/ 


19.25 
9-53 
9-52 
4.85 


-0.05 
+0.07 
+0.08 
-0.05 


0.858 9-87 
0.499 jio.68 

0.41 1 7,06 
0.211 4.37 


37-5 | 22.0 

12.8 23.2 

1 1 . j 24.0 

3-32| 21.4 


1 


"Calculation 
form in which t 
without clothing 
stituted in the f 
by the use of a s] 
is a modified 10- 
matical principle 
comes purely me 
culation is most < 

* Van Slyke, 
use in the Detei 
A. M. A., May 
Slyke and Culle 
with directions f 

t Case 1.— C 
stitial nephritis. 

% The rule, wi 
Fulton Street, N 
described in pre\ 


of the 1 
bey are 
, shoul 
ormula 
serial c 
men sli( 
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easily p 

D.D., 
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A. P., 

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Index — 
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and t 
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1, and r 
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and Cu 
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I. P- 15 
e Arlin 

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:tions f 
k. Th 
pers. 


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express 
own to 
ae inde 
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Vith a 
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lien, G. 
Jrea, J< 
58. Ui 
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xmds.t 
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ed accor 
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general ai 

ed from 
or calcul 


lations are cal 
le w r eight of t 
The four vari 
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53. With this 
r the formula r 
g the scales, c 
Without this 
or by the aid 

paration of U 
, xix, 211; id. 
ding to the m 
mkers, NY., 

•teriosclerosis, 

Keuffel and ] 
ation of the cl 


culated to the 
he individual, 
ables are sub- 
ndered simple 
device, which 
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of logarithms. 

rease and Its 
, The Journal 
ethod of Van 
and furnished 

chronic inter- 

^sser Co., 127 
ilorid formula 





208 



MEDICAL DIAGNOSIS 



"Application of the Index. — Numerous studies have been made, or are in progress, 
using the index as a measure of urea function. It is not the purpose of this paper to present 
cases or conclusions, but certain points regarding the applicability and value of the index 
are illustrated. 

"Table I illustrates the fact that the index is independent of nitrogen intake. It also 
shows clearly that the actual blood urea figure may be very misleading, if taken by itself, 
as an indication of the ability of the kidneys to excrete nitrogen. In the case illustrated, 
reduction of nitrogen intake was followed by a corresponding decrease in nitrogen elimina- 
tion, the patient coming rapidly to equilibrium. The balance between intake and output 
was maintained at a lower level of urea in the blood, the index remaining constant. Had 
the blood urea alone been determined at the lowest level, which is lower than the usual 
normal, one could not have said that there was evidence of impaired renal function. By 
application of the index, the actual ability of the kidney to excrete urea is seen to be the same at 
the lowest level in the blood as at the highest. 

"This case also throws light on the mechanism of so-called nitrogen retention. One 
can easily see that the increased level of urea in the blood on the higher nitrogen intake is 
purely compensatory, and is not due to a lack of ability on the part of the kidney to excrete 
the larger amounts of urea being formed in the body. The kidney actually does excrete 
the larger .amounts of urea just as well as the smaller amounts, but it requires a higher concen- 
tration of urea in the blood to bring this about. To speak of nitrogen retention on the basis 
of increased concentration of non-protein nitrogen in the blood is therefore apt to be mis- 
leading. 

Table II. — Illustration of the Comparison between the Urea Index and Percent- 
age of Phenolsulphonephthalein. Excreted in Two Hours 



Subject 



Diagnosis 



Blood urea, 

grams 

per liter 



Urea index 



Phenolsulpho- 
nephthalein, 
per cent, in 
two hours 



2 
3 
4 
5 
4 
4 
6 

4 
7 
8 

7 
7 
8 

4 

9 

io 

ii 

ii 

12 

4 

4 

13 

14 

ii 



Mitral stenosis 

Parenchymatous nephritis 

Mitral stenosis 

Acute nephritis (convalescent) , 

Heart block 

Acute nephritis (convalescent) . 
Acute nephritis (convalescent) . 

Chronic nephritis 

Acute nephritis (convalescent) . 

Chronic nephritis 

Chronic nephritis 

Chronic nephritis 

Chronic nephritis 

Chronic nephritis 

Acute nephritis (convalescent) . 
Mercuric chlorid poisoning 

Chronic nephritis 

Chronic nephritis 

Chronic nephritis 

Chronic nephritis 

Acute nephritis 

Acute nephritis 

Chronic nephritis 

Chronic nephritis 

Uremia „ 



0.132 
0.216 
0.196 

0-383 
0.480 

o-395 
0.317 
0.388 
0.406 
0.446 
o.437 
Q-454 
0.546 
o .400 
0.634 
0.610 
0.488 
0.977 
1. 016 
1.850 
1.320 
0.966 
I. no 

2.147 
3-430 



250.0 

139.0 

105.0 

92.0 

91.0 

89:0 

68.0 

60.0 

56.0 
52.0 

47 .0 

44.0 

39 -o 

37-o 

33-o 

19.0 

18.0 

8.1 

7.9 

7-4 

7.0 

6.1 

4.2 

1.0 

0.27 



S3 
66 

65 
46 

58 

5i 

4i 

45 

34 

41 

38 

33o 

42.0 

27.0 

25 

15 

25 

8 

8 



13 

2-5 
Trace 

0.0 



THE EXAMINATION OF THE URINE 209 



"Relation to Phenol sul phone phthalein Output. — Numerous simultaneous observations 
on urea and phenolsulphonephthalein elimination make it appear that the mechanism is 
the same in the two instances. The curves of the percentage of phenolsulphonephthalein 
excreted in two hours, and of the urea index are parallel and are quite striking. No con- 
siderable divergence has been found in any case, with the exception of some patients 
suffering from heart failure. These subjects were not excreting enough water to carry off 
the urea formed in the body, but were able to eliminate phenolsulphonephthalein fairly 
well. In Table II are given figures comparing the results by the two methods. These 
observations were all in individuals who were excreting water at a rate sufficient to eliminate 
all the urea being formed in the body. They were either simultaneous observations on 
phenolsulphonephthalein and urea elimination, or the two observations were made within 
a short time of each other. 

"These figures are in close agreement with those of a similar study published by Widal, 
Weill and Vallery-Radot, their figures for urea excretion being recalculated in the form of 
the index of urea excretion. Both studies show a remarkably close parallelism between the 
index and the percentage of phenolsulphonephthalein excreted in two hours. In the cases 
with normal or increased excretion of both urea and phenolsulphonephthalein the figures for 
the index are naturally higher, since the ideal normal index is 100, and higher figures are 
attained in persons with increased excretion, while the normal phenolsulphonephthalein 
excretion is about 60 per cent, in two hours, and 100 per cent, can be approached by individ- 
uals with increased excretion, but not exceeded. In the lower figures the two tests show 
in practically every instance the same diminution in rate of excretion of urea and of phenol- 
sulphonephthalein. Both show the failure of the blood urea figure alone to indicate the 
degree of disturbance in urea elimination, since many cases show blood urea figures below 
the upper limits in normals, though both the index and phenolsulphonephthalein figures 
are low. 

"These findings confirm the value of the use of phenolsulphonephthalein as a clinical test 
of the ability of the kidneys to excrete substances belonging in the same class with urea. 
While a rational basis for the use of phenolsulphonephthalein is thus given, certain factors 
make the direct determination of urea function of still more value than the phenolsulpho- 
nephthalein. In the first place, it is a direct determination of a normal function, of which 
the phenolsulphonephthalein test is an indirect determination. Interpretation of possible 
discrepancies between the two methods must recognize this fact. For study of the effects 
of treatment in a given case, the index is certainly the more delicate indicator, and the line 
of demarcation between normal and abnormal cases is sharper than in the case of phenol- 
sulphonephthalein. The index has an added advantage in that, as it tends to approach 
zero, smaller differences are of greater import, and are more easily determined than in the 
case of phenolsulphonephthalein. Thus the difference between 3 and 6 per cent, phenol- 
sulphonephthalein excreted in two hours is difficult to determine colorimetrically, while it 
is a very considerable difference in the case of the index. From the standpoint of deter- 
mining whether the condition is stationary or progressive, the index is therefore much 
more delicate than determination of the small amounts of phenolsulphonephthalein excreted 
in cases with advanced impairment of function. 

"In addition to the index itself, the analyses necessary in determining it are of direct 
value. We have learned to attach a certain amount of import to the blood urea figure 
alone. The index, therefore, adds enormously to the value of an already recognized 
method, with the addition of practically no technical details. The determination of urea in 
the urine, the only laboratory work required in addition to the blood urea, demands only 
a moment's extra time. 

"Neither the phenolsulphonephthalein nor the index, in itself, furnishes positive 
information as to the cause of the impairment of function. Indirect information is, 
however, furnished by the determinations made in arriving at the index. A low index, 
associated with a diminished excretion of urine, with a high urea content, suggests 
passive congestion of the kidneys. The same index, occurring with the excretion of 
normal or increased amounts of urine, with a low urea content, may be characteristic of 
14 



2IO MEDICAL DIAGNOSIS 



certain forms of nephritis. Thus additional information is obtained in the determination 
of the index. 

"For the present we prefer to study cases of nephritis with both the index and the phenol- 
sulphonephthalein test. Each serves as a check on the other, and the maximum of informa- 
tion is obtained in the simplest way possible. 

u Practical Value of the Method. — Applicability of the method as a guide to diagnosis, 
prognosis and treatment will depend on further clinical reports, but certain facts have 
become evident: 

"An index below 80 is to be considered as abnormal, though not necessarily seriously so. 
In renal disease an index below 50 is indicative of a considerable degree of impairment of 
functional ability. The amount of damage to the kidneys, it is believed, is increasingly 
greater as the index is lower, and tends to approach zero. But a low index may be only 
temporary, as in the passive congestion of heart failure or in acute nephritis, and may return 
to normal on improvement of the condition which is responsible for impaired function. 
The actual figure obtained for the index should be of value in prognosis in renal disease, 
though renal function alone is often not the determining factor in prognosis. In our ex- 
perience a low index has at times been the first indication of a serious kidney involvement. 
When the condition is stationary, life may be maintained for some time with a low index. 
For example, we have seen patients with chronic nephritis survive for several months 
with an index of from 5 to 8, and we have seen recovery from acute nephritis after a number 
of weeks, during which time we have obtained the same figures. In another instance, the 
patient survived for about a month after the index was as low as 1.2. Such figures, in 
chronic disease, certainly determine a grave prognosis. But, unless the condition is known 
to be progressive, it is difficult to give a prognosis with regard to the duration of life. Other 
aspects of the disease must, of course, be considered in attempting a prognosis. 

"Progressive decrease in the index, usually associated with a corresponding increase in 
the concentration of urea in the blood, is of serious import. Two cases have recently been 
under observation in which such a fall in the index was followed by death within a short 
time. In one case the fall in the index was the first indication of impending uremia, al- 
though the first symptoms did not occur until ten days after the discovery of a change in 
the index. 

"Use of the index as a guide to dietetic or other treatment of nephritis must depend 
on further studies. It is doubtful whether the diminished urea content of the blood which 
follows a diminished nitrogen intake has any direct beneficial effect. Whether a long- 
continued rest of the urea function will improve that function remains to be demonstrated. 
On general principles, an impaired function should not be overtaxed, and a restricted 
protein intake should be advised in cases with a markedly lowered index of excretion. 
But brutal restriction of nitrogen intake to below the nitrogen requirement of the body 
does not seem to be indicated in cases capable of excreting normal amounts of urea, though 
the blood nitrogen may be high and the index low. 

"The influence of diuretic drugs also requires further study. Here the findings will 
depend on the type of case studied, and it is necessary to have a satisfactory method for 
grouping them. Study of diuretic drugs, involving also their effect on chlorid function, 
is in progress. 

11 Application of the index is seriously interfered with when water excretion is greatly 
diminished, as in passive congestion or in some forms of nephritis. The laws of urea 
excretion depend on a sufficiently rapid rate of urine excretion, and they fail to apply 
when the water output is greatly diminished. We make it a general rule not to attempt 
to apply the index when a rate of urinary outflow equal to at least 500 c.c. in twenty- 
four hours cannot be attained. Otherwise there are practically no limitations as to its 
applicability." 

URIC ACLD (0.2 to 1.0 grams daily). — This is a body of that "purin 
group" which also includes guanin, adenin, xanthin and hypoxanthin, and 
the methyl xanthins of tea and coffee, caffein, theophyllin and theobromin. 



THE EXAMINATION OF THE URINE 



211 



Purin-poor, 



Cayenne- 
pepper 
sediment. 



Exogenous pur ins arc those derived from ingested foodstuffs, especially such 
as are rich in nuclein. Such are thymus gland (sweetbreads), liver, spleen, 
pancreas, brain, kidney, and the roe of fish. 

Endogenous pur ins are products of the cell metabolism within the body. 

^ Nuclein or nucleo-protcin is the basis for all the purin bodies of the urine, 
90 per cent, of the total being uric acid. 
A purin-rich diet greatly increases the output of exogenous uric acid. 
A diet of milk, cheese, eggs, fat and vegetables keeps the purin bodies at 
a minimum though no adequate dietary can be wholly free from nuclein. 

Uric Acid Sediment.- — As a sediment, uric acid is easily recognized by 
microscopic examination or by the deposit of a macroscopic substance resembling 
cayenne pepper. 

The urinary conditions favoring a uric acid deposit are: (a) Concentrated 
urine, (b) High acidity, (c) Deficiency of salts and pigment, (d) Excess of 
the uric acid. 

The amount of uric acid in centigrams, contained in each liter of the given 
urine, may be roughly approximated by multiplying the last two numbers of ; Rough 
the specific gravity by 2, but as a matter of fact, neither the ratio of uric acid 
to urea nor to total nitrogen is constant. Any sediment may be tested for 
uric acid by heating with a drop of dilute nitric acid upon a porcelain plate. 
Upon evaporation a reddish residue appears which strikes a beautiful deep red 
with dilute ammonia. 

Quantitative Test. — There is no accurate simple test and the complicated 
exact tests (Hopkins- Worner, etc.) are not adapted to the practitioner's 
use in view of the slight clinical value of the procedure. But one approxi- 
mate method will be given and it, like other quantitative tests, must be 
applied to a portion of the twenty-four hours' urine to show an actual excess 
of uric acid. 

Heintz's Test. — To 200 c.c. of clear urine add 10 c.c. of C. P. HC1 and 
mix thoroughly. After twenty-four hours filter through a dry filter-paper 
of known weight. Dry and reweigh. The difference in weights represents 
the amount of uric acid in each 200 c.c. of urine. 

Clinical Importance. — The uric acid sediment is not a clinical index of 
uric acid excretion, and an actual excess of uric acid is much oftener due to a 
diet rich in nuclein than to other causes. 

In chronic gout there is a diminished excretion of both exogenous and 
endogenous purins tending to produce an accumulation of these bodies in 
the blood, and during, and for several days preceding, an acute attack a more 
or less decided retention of the latter group occurs.* 

During an acute attack the excretion rises rapidly only to fall far below 
normal a few days later. 

In leukemia the amount of the daily uric acid excretion may be treble the 
normal and u uric acid showers" may at intervals replace sugar in certain cases 
of diabetes. 

* Brugsch and Schittenhelm have found uric acid in the blood of gouty subjects even 
when the diet was purin-free. 



Rich in purins. 



Chronic gout. 



Acute gout. 



212 



MEDICAL DIAGNOSIS 



Old theories 
upset. 



Ferment 
deficiency. 



Lithemia. — Certain cases of so-called "lithemia" behave like and probably 
represent irregular gout, but most of the cases so named are examples of faulty 
diet or mere chronic indigestion* 

Nevertheless, the recent work upon the physiological chemistry of gout 
gives to uric acid a renewed importance and indicates that such a condition 
as the "uric acid diathesis" apart from frank clinical gout may deserve 
consideration. 

On the other hand, it has left us once more in the dark as to the causes of 
uric acid deposits in the joints of gouty subjects inasmuch as late researches 
show that in gout the blood is neither saturated with uric acid nor does it 
lose its alkalinity and thus throw this substance out of solution. 

It would seem that in certain individuals the transformation of purin 
bases into uric acid and the oxidation of uric acid itself are alike deficient. 

Gout and its congeners would seem, therefore, to represent an acquired or 
congenital ferment insufficiency combined perhaps with a tendency to diminished 
renal permeability for uric acid especially marked in certain chronic arthritic 
cases. 

The true cause of gout remains obscure. The presence of an uric acid excess 
in itself is certainly not the determining factor. 

URINARY CHLORIDES (10 to 15 grams daily,, usual proportion to urea 
is as 1 : 2). 

Rough Test. — Filter the urine if it be not perfectly clear; remove albumin 
by boiling if necessary (a trace does not matter). Prepare a solution of 
silver nitrate and distilled water (silver, 1 part; distilled water, 8 parts) 
Add this, drop by drop, to a portion of the suspected urine, which has been 
treated with a few drops of nitric acid. 

A curdy precipitate indicates normal chlorides. Milky turbidity or simple 
cloudiness shows a marked reduction of the chlorides. Xo precipitate indicates 
absence of chlorides. 

A simple quantitative test may be used if desired, its errors being so 
slight as not to affect its clinical value. 

Mohr's Test. — 10 c.c. of urine freed from albumin is diluted with 100 c.c. 
of water, a few drops of potassium chromate solution added (enough to pro- 
duce a yellow color) and the whole placed in a porcelain capsule. This is then 
titrated with a standard silver nitrate solution (AgN03 C. P. 29.06 grams to 
the liter), 1 c.c. of which should precipitate 1 eg. of sodium chloride; a perma- 
nent and diffused orange color ends the titration and multiplying the number 
of cubic centimeters used by 0.01 gives the amount of chlorides present in 
10 c.c. of urine. 

The Centrifugal Estimation. — Purdy's method is simple and clinically 
sufficient. 

'test. — Fill one of the graduated tubes with urine to the 10 c.c. mark, add 



* It is but a few years since "lithemia" was as common a diagnosis as "heart failure," 
"liver trouble" and the like. 

It was not only a convenient cloak for ignorance but highly popular with patients be- 
cause of its kinship with that most aristocratic of ailments, "gout." 



THE EXAMINATION OF THE URINE 



213 



15 drops of nitric acid to prevent precipitation of the phosphates (more if 
the specific gravity be high), add (1 to 8) nitrate of silver solution, mix thor- 
oughly, and centrifugalize at high speed for fifteen minutes; normal bulk 
percentage reading is from 10 to 12 and each division represents 0.123 by 
weight. 

Clinical Application. — The outpouring of either a serous or fibrinous exudate of 
slight importance in acute disease may be associated with a marked diminution or 
total absence of the urinary chlorides. The reappearance of the lost chlorides is one 
of the clinical evidences of resolution in pneumonia or of the reabsorption of an 
exudate or transudate. 

The absence or marked diminution of chlorides in lobar pneumonia is j 
not pathognomonic of that condition even in the absence of meningitis or j 
effusions into the great lymph spaces, inasmuch as the same diminution may 
occur in many other sthenic fevers though usually to a lesser degree. 

Their estimation is sometimes of slight value in making a differential 
diagnosis between meningitis and typhoid fever,* they being markedly 
reduced in the former, and little affected in the latter disease. They are also 
greatly reduced in acute rheumatism and their sudden entire disappearance 
without an extension of the joint involvement suggests pericarditis with 
effusion. 

In normal individuals a rapid increase of body weight follows the ingestion 
and retention of the chlorides in quantity and a reduction of weight follows 
if the substance be withdrawn. 

Chloride excretion is more or less decidedly diminished in various types 
of renal disease, in most wasting diseases, in starvation or a milk diet, 
in cancer of the stomach with obstruction, in severe vomiting and in 
diarrhea. 

Relation to Edema and Albuminuria. — It is now believed that the albumin- 
uria and edema of Bright' 's disease is in some measure due to the retention of 
chlorides in the tissues. 

Water retention is favored by the chemical combinations formed by 
the chlorides, the relative impermeability of the kidney and a poor circulation, 
hence it is urged that in both incompensated heart disease and nephritis the 
amount of sodium chloride ingested should be reduced to a minimum if edema 
is present. The author believes this to be good advice with respect to per- 
sistent edema of the renal or cardiorenal type but would not advise or prac- 
tice it as a routine procedure or continue it radically over long^periods. 

THE PHOSPHATES (normal excretion 2.5 to 3 grams).— Urinary 
phosphoric acid is met with largely in combination with potassium, sodium, 
and ammonium (%), to a less extent with calcium and magnesium. It is 
derived to some extent from tissue and food nucleins and is increased under a 
vegetable diet or a rich proteid intake. 

The term " phosphaturia" is probably a misnomer representing merely a 
condition of reduced urinary acidity which leads to the constant or almost 
constant presence of the phosphates as a precipitate. It is met with chiefly 

* E. S. Wood. 



Of slight 
importance. 



Lobar 
pneumonia. 

Meningitis. 



Acute 
rheumatism. 



Weight loss 
or gain. 



Renal disease. 



Phosphaturia. 



214 



MEDICAL DIAGNOSIS 



Two varieties. 



Clinical 
value slight. 



Of slight 
importance 

clinically. 



in cases of asthenia or temporarily in nervous overstrain, and may accompany 
hyperchlorhydria. 

A marked increase occurs in severe anemias, leukemia and wasting diseases 
in general. 

A marked decrease is observed in most febrile diseases, with high tem- 
perature, acute and chronic rheumatism, acute yellow atrophy of the liver, 
lead or copper poisoning, Addison's disease and hysteria. 

Phosphates are readily recognized by the methods mentioned elsewhere 
and their quantitative determination is of too little importance to be de- 
scribed here. It should be remembered that a phosphatic sediment occurs 
frequently in normal individuals and many u phosphaturias" are little more 
than the result of morbid introspection and too careful attention to the 
appearance of the excreted urine. In ammoniacal urines both the fixed and 
the volatile alkali combine to form the characteristic crystals so frequently 
found in the precipitate. 

THE SULPHATES (normal excretion 1.5 to 3 grams) .—These exist 
either as preformed or as ethereal or conjugate sulphates. The former run 
nearly parallel with urea, while the latter follow indoxyl so closely as to 
justify but slight attention here. These latter are, however, increased by the 
ingestion of drugs such as creosol or phenol and phosphorus and occasionally 
without an indoxyl excess. 

THE OXALATES. — "Oxaluria" is another condition which modem in- 
vestigation has shelved. 

The diagnosis was based chiefly upon the presence of calcium oxalate 
crystals in quantity in the urinary sediment. These occur usually as a result 
of gastro-intestinal disturbances to which the symptoms formerly attributed 
to them are more properly ascribed. The relation of the crystals to the for- 
mation of calculi and their suggestion of disturbed metabolism are the only 
clinical features of importance. 

Dunlop has shown that their presence indicates about 25 mg. of oxalic 
acid to 1000 ex. of urine, but this amount does not exceed the maximum 
normal. Very frequently they are associated with an increase of indoxyl 
and sometimes with increased ethereal sulphates without increase of 
indoxyl. 

IRON. — This exists in the urine to the amount of 1 mg. but its estimation 
has no clinical value. 

AMMONIA (normal 0.6 to 1.2). — The ratio of nitrogen derived from 
urinary ammonia to total nitrogen is about 5 to 100 and the variation of the 
two substances under dietetic influence is almost parallel. 

In cirrhosis of the liver ammonia is usually increased as also in hyper- 
chlorhydria, pyloric stenosis and acute gastro-enteritis. It is diminished 
slightly upon a vegetable diet and the administration of fat not only increases 
it, but causes a corresponding but later increase in the urinary acetone, and 
such urine may show beta-oxybutyric and diacetic acids. The methods of 
estimation are too complicated and time-consuming and the results too at- 
tenuated to be of clinical use and they are therefore omitted. 



THE EXAMINATION OF THE URINE 



21 



ALBUMINURIA 

Albumin in Normal Urine. — Normal urine does not contain a sufficient 
amount of serum-albumin to respond to certain approved clinical tests if these 
are properly made; therefore a reaction under such conditions is pathologic. 

Temporary albuminuria due to exposure to extreme cold, to excessive 
exertion, profound fatigue and other like causes doubtless occurs, especially 
in individuals of the asthenic type. 

Such urines are not normal but temporarily abnormal. 

Derived Albumin. — On the other hand, the presence of albumin does not of 
itself prove a nephritis, as both pus and blood yield a portion of their albumin 
to the urine and any hemorrhagic or suppurative lesion within or communicating 
with the urinary tract may cause albuminuria. 

Occasional Absence in Nephritis. — The absence of albumin in a given 
specimen does not exclude chronic interstitial nephritis, as in that disease the 
urine may be albumin-free for long periods, appear only at certain times of the 
day or occur only in definite relation to some exertion, mental or physical, or a 
dietetic indiscretion. 

The mere detection of albumin is but a part of the diagnosis, the arterial 
tension, tests of renal permeability, and recourse to the microscope playing the 
larger part. 

One of the commonest sources of error arises from contamination of the 
specimen by leucorrheal discharge or the pus and blood of urethritis, less 
commonly from fistulous openings draining abscesses of the surrounding 
structures. 

Varieties. — The term "albumin" means in its clinical sense, serum-albumin 
usually associated with serum globulin, which acts the same, has essentially 
the same significance and need not be separately sought. 

NUCLEO -ALBUMIN. — This substance frequently obscures some of the 
more delicate tests. It is increased after overexertion, in actual inflammation 
of the urinary tract, especially in purulent accumulations, in leukemia, jaun- 
dice and in acute infections with marked toxemia. 

Test. — Nucleo-albumin is readily detected by diluting the urine with three 
times its bulk of water, rendering it strongly acid with acetic acid and setting 
it aside until the substance forms a cloud. It may produce confusion if the 
physician is satisfied with the heat test for albumin and fails to use the acid 
layer test as well. In the latter the nucleo-albumin ring lies well above (i 
cm.) the zone of contact. 

ALBUMOSES. — These, chiefly the secondary (deutero-albumoses), appear 
in the urine and have some clinical importance because of their association 
with suppurative processes outside the urinary tract. Their presence, for 
example, in a pleurisy would suggest empyema; in meningitis, a septic rather 
than a tuberculous process; in a severe intestinal lesion, dysentery or typhoid 
rather than tuberculous ulceration; in hepatic disease, abscess or suppurative 
cholecystitis; in tumors, malignant ulceration. 

Combined with a leucocytosis, albumosuria speaks positively for infection 



Transient 
Albuminurias 



"Accidental 
albuminuria. 



Misleading 
findings. 



Vital factors. 



A clinical 
nuisance 



Septic 
processes. 



2l6 



MEDICAL DIAGNOSIS 



Practical value 
of test. 



Osteomalacia 
and myeloma. 



Altered renal 
or glomerular 
epithelium. 



Multitude of 

etiologic 

factors. 



I by a pyogenic organism or the actual presence of a purulent accumulation or 
focus. 

Albumose appears, however, in many non-septic conditions both febrile 
and afebrile. 

Test. — Secondary albumoses are precipitated by acetic acid saturated 
with sodium chloride or the biuret reaction may be obtained as follows: Re- 
move all albumin by treating the urine with sodium acetate and then with 
ferric chloride until it produces a deep red color, neutralize carefully with 
sodium hydrate, boil and filter. Repeat if a potassium ferrocyanide test ap- 
plied to the fluid shows albumin. Nucleo-albumin and mucin may also need 
to be first removed if present in quantity. This is readily accomplished by 
strongly acidulating with acetic acid and filtering after several hours. 50 
c.c. of albumin-free urine are then acidulated with HC1 (5 c.c.) and phos- 
photungstic acid solution added until no further precipitate is obtained, 
gentle heat is then applied until the precipitate shrinks and collects on the 
bottom of the receptacle. After decanting, the precipitate is repeatedly 
washed, dilute sodium hydrate added and the solution warmed until the deep 
blue becomes a light yellow. After cooling, a dilute solution of copper sul- 
phate is run down the side of the tube or beaker and a rose color indicates 
albumose. Practically all cases of so-called peptonuria are albumosurias and 
their significance is exactly the same. 

THE BENCE-JONES PROTEIN.— A Clinical Curiosity.— This was form- 
erly supposed to be an albumose, but is as yet a doubtful body. It appears 
in cases of osteomalacia and multiple myeloma and constitutes one of the 
clinical curiosities. Its most characteristic feature is its behavior when heat 
is applied to urine containing it. Commencing as an opacity at 5o°C, 
becomes precipitated at about 58°C.,"and increases up to 7o°C. when it begins 
to disappear and at boiling point has returned to its first opalescence. 

The presence of the Bence- Jones protein in the urine indicates, almost 
invariably, multiple myeloma, characterized by pains in the bones, deform- 
ities of those of the trunk and the Bence- Jones protein. 

Without discussing the theories relating to the causation of albuminuria, 
one may say that under certain conditions any or all of the protein bodies found 
in blood plasma may appear in the urine. 

THE SIGNIFICANCE OF ALBUMINURIA.— Osier aptly covered the whole 
field in saying, u the presence of albumin in the urine in any form and under any 
circumstances may be regarded as indicative of changes in the renal or glomerular 
epithelium, a change, however, which may be transient, slight and unimportant, 
depending upon the variations in the circulation or upon irritating substances 
taken with the food, or temporarily present, as in febrile states." 

We know that transient albuminuria may follow emotional disturbances, 
violent exhausting exercise, cold baths, the ingestion of excessive amounts of 
nitrogenous foods or infections of various kinds. 

In young persons it may be irregularly intermittent or occur at definite 
intervals {cyclical), and wholly lack the general and circulatory symptoms 
of Bright's disease. 



THE EXAMINATION OF THE URINE 



217 



Traces of albumin (0.5 to 1 per mille) constitute the "albuminuria 
minima" so frequently discovered in the course of life insurance examina- Cold weather 
tions, especially during severely cold weather. 

Such cases may entirely clear up, but a considerable proportion later become ' 
fully developed cases of chronic nephritis. 

Even the true nephritis albuminurias may be regularly or irregularly inter- 
mittent and often bear a definite relation to the time of day, exercise and meals. A source of 

. . . ... serious 

In most cases of, this kind the first urine passed in the morning is free from al- errors. 
bumin, but thereafter during the day it is present, and' increases as evening 
approaches. 

Muscular fatigue increases it, though regulated moderate exercise fre- 
quently diminishes the albumin output. 

Cases in which it is affected by mere changes of posture are known as 
"orthostatic albuminurias." 

In albuminuric children and young adults a delicate bony framework, 
weak circulation and tendency to vasomotor instability and low arterial 
tension frequently coexist with impaired general nutrition and, in the author's 
opinion, the entire clinical picture most often resembles the asthenia uni- 
versalis congenita of Stiller which carries with it the visceroptotic habitus so 
favorable to circulatory renal disturbance. 

In every case the adequacy of the kidney, as proven by the excretion of 
solids, special tests, the absence of true casts and of secondary vascular 
changes, must be the guide to prognosis, and inquiry as to past infections, 
such as scarlatina and diphtheria, is often illuminating. 

Unrecognized Chronic Infections. — Every physician who has followed the j 
recent investigations relative to chronic infections of the tonsils, accessory nasal 
sinuses, teeth and prostate, or who fully appreciates the frequency of unrecognized Septic foci. 
tuberculosis and lues, must realize the frequency with which an albuminuria 
or an actual nephritis rests upon such an etiologic basis. 

TESTS FOR ALBUMIN.— As a result of an extended series of tests under- 
taken by Dr. P. A. Hoff and the author, covering both normal and abnormal 
urines, he is convinced that for the general practitioner the three best tests 
are: (a) the-heat-and-nitric-acid-procedure; (b) the-heat-test-with-acetic-acid- 
and-brine; and (c) the-nitric- acid-layer-test which is practical and accurate if per- 
formed with care and a proper knowledge of its disturbing factors, and should be 
applied invariably as a check. 

Every other test used in our experiments gave confusing results when it 
became a question of determining the small traces of albumin yielding a haze 
but no definite precipitate. 

In this connection several other tests are mentioned because of their 
general acceptance by physicians, but are not recommended. 

General Considerations. — The essentials of a clinical test for albumin are: 
(1) Simplicity. (2) A reasonable degree of delicacy. (3) Decisiveness. 

Simplicity reduces careless or imperfect work to a minimum; if one exceeds 
a reasonable delicacy he finds disturbing reactions in almost every urine, and, 
finally, a test must be so decisive as to make unnecessary the more complicated 



Three best 
tests. 



218 



MEDICAL DIAGNOSIS 



Mere boiling. 



Nitric acid 
alone. 



Layer test. 



To clear resins. 



Dark 

background 
indispensable. 



Clear 

specimen. 



Avoid urates 
and nucleo- 
albumin. 



Use control 
tube. 



Boil upper 
stratum. 



Add nitric acid 
to 4 minims. 



Stop short. 



An excellent 
method. 



Alternative 
procedure. 



tests for disturbing urinary proteids and permit a positive and convincing 
opinion. 

Faulty Technic. — The-heat-and-nitric-acid test, as usually applied, does 
not fulfill these requirements. 

Merely boiling the urine coagulates both serum-albumin and nucleo- 
albumin, and precipitates the phosphates. 

Nitric acid used alone and diffused through the urine coagulates serum- 
albumin, the primary and secondary albumoses, nucleo-albumin and the 
resins, and, in concentrated urines, precipitates urates if these be present in 
excess. 

The careless application of the layer test (Heller's test) may result in 
the confusion of the low-lying or, rather, junction- point band of albumin 
with the higher stratum of nucleo-albumin or resins, or the albumin ring 
may be obscured in dark-colored urines by the pigment developed at the point 
of contact. 

Clouded Urine. — A failure to thoroughly clear the urine before examination 
is a frequent source of error. 

If ordinary filtration fails, this is best accomplished by the addition of 
magnesium oxide or sawdust, not lead acetate, and passing the urine through 
several thicknesses of filter-paper. Bacterial urine always requires such 
treatment. 

Resins may be present and cause opacity if turpentine, oil of sandalwood, 
copaiba and the like are taken, and bile pigment may precipitate in icteric 
urines, but both disappear on shaking up with alcohol. 

Proper Background. — Another astonishingly frequent and unpardonable 
source of error lies in the failure to Iwld the tube toward the light, but always 
against a background, such as the coat sleeve or a book. 

The Proper Application of the Heat-and-nitric-acid Test. — (a) Clear 
the specimen and set aside a portion of the urine for use as a control and for 
repetitions of the test. 

(b) If the urine be extremely concentrated, dilute it with its own bulk of water, 
if of low specific gravity, add one-fifth its volume of a saturated solution of sodium 
chloride. 

(c) Then fiU two perfectly clean and clear test-tubes two-thirds full of the 
urine and set one aside for subsequent comparison of transparency. 

(d) Boil the upper portion of the liquid in the remaining tube and directly 
after boiling add i or 2 drops of strong nitric acid and 1 or 2 drops more if no 
persistent cloudiness or precipitation appears. Any such persistent cloudiness 
or precipitate is serum albumin. 

Caution. — Do not add acid before boiling nor boil again after the addition 
of the acid. * 

The Nitric Acid Contact Test {Heller's Test). — Place in a conic glass or 
test-tube a dram or two of pure nitric acid, and, using a pipette, allow the urine 
f flow gently down the side of the inclined glass and upon the surface of the acid. 

* The latter procedure especially will often cause the conversion of large amounts of 
albumin into a soluble acid-albumin as is readily proven by any one interested. 



THE EXAMINATION OF THE URINE 



219 



The albumin 
ring. 



Urinary pig- 
ments. 



Nucleo- 
albumin. 



Mucin. 



If the mouth of the pipette be placed against the side of the glass, just 
above the level of the acid, and a very gentle flow established, the result is 
extremely clean-cut and beautiful.* The tube or glass should be set aside, 
as two or three minutes may be required to develop the reaction. 

Albumin, if present, appears as a band or ring at the junction of the two fluids 
and is more or less distinct in proportion to the amount of albumin present. 

Urinary coloring matters appear near the surface of the acid, but usually 
at a point just below the albumin ring, if the test has been properly made. 

If within ten minutes there ap- 
pears another ring resembling albu- 
min, but at a distinctly higher level 
(0.5 to 1 cm.), one may assume it to 
be nucleo-albumin. A relative excess 
of uric acid or acid urates may pro- 
duce an obviously crystalline deposit 
if the specimen be over concentrated Urate ring 
or if the individual from whom the 
urine was received has fever. f 

. Mucin, even if present in excess, 
is usually dissolved promptly and is 
not a disturbing factor. 

The heat-and-nitric-acid and the 
cold-nitric-acid tests as thus applied 
are excellent and quite sufficient for 
ordinary purposes. 

If space permitted, much that is 
of interest might be said of the 
urinary chromogens and pigments. 
If one wishes to bring out certain 
of the coloring matter, the urine should be placed in the glass and a con- 
siderable quantity of the acid poured rather briskly down the side. When 
this is done, the colors are prominently"displayed and the albumin ring, if 
present, is raised to a level that nearly corresponds to that of uric acid and 
acid urates, when the test is applied by the first method. 

Of the two, the heat-and-nitric-acid test is the more definite and positive. 
As too often carried out, they are most misleading and fallible. 

Faulty Older Method. — It will be remembered that this method consisted 
in adding nitric acid, drop by drop, while boiling the urine. 

The following errors may result from such methods: (a) A small amount 



* The use of the " horismascope " (see Fig. 64) yields even better results. 

t According to C. E. Simon, the subsequent appearance of a film-like hoarfrost on the 
sides of the glass indicates that about 25 grams of urea are contained in a liter of the urine 
under examination. Similarly spangles of this urea nitrate point to 45 grams, and the separa- 
tion of a dense mass to 50 or more grams to the liter. It must be remembered that such 
deductions are not of much value unless the specimen be a part of the twenty-four hours, 
urine. 




Fig. 64. 



-Horismascope: adding the reagent. 
(Todd.) 



Robin's 
method. 



Relative value 
of test. 



To be 
shunned. 



220 



MEDICAL DIAGNOSIS 



Soluble acid- 
albumin. 



Soluble 
alkali- 

albuminate. 



Esbach's test. 



of albumin boiled with an excess of acid might form a soluble acid-albumin and 
escape detection* 

(b) In an alkaline or neutral urine with phosphates present in excess, a 
failure to acidify the specimen might result in the disappearance of any albumin 
present through the formation of a soluble alkali- albuminate, and neither acid 
nor alkali albuminates are precipitated by subsequent boiling. 

Furthermore, according to Purdy, mucin, globulin and albumoses are 
precipitated by this method. 

The Potassium Ferrocyanide Test. — Into a clean test-tube pour a dram 
or two of acetic acid (50 per cent)., to this add twice its volume of an aqueous 
solution of potassium ferrocyanide (1-20). Shake the mixture and overlay 
with the suspected urine, as is done in the nitric acid contact test. Albumin, 
if present, appears at once as a band at the junction of the two fluids. 
Albumoses may give a cloudiness, and hence the urine should 
always be heated after the ring is obtained, and its behavior 
noted. The full amount of acetic acid must be added. 

Disadvantages. — It precipitates albumoses and nucleo- 
albumin. 

Robert's test solution (HN0 3 1 part, saturated solution 
of magnesium sulphate, 5 parts) may be used as in Heller's 
test, but is, if anything, too delicate and subject to the same 
elements of error. 

Spiegler's Test. — This is too delicate for clinical work, 
showing one part of albumin in 250,000 of urine containing 
abundant chlorides. 

The trichloracetic acid test can be made by dropping a 
crystal into the urine contained in a small test-tube. It is 
extremely delicate, partially precipitates albumose and, in 
concentrated urines, urates, as a distinct upper ring. These 
three tests may show albumin in all urines, or so nearly all as 
to rob the rinding of a mere trace of albumin of all clinical sig- 
nificance. Nevertheless the author has seldom found a dis- 
tinct ring with trichloracetic acid without confirmatory micro- 
scopic findings. 

QUANTITATIVE TESTS FOR ALBUMIN.— Two simple tests suffice for 
the quantitative estimation of albumin. The first demands the use of Esbach's 
albuminometer ; the second requires a centrifuge. Both tests are extremely 
simple in execution, and as no physician's office is complete without a centri- 
fuge and as the Esbach tube is inexpensive and easily obtained, no hardship 
is involved in their application. Esbach's albuminometer is merely a glass 
tube graduated and lettered as shown above. This tube is filled to the letter 
U with urine, if necessary previously diluted until its specific gravity is 1008 
or lower, and a solution of picric acid (picric acid, 10; crystalline citric acid, 

* The author recently saw a case in which a specimen of urine containing 0.25 per cent, 
of albumin was reported normal after the application of this test in the faulty manner 
described above. 



Fig. 65. 

Esbach's 

albuminometer. 



THE EXAMINATION OF THE URINE 



221 



20; distilled water, 1000) is added until the level of the liquid has reached the 
letter R. A rubber stopper is then inserted, the tube is inverted several 
times to thoroughly mix the urine and test solution, and is then set aside for 
from twenty-four to forty-eight hours. The albumin is precipitated, and 
its height, measured by the numerals upon the scale, represents in grams 
the amount of albumin present in 1 liter (1000 c.c.) of the urine. This 
method is sufficiently accurate for practical purposes (although peptones, mucins, 
etc., if present, are precipitated together with the albumin), but is slow and jar 
inferior to Purdy's direct centrifugal method. 

Centrifugal Method. — Fill the graduated tube supplied with the centrifuge 
to the mark 10 c.c. Add 3 c.c. of a 10 per cent, solution of potassium 
ferrocvanide and 2 c.c. of acetic acid (50 per cent.). Mix thoroughly, set Best clinical 

7-7 'x *7 7 method. 

aside for ten minutes, and thoroughly revolve in the centrifuge until the super- 
natant fluid is clear and the albumin evenly deposited at the bottom of the tube. 
Each mark represents Jro c.c. and corresponds to a bulk measure of 1 per 
cent, or 1 qq of 1 per cent, by weight (Ogden).* The old-fashioned methods 





Fig. 66. — Electric centrifuge. 



Fig. 67. — Purdy's graduated tubes 
for the centrifuge. 



of estimation by boiling the urine in a test-tube, or by judging the amount 
by the depth of the ring produced by the contact test with nitric acid are 
useful, but not sufficiently accurate and introduce too much of the personal 
equation. On the otherhand, the very exact methods of the chemical labora- 
tory are laborious, and demand more time than the busy practitioner can 
give. 

* If urates are present in excess the supernatant fluid may be replaced by boiling water 
after centrifugalization and the process continued a short time longer. 



222 



MEDICAL DIAGNOSIS 



Rough 
estimation. 



Effect of 
reaction. 



Color 
deceptive. 



Small 
quantities. 



A misleading 
color. 



E. S. Wood's Approximation Method. — The following classification for 
rough work is based upon the cold nitric acid test performed as follows: An 
ordinary wine-glass is half filled with urine, inclined until the liquid nearly 
overflows and then underlaid with nitric acid, poured in as slowly as possible, 
until it equals one-third of the urine volume. If then the wineglass be per- 
fectly clean and placed obliquely in front of a dark background, the observer 
facing the light, one distinguishes: 

i. The self-explanatory u faintest possible trace" 

2. A very slight trace, i.e., a. faint cloud definitely seen only against the dark 
background. 

3. A trace, visible without background, both from the side and from above 
but not concealing the bottom of the glass when so viewed. 

4. A large trace, i.e., a sharply defined zone, but not flocculent nor wholly 
opaque when viewed from above (represents about J^o of I P er cent.). 

5. A % of 1 per cent, reaction i.e., a sharp, non-flocculent zone obscuring 
the bottom of the glass. 

6. One-fourth of 1 per cent., band flocculent and opaque. 

7. One-half of 1 per cent., band dense and flocculent.* 

PUS. — Pus in the urine is readily recognized by chemic or microscopic tests. 
As a gross sediment phosphates and the pale urates may mislead the careless 
observer, but should never cause confusion. Urates are dissolved by heating. 
Phosphates disappear if an acid be added, whereas both the foregoing pro- 
cedures will increase a turbidity due to pus. 

Chemic Test. — Add liquor potassce to the suspected urine and shake the 
solution vigorously. The persistence of suspended air bubbles and viscidity 
indicates pus. 

If the amount be very large or if the liquor potassae be added to the 
sediment after decanting the supernatant fluid, a gelatinous mass results. 
T.he microscopic test is more definite when mere traces of pus are present. 
The addition of a drop of very dilute acetic acid solution to a microscopic 
preparation clearly brings out the nuclei of pus cells under the microscope. 

BLOOD {Hematuria, Hemoglobinuria). — In general, acid urines containing 
considerable blood are dark or smoky, and alkaline urines bright red. 

Oftentimes, however, its presence must be detected even though the 
amount is insufficient to color the urine, and, moreover, mere color cannot be 
depended upon in any case. 

For the detection of small quantities of blood the microscopic examination, 
chemical tests and the spectroscope are extremely important, as only the 
coloring matter may be present either primarily, or later as a result of fer- 
mentation changes. The color due to poisoning by coal-tar products closely 
simulates the smoky urine of hematuria. 

Heller's Test for Blood. — (a) Boil the urine in a test-tube, (b) Add 
caustic soda and continue the boiling as long as precipitation continues. 

* It will be seen that such distinctions require much practice and the method can hardly 
be justified at the present day, but from personal experience in the old Harvard laboratory 
the author can attest the accuracy there attained. 



THE EXAMINATION OF THE URINE 



223 



// blood be present, the phosphatic precipitate is brownish-red and the supernatant 
fluid, a bottle-green. This test is said to detect 1 part of blood to 1000 parts 
of urine.* 

The Guaiacum Test for Blood. — Shake in a test-tube equal parts of old 
turpentine (or hydrogen peroxide solution) and fresh tincture of guaiacum. 
Pour this mixture gently down along the side of the tube so as to overlay the 
urine. If blood or pus be present, a blue band appears at the point of junc- 
tion. If this be due solely to blood, it persists when the temperature of the 
mixture is raised to the boiling point, whereas, if pus alone be present, the 
color disappears. As oftentimes both are present in the urine, the reaction 
may lack precision.! 

Comment. — 77 need hardly be said that in all cases of hematuria the micro- 
scopic examination is the usual and proper test. In the rare hemoglo- 
binurias the chemical methods find their place. 

The Sources of Hemorrhage. — Aside from acute Bright's disease, severe 
acute congestion, and the rare cases of so-called " renal epistaxis," the 
commonest sources of blood are urinary calculi and new growths. 

Clots occasionally exist if the blood is from the bladder, or small clots may 
represent the lumen of the ureters. 

Blood from the kidney is usually well distributed and lacks clots, and further 
indications of its source are found in the presence of blood casts and fibrinous 
casts. 

If from the kidney pelvis, the blood cells are thoroughly distributed and 
associated with the peculiar epithelium of that region, and may be due to 
calculi, acute inflammations, or varicosities. Associated leucocytes in 
quantity point to inflammation, whether simple, septic or tuberculous. 

Bladder hemorrhages suggest ulceration, calculi, tumors or acute inflam- 
mation and, rarely, the filaria sanguinis hominis, may be found together with 
a chyluria. 

If from the urethra, the first jet of urine contains the blood or pus, though 
if from the prostatic portion, it may appear chiefly at the end of micturition. 

Accidental blood may occur, especially in the female during menstruation, 
and must always be borne in mind as a possibility. 

In hemoglobinuria or methemoglobinuria the blood cells are scant or absent 
but the spectroscope shows the characteristic bands of oxyhemoglobin, 
reduced hemoglobin or methemoglobin and the chemical tests reveal the true 
condition. 

The washed out, swollen "phantom" blood cells so often encountered 
in old specimens may be overlooked and mislead the novice into a false 
diagnosis of hemoglobinuria. 

Conditions Associated with Hemoglobinuria. — This condition occurs in 
poisoning by nitro-benzol, sulphonal, antipyrin, phenacetine, naphthol, 

* If the urine be primarily alkaline and its phosphates precipitated one may add some 
acid normal urine before testing. 

f If the slightest trace of copper remains from a previously performed Haines' or Feh- 
Hng's test in an imperfectly cleaned tube, a false reaction will appear. 



Blood vs. Pus. 



Renal 
epistaxis. 



Renal blood. 



Pelvic blood. 



"First jet' 
blood. 



Menstrual 
blood. 



"Phantom' 
blood cells. 



224 



MEDICAL DIAGNOSIS 



Simple and 
effective. 



Excellent test. 



mushrooms, in severe tropical malaria, and certain rare cases of syphilis, 
typhus and scarlatina. 

BILE. — Bile acids and bile pigment are both found in the urine under 
certain conditions. Bile pigment, if present in considerable quantity, is 
readily detected by the yellow-tinted foam produced by shaking. 

Test. — The best simple chemic test is made as follows: Filter the suspected 
urine several times through the same filter-paper. Drop fuming nitric acid 
upon the wet paper and watch for the characteristic color-play, viz., orange, 
red, violet, and green, the last being the essential color. 

Rhombic crystals of bilirubin are readily obtained by shaking up thoroughly 
with chloroform, decanting and evaporating the chloroform extract. 

Marechal's Test for Bile Pigment. — Overlay a portion of the suspected 
urine in a test-tube with an alcoholic solution of iodine (tincture iodine, 10 
parts; alcohol, 90 parts). If bile be present, a beautiful green band appears 
at the junction point. 

Haycraft's Test for Bile Acids. — This is made by dropping a pinch of 
"flowers of sulphur" upon the surface of the suspected urine. If the bile 
acids are present the powder drops to the bottom of the tube. 

This old test has been recently studied by Frankel and Cluzet. They 
find it accurate, sensitive, and, as applied to the urine, very definite. The 
reaction depends upon the diminution of surface tension and the presence 
of bile acids indicates the presence of hepatogenous jaundice, though their 
absence does not exclude it. 

TESTS FOR GLUCOSE IN URINE.— All clinical tests for glucose in 
solution depend upon one of the following properties: 

(a) The fact that when glucose is brought into contact with certain oxides, 
as for example, those of copper and bismuth, it becomes oxidized at their expense, 
i.e., acts as a reducing agent. 

(b) Its ready fermentability. 

(c) The fact that it is dextrorotatory. 

The Copper Tests. — The well-known Trommer's test has been superseded 
Relative value. , by better and more accurate methods, but Fehling's solution is so widely used 
still as to require a description of the test. 

This solution is distinctly inferior to Haines 1 modification qnd is so unstable 
that it must be kept in two parts and mixed whenever needed for use. 

Fehling's Test. — Directions: (a) Remove albumin by boiling and subse- 
Test fluid { quent filtration, (b) Pour into a test-tube one finger-breadth each of the follow- 
ing stock solutions, which when mixed should form a deep blue solution. 

. Stock Solutions. — Solution A. — Dissolve 34.64 grams of pure, dry, 
powdered copper sulphate in 200 c.c. of warm distilled water and add distilled 
water to make 500 c.c. of the light blue solution. 

Solution B. — Dissolve in 306 c.c. of hot water 180 grams of Rochelle salt. 
Filter. Add of pure caustic soda, 70 grams. Cool, and add distilled water 
enough to make 500 c.c. of a colorless solution. Keep in a dark place. 

Test— Heat test solution to boiling point, add at once 20 to 30 drops of 
the suspected urine and boil no longer, but in the absence of a reaction set 



THE EXAMINATION <»F THE URINE 






aside for from hve to thirty minutes. A positive reaction proves nothing but 
the presence of a reducing agent unless the ultimate precipitate is red, net yellow 
or green. 

Objections to Fehling's Solution. — Fehling's solution as ordinarily prepared 
is open to : (a) It is unstabh An excess of glucose ob- 

scures the terminal reaction by becoming caramelized if boiling is prolonged. 
(c) 77 cannot be applied directly to ammoniacal urine unless the specimen be 
led. [d) A large number of substances may reduce its cupric 
oxide. 

Such are glycuronic and glycosuric acid, alkapton, creatinin, uric acid, 
and various drugs, such as benzoic acid, chloroform, chloral, glycerin, the 
salicylates, turpentine, etc. 

Hence, if :■>:>: uses Fehling's solution for qualitative work, he must bear in 
mind that it is /.liable as a negative than a positive test. 

A urine that does not reduce Fehling's solution is free from glucose, but 
reduction does not conclusively establish its presence. 

Haines' Solution. — This is a much simpler, more stable and permanent 
copper solution than that of Fehling. 

Formula. — Take of pure copper sulphate 50 grains; of distilled water 1 
ounce. Make a perfect solution and add, of pure glycerine J-9 ounce; mix 
thoroughly and add liquor potassa? 5 ounces. 

Application of Test. — Boil a few cubic centimeters of the solution gently 
in a test-tube, add guttatim 6 to S drops of the urine, boil gently for a moment 
only. The color reaction is identical with that of Fehling's solution. 

All concentrated urines should be diluted before a copf :de. 

This procedure minimizes the risk of misleading reductions due to drugs 
and other substances. 

ALLEN'S TEST.— This is said by Hutchinson and Rainy to have the fol- 
lowing advantages: [a) Albumin need not be removed. b Trie acid, 
creatinin and like substances do not affect the reaction. 

The test derives its value from the fact that acid solutions of sodium 
acetate precipitate the interfering substances without removing or affecting 
any glucose that may be present. 

Test. — In a perfectly clean test-tube heat S c.c. of urine to the boiling 
point. Pay no attention to any precipitate ('albumin' 1 . Add 5 c.c. of the 
solution of copper sulphate used in making Fehling's solution (solution A. as 
described . Cool partly. Add 2 c.c. of a saturated solution of sodium 
acetate that has been rendered faintly acid by acetic acid. Interfering 
substances are now precipitated. Filter and add to the clear nitrate 5 cc. 
of the solution B used in making Fehling's solution. Boil twenty seconds. 

If sugar is present, the solution becomes opaque and green, and deposits, 
either immediately -:utes. a fine yellow precipitate. 

Control Positive Copper Tests. — The tests already given are pla: 
direct order or their convenience and rapidity, but tlie inverse order of accuracy. 
Yet error will seldom occur if every sugar reaction is cliecked by the one accurate 
test for glucose, namely: 
is 



Coppery red is 
true color. 



Of value in 
negation. 



A better test. 



Avoid 
overboiling. 



For albumin- 
ous urines. 



Avoidance of 
error. 



226 



MEDICAL DIAGNOSIS 




^ 



Quick but 
inaccurate. 



THE FERMENTATION TEST.— This test depends upon the fact that 
glucose is a fermentable substance, and practically the only one that urine ever 
contains. 

The Test. — The most convenient apparatus is that of Einhorn. If 
Einhorn's saccharometer is not to be had, the Doremus ureometer tubes will 
answer the purpose of proving sugar present or absent. 

Each step in the process should be checked by comparison with a normal 
urine, therefore, two tubes are required. 

Technic. — (a) Boil the two specimens 
for several minutes, to drive of any air 
they may contain. 

(b) Add to each a pinch of tartaric 
acid in order to maintain their acidity 
and prevent ammoniacal decomposition. 

(c) Dissolve in each the same amount 
of yeast (about one-sixth of a fresh 
yeast cake is sufficient). If there be 
any doubt as to the freshness of the 
yeast, it is well to test it with a control 
solution of glucose. 

(d) Fill the long limb of the fermenta- 
tion tube of the saccharometer or of the 
Doremus ureometer with urine, and place 
the two specimens side by side in a warm 
place. 

About twenty-four hours are re- 
quired for complete fermentation and 

quantitative estimation, but the diagnosis can often be made in a very short 
time, as the appearance of any considerable amount of gas proves the 
presence of glucose. 

By using Einhorn's saccharometer, the amount of sugar may be determined 
with sufficient clinical accuracy by the scale measuring the volume of gas produced. 

Rougher Method. — Lacking any form of fermentation tube, the test may 
, be made by first taking the specific gravity of the two specimens, to one of 
I which yeast is added. Both are then set aside in a loosely stoppered flask or 
bottle and in a warm place. 

If glucose be present, fermentation occurs, the specific gravity is thereby 
lowered and each degree of density lost roughly corresponds to i grain of 
glucose to the ounce of urine (0.21 gram to 100 ex.). 

The specific gravity sJwuld not be taken the second time until the urine has 
cooled to the temperature it had when the first estimate was made. 

QUANTITATIVE ESTIMATION WITH WHITNEY'S REAGENT.— 
(Much used but not recommended). — In addition to the previously described 
tests may be mentioned that of Whitney, which, more rapid than the fermen- 
tation test, but inaccurate, depends upon the decolorization of an am- 
monic-cupric-sulphate solution. 




Fig. 67a. — Einhorn's saccharometer. 



THE EXAMINATION OF THE URINE 



227 



Test. — One dram of this solution is heated to the boiling point and the 
urine is added drop by drop, the mixture being boiled for from three to five 1 
seconds after each addition. If no change occurs, the process is continued 
until 10 or 15 drops have been added. If sugar be present, the blue color 
begins to fade, and is finally entirely removed, leaving a colorless solution. 
The amount of sugar present is then estimated by the following table: 

If reduced by minims It contains to the ounce Percentage 



I. 

2. 

3- 
4- 
5- 

6. 

7- 
8. 

9- 
10. 



16 or more grains 3 . 33 



5-33 

4 

3.20 

2.67 

2. 29 

2 

1.78 

1.60 



grains 
grains 
grains 
grains 
grains 
grains 
grains 
grains 
grains 



.1.67 
.1.11 
.0.83 
.0.67 
0.56 
0.48 
0.42 
0.37 
o.33 



Caution. 



If the amount of sugar be large, as indicated by the loss of color following 
the addition of 1 drop, the urine should be diluted by doubling or trebling its j Dilution 
volume by the addition of distilled water, and the result then obtained must 
be multiplied by 2 or 3, as the case may be. 

The duration of the boiling period must be neither more than jive nor less than 
three seconds. In the author's hands it has proven far inferior to the fer- 
mentation test, yet convenient for rapid rough w T ork. 

THE POLARIMETER.— Direct estimation of the sugars by this means is 
by far the most satisfactory method and requires no special training, but the 
instrument is somewhat expensive. The percentage of sugar is read directly 
from the vernier scale in the clinical instruments, such as Ultzmann's, but it 
is necessary to decolorize the specimen with lead acetate and magnesium 
oxide, if necessary, to attain a clear solution. The urine must be albumin- 
free and the containing tube dry or, if containing water, it should be rinsed 
out with some of the urine to be tested. 

LEVULOSE. — Levulose is abundant in ripe fruits and honey, is absorbed 
unchanged and occasionally appears in the urine, yet it can be taken in quan- 
tity in diabetes without causing a marked excretion, and in ordinary gly- 
cosuria may replace cane-sugar or glucose in the diet. Instances of pure 
levulose diabetes have been reported, but they are exceedingly rare. 

// 100 grams of honey be taken on a fasting stomach by a non-diabetic not 
more than 10 to 15 per cent, will show levulosuria, but in diseases of the liver, 
such as cirrhosis, carcinoma and syphilis, the same test may result in a marked 
excretion and indeed the same substance may appear spontaneously in such 
cases. 

Test. — The polarimeter shows rotation to the left, but the substance reacts 
to fermentation and Fehlings solution exactly like glucose. 

For identification, therefore, one must often use Seliwanoffs test. Add to 
10 c.c. of urine (showing levo-rotation) a little resorcin, and 2 c.c. of dilute 
HC1: a bright red reaction appears on heating if levulose be present. 



I A glucose 
substitute for 
diabetics. 



Levorotatory. 



228 



MEDICAL DIAGNOSIS 



Appears post 
partum. 



Specific test. 



Non- 
fermentable. 



Levorotatory 
and non- 
fermentable. 



Acidosis. 



LACTOSE appears in the urine of women after childbirth (not during 
pregnancy), and more frequently in those who do not nurse the child (80 per 
cent, as against 20 per cent.). It is most abundant about the fifth month 
after delivery and seldom exceeds 0.5 per centr 

Rubner's Test. — // reduces Fehlings solution and is fermentable with diffi- 
culty, but whenever any sugar reaction appears in women after delivery 
Rubner's test should be applied: To 10 c.c. of urine are added 3 grams of 
lead acetate, the resulting precipitate is filtered off and the filtrate heated 
until it assumes a brownish color, and again after the addition of ammonia. 

The appearance of a brick-red color and a cherry-red precipitate indicates 
lactose if there be more than 0.3 per cent. Specimens of high specific gravity 
should be diluted one-half and less amounts require evaporation of the urine 
and a test of the residue. 

PENTOSE. — After the ingestion of large quantities of fruit, or more rarely 
after taking excessive amounts -of vegetables, coffee, tea or milk, pentose may 
appear in sufficient amount to reduce Fehlings solution slowly and atypically. 

A very few cases of true pentosuria with otherwise unimportant symptoms 
have been observed. It does not yield gas production by fermentation even 
though the pentoses are thereby decomposed, which differentiates it from the 
more important substance, glucose. 

Bial's Test for Pentose. — Test Solution. — One gram of orcin and 30 drops 
of 10 per cent, ferric chloride solution are added to 500 c.c. of concentrated 
hydrochloric acid. 

Test. — To 10 c.c. of the solution 5 c.c. of the suspected urine is added and 
the mixture raised to the boiling point but no further. A green precipitate 
on cooling indicates the presence of pentose. 

If the urine has shown glucose this reaction will be imperfect. 

F. C. Wood recommends short preliminary fermentation with a pure 
culture of saccharomyces in such cases. 

MALTOSE. — Its chief interest lies in its presence in certain cases of pan- 
creatic disease, but the tests are not suitable for the practitioner. 

GLYCURONIC ACID. — This substance may in certain combinations reduce 
Fehling's solution, but it has no definite clinical significance, does not undergo 
fermentation with yeast and is levorotatory in acid solution. 

The only specific test for this substance is the complicated one of Neuburg, 
a description of which may be found in the physiological chemistries. 

ACETONE, DIACETIC ACLD AND OXYBUTYRIC ACID.— Although 
oxybutyric acid as the mother substance plays a basic part in acidosis, one 
need only consider here the clinical recognition of the two former substances. 
A distinction may be drawn between the diabetes of a severe and that of a 
mild type by the behavior of the acetone and diacetic acid as affected by diet. 

These substances may be found in conditions other than diabetes and in this 
ailment are prone to appear if the diet is rigidly and excessively proteid and fatty 
and disappear when a proper regimen is established, but if they persist in excess 
in a case of diabetes the case is a bad one and the end not far distant. (See 
" Diabetes.") 



THE EXAMINATION OF THE URINE 



229 



Acetone and diacetic acid have essentially the same significance, but the 
former precedes the latter and should be sought in diabetic urines if diacetic 
acid is proven to be absent. 

DIACETIC ACID.— Test.— If a few drops of the tincture of ferric chloride 
be added to the freshly passed urine containing diacetic acid, a bordeaux-red 
appears together with a precipitate of phosphates. 

For accurate results these should be allowed to settle or be filtered out and 
the addition continued.* 

Heat should be applied and should cause a diminution of intensity in the 
color on boiling if it be due to diacetic acid. 

The presence of diacetic acid indicates the presence of acetone to an 
amount of at least 0.02 gram in the twenty-four hours' urine, and is seldom 
absent when the daily acetone excretion reaches 1.5 grams. 

Acidosis. — Diacetic acid in the urine, with or without oxybutyric acid, 
indicates acidosis. 

This represents a condition of the blood inviting fatal coma in cases 
of diabetes and demanding immediate recourse to alkalies, periods of starva- 
tion, the introduction of carbohydrates to tolerance and the withdrawal of 
fats and diminution of proteids. 

Increased diacetic acid excretion with coincident diminution of acetone 
is said to be an immediate forerunner of diabetic coma. 

ACETONE. — LegaTs Test. — Distil a few cubic centimeters of urine by 
using a simple distillation flask with its neck corked and its lateral arm lead- 
ing into a test-tube or ordinary flask; a bunsen burner or alcohol lamp 
completing the outfit. The distillate collected in three or four minutes is 
treated with a few drops of a fresh solution of sodium nitro-prusside, a few 
drops of acetic acid are added and the mixture rendered alkaline by sodium 
hydrate. If acetone be present a red appears deepening to carmine and 
purple-red. 

Lieben's Test. — Add to distillate a few drops of Lugol's solution and 
sodium hydrate. If acetone is present it will form a macroscopic or micro- 
scopic sediment of the star-like yellow crystals of iodoform, and on heating 
the characteristic odor may appear. 

The excretion of acetone may promptly follow the withdrawal of carbo- 
hydrates in diabetes and in such cases is removed usually by the adminis- 
tration of even relatively small amounts of such foods. 

As stated previously, the best, most effective and. in fact, obligatory 
method of relieving the acidosis of the diabetic lies in brief periods of total 
starvation, administering sodium bicarbonate until the urine is neutral or 
alkaline, and adjusting a carbohydrate intake to the tolerance of the patient. 

Acidosis in Non-diabetics. — Acidosis may occur in- many conditions other 
than diabetes. 

Among these are advanced gastric or intestinal malignant growths, 
locomotor ataxia, melancholia, prolonged chloroform anesthesia, severe 

* Crofton states that color due to ingested drugs is permanent, whereas that due to 
diacetic acid soon disappears. 



Use fresh 
urine. 



Filtration 
important. 



An ominous 
symptom. 



Simpler 
method. 



230 



MEDICAL DIAGNOSIS 



Chloroform. 



Light and 
leases. 



Avoid over- 
illumination. 



Misleading 
objects. 



typhoid, senility, terminal cardiac incompensation with general dropsy, 
and many other conditions. 

It should always be sought for and if present corrected in cardiorenal 
insufficiencies, and in stuporous states or low delirium associated with pro- 
found exhaustion or inanition. 

The Preservation of Urine for Microscopic Test. — As previously stated, 
the preservation of specimens is best accomplished by the addition of a slight 
excess of chloroform which is easily removed by heat before any tests are applied. 

Many agents may be used if the sediment alone is to be examined (for- 
malin, chloral hydrate, thymol, boracic acid, etc.), but are likely to cause 
some confusing reactions in the tests for albumin or sugar. 

THE EXAMINATION OF URINARY SEDIMENTS.— The accurate 
microscopic examination and correct interpretation of urinary sediments 
demand a thorough knowledge of the special technic involved. 

Gross error is possible in two directions: (i) Through failure to detect 
important abnormal elements. (2) Through misinterpretation of the elements 
found. 

Every physician must not only own a microscope, but be able to use it, 
and no time can be more profitably employed than that which is spent in 
acquiring a correct technic. He who graduates from the schools of today 
is, or at least should be trained to a degree that will enable him to do reason- 
ably accurate work in this line. On the other hand, many excellent men of 
the older generation through lack of early training and opportunity are still 
sadly deficient in this important branch of clinical medicine. In many med- 
ical schools, moreover, even at the present time, the training is wholly inadequate. 

Illumination. — In examining a urinary sediment microscopically, the 
first essentials are correct focusing and a dim light. 

Every microscope should be provided with an iris diaphragm and a nose- 
piece holding three objectives, one low-power, one medium, and for the third, 
a high-power oil-immersion lens. In urinary work only the first two are 
required, save in those cases in which the tubercle bacillus is the object sought. 
The physician should commence operations with a dim light and his low-power 
lens (1 inch or J^ inch objective), this being by far the best for finding casts 
as it distinctly shows their outline and gives a larger field. He should then 
slightly increase his light and bring his medium-power objective (J4 to }/§ 
inch) into focus. This brings out the structure of casts and renders distinct 
any cellular elements or crystals that may be present in the field. Having 
once found any object of interest, the lenses and the illumination may be 
changed at will. 

Substances Found in Urinary Sediments. — The following are the inorganic 
substances most frequently found in urinary sediments: 

(a) Extraneous material, such as fibers of cotton,- linen, wool or silk, various 
vegetable forms from the rinsing water, if it be not distilled, starch grains, 
etc. 

(b) Phosphates. — The macroscopic appearance of the phosphatic deposit 
is well known. This grayish-white material so often mistaken for pus is 



THE EXAMINATION OF THE URINE 



2 3 I 



composed of amorphous calcium and magnesium phosphates and their ready 
solubility in mineral acids at once identifies them. They are found only in 
alkaline urine, and, if ammoniacal fermentation has occurred, will be asso- 




Fig. 68. — a. Calcium phosphate, b. Calcium sulphate. (After Jakob.) 




Fig. 69. — Calcium oxalate crystals. 

ciated with beautiful crystals of the triple phosphate. Calcium phosphate 
may also appear in crystalline form. 

(c) Urates. — The ordinary deposit of urates occurs in moderately acid, 



232 



MEDICAL DIAGNOSIS 



"Brick-dust' 

deposit. 



concentrated urine during the process of cooling or when exposed to an 
unusual degree of cold. The color varies from yellow to rose-red, the latter 
constituting the so-called brick-dust deposit (sedimentum lateritium). 




Fig. 7.1. — Ammonio-magnesium (triple) phosphate. 




Fig. 72. — Uric acid crystals. 

Upon application of heat they promptly disappear. When nitric acid is 
added to a urine rich in urates, a deposit of nitrate of urea is formed. The 
deposited urates are amorphous, excepting only the ammonium urate, which 



THE EXAMINATION OF THE URINE 



233 



occurs in ammoniacal urine as the so-called thorn-apple crystals (see Fig. 

74). 

a 




Fig. 73 — a. Cystin. b. Leucin. 




Fig. 74. — Calcium carbonate. (After Jakob.) 

(d) Uric Acid. — Uric acid may be precipitated from any urine, if con- 
centrated, during the so-called acid fermentation or in hot weather when the 



234 



MEDICAL DIAGNOSIS 



Cayenne 
pepper deposit, 



high temperature prevents precipitation of the urates. Excessive acidity and 
concentration or a pathologic excess may occur in certain conditions, but, 
when passed, urine should never contain the crystals as a precipitate. The 
macroscopic deposit resembles cayenne pepper. The microscopic appearance 
: is best shown by the plate (see Fig. 71). 

(e) Calcium Oxalate. — This rarely forms a visible sediment and is ab- 
normal if found in urine freshly passed. The crystals are characteristic 
and unmistakable (see Fig. 69). Leucin, tyrosin, and cystin are rarely seen, 
but may be readily recognized by comparison with the illustrations (see 
Figs. 72, 75). 

(J) Calcium Carbonate. — This is occasionally precipitated with the 'earthy 
phosphates. Usually it is amorphous but occasionally it forms crystals 




Fig. 



Ammonium urate. 



Effervescence. 



Normal vs. 
Abnormal. 



Easily 
overlooked. 



Crenation. 



shaped like a dumb-bell. It is easily recognized by the effervescence 
produced when a mineral acid is added (Fig. 73). 

(g) Blood. — Erythrocytes. — The blood as it appears in the urine may be 
quite normal in appearance or, on the other hand, be so changed as to make 
its recognition difficult. If hemorrhage has taken place in the urethra, pros- 
tate, bladder, ureters or in the pelvis of the kidney, and the urine is acid and 
fresh, the red corpuscles appear as yellow biconcave discs, with rounded edges 
and a light central portion. 

Phantom Cells. — If, on the other hand, the hemorrhage has taken place 
into the cortical portion of the kidney, the urine has stood for some hours 
or is alkaline, the corpuscles may become pale and swollen, their diameter 
lessened and they may appear as mere shadowy circles and as such are easily 
overlooked. Crenation of the normal cells mav also occur in a urine that is 



THE EXAMINATION OF THE URINE 



235 



deficient in salt. Such cells have irregular, star-like processes along their 
border, but retain the yellow tinge of the normal cell. 

(//) Pus. — Pus in quantity is in most cases easily detected by the chemic 
test. The pus cell as seen under the microscope is identical with the white 
cell seen in a smear preparation of normal blood but is less easily recognized 
as such in the urine. 

/;/ the acid urine the pus cells are usually larger than the red cells, are color- Differentia- 
less, granular and, as a rule, in fresh specimens, their nuclei may be readily 
distinguished by careful focusing. 

The presence of these nuclei serves to distinguish them positively from the 
red cells and any doubt upon this point may be readily removed by allowing | 
a drop of very dilute solution of acetic acid to run beneath the cover-glass, maneuver. 



tion. 




Fig. 76. — Tyrosin. 

assisting the process, if necessary, by laying the edge of a piece of filter or 
blotting paper against the opposite edge. The acetic acid dissolves the 
granules and brings out clearly the cell nuclei, but unless very dilute, will 
destroy any hyaline casts that may be present. In ammoniacal urine, the pus 
corpuscles are soon destroyed, becoming agglutinated and losing their structural 
characteristics. 

This maneuver is also useful in differentiating the leucocytes from renal cells. 
Varying Significance of Pus in the Urine. — As to the significance of pus ! Diagnostic 
in the urine, it may be remembered that: 

(a) Pus that comes with the first jet of urine, the remainder being clear, is 
from the urethra. 

(b) A moderate amount of pus, appearing in an acid urine, is usually from 
the renal pelvis, but may be due to tuberculosis of the bladder. 



236 



MEDICAL DIAGNOSIS 



(c) Large quantities of greenish pus point to rupture of an abscess* in the 
urinary passages or to a pyelonephrosis. 

(d) Pus in a urine which is ammoniacal when passed is usually, but not 
always, from the bladder. 

In all cases the diagnosis must depend upon the character of the associated 
epithelium and the presence of casts or specific microorganisms. 

(i) Spermatozoa are easily recognized by their well-known form. 

(j) Bacteria and Yeasts. — Bacteriurea. — Aside from the tubercle bacillus, 
many forms of bacteria may be found in the undecomposed urine, and their 
presence may be unattended by symptoms or accompanied by a variable 
amount of irritation of the bladder. So, also, in fermenting urine one finds 




Fig. 77. — a, b. Various forms of fungi and bacteria, c. Pus cells before and after treat- 
ment with acetic acid. d. Various forms of red blood cells. 

both bacteria and spores. The spores are highly refractile and tend to form 
chains. The most important bacterium is the tubercle bacillus, only to be 
recognized by such staining methods as are described elsewhere. 

The ordinary bacterial urine is persistently cloudy, has a musty odor, and 
presents on shaking a swirling appearance, as if fine grains of sand or dust were 
put in motion. 

(k) EPITHELIUM.— Limits of Differentiation.— In spite of the efforts put 
forth by microscopists, the exact differences existing between the epithelial cells of 
different portions of the urinary tract have been determined only in part. 

Such variations are shown by the plates, but must be learned from the 
careful study of specimens obtained from known cases of cystitis, nephritis, 
etc., a mere description being of slight value. 

* Most commonly prostatic. 



THE EXAMINATION OF THE URINE 



237 



»The renal cell as seen in the urine is usually small, though almost double 
the size of a red blood cell, round or cubical, and mononuclear. 

Cells from the straight tubules are somewhat larger and have a more irregu- 




FiG. 78. — Renal cells. Various forms, including compound granule cells. 




Fig. 79. — Bladder epithelium. {Various forms.) 

lar shape, being sometimes polygonal or cubicular, but, as contrasted with 
the leucocyte, all renal cells are mononuclear * 

* Degenerated cells may of course show no trace of a nucleus. 



Always 
mononuclear. 



2& 



MEDICAL DIAGNOSIS 



Pelvic cells. 



Pavement 
epithelium. 



Significance. 



In cases of "obstructive" jaundice the renal cells are often distinctly bile- 
stained. 

Caudate cells arranged in overlapping layers are often described as the 
characteristic cells of the renal pelvis, but, as a matter of fact, they represent 
only the superficial layer, and are seen only in early or mild cases of pyelitis. 
The cell from the deeper layer strongly resembles the renal cells. 

Ureteral cells are spindle-shaped: 

Bladder epithelium is large, mono- or polynuclear, and generally of the 
well-known tessellated or pavement variety. Such cells often occur in aggre- 
gations, may be distinguished from vaginal epithelium only by the fact that 
the cells are somewhat smaller, never overlap, and occur in a single layer. 




Fig. 80. — a. Epithelium from renal pelvis, b. Vaginal epithelium. 

Bladder cells from the middle layers are smaller, often somewhat drawn 
out, or perhaps definitely "tailed." Those of the deep layer may be round, 
cuboid or polygonal. All carry a vesicle-like nucleus. 

Vaginal epithelium is rather larger : the cells overlap like the shingles on a 
roof, and are likely to occur in masses consisting of several layers. 

The epithelial cells from the neck of the bladder, prostate, and the calices of 
the kidney pelvis are almost identical. 

An absolute differentiation of the epithelial cells in a urinary sediment is 
oftentimes impossible and will often demand the corroborative testimony of other 
findings. 

Fatty Renal Cells and Compound Granule Cells. — The former are much 
smaller than the latter which are large, round, bulging with refractile granules 



THE EXAMINATION OF THE URINE 



239 



and frequently spiculated by fatty crystals. They have no exclusive disease 
relation, but may be found in any form of renal lesion characterized by fatty 
casts and in other chronic inflammatory and ulcerative lesions of the urinary 
tract. 

Renal cells reflect the same changes as are shown by the various types of casts. 

CASTS. — Casts are of two kinds: (1) The true cast, which has its origin 
in an exudate from the tubules of the kidney. (2) The pseudo-casts, or cast- 
like bodies, which may or may not originate in the kidney. 

True Casts. — The exact nature and source of the true casts are not positively 
known. Whether they consist of disintegrated and modified epithelium, or a 
morbid secretion of the epithelium itself, or are simply a coagulated albuminoid 
transudate from the blood, the fact remains that they appear clinically as casts 




Fig. 



ii. — This figure shows the appearance of a group of casts under correct dim 
illumination. 



of the renal tubules, having to a great extent a form and caliber corresponding 
to that portion from which they come, and appearing hyaline, waxy, fibrinous, 
granular, fatty, epithelial or bloody, according to the nature and extent of the 
underlying pathologic changes. 

If we assume, for convenience of description, that their basis is that pathologic 
change known as hyaline degeneration, it becomes very easy to understand most 
of their modifications. 

Such a process would lead ordinarily to the formation of a hyaline cast. 
If the granules of the degenerated cell adhered to or became intermixed with 
the deposit, a granular cast would result, and this would be finely or coarsely 
granular, light or dark, according to the activity of the pathologic process. 
Fatty degeneration in the cells would be reflected in the fatty cast. Adherent 



Exact nature 
unknown. 



Possible 
origin. 



Varieties. 



A convenient 
hypothesis. 



Hyaline. 

Granular. 

Fatty. 



240 



MEDICAL DIAGNOSIS 



Epithelial. 



desquamated cells would form epithelial casts; adherent blood cells, the blood 
cast, etc. 

A Reasonable Assumption. — It is reasonable to suppose that the basis 
is the same for all varieties, and that in the hyaline, waxy, and fibrinous casts 
we have but slight variations in fundamental structure, though the conditions 
attending their presence maybe quite different and distinct, and their clinical 
significance definite and important. 

The Hyaline Cast. — This is transparent, and shows an apparently homogen- 
eous structure; its size is variable, its ends rounded, and its sides nearly parallel. 

Its shape is best shown in Figs. 80, 84. Unless careful focusing and 
proper shading of the light be employed, it will certainly escape detection. 

Representing, as these hyaline casts do, the least degree of pathologic or at 
least of inflammatory change, it becomes at times a difficult question io determine 
the significance and importance of an occasional cast. 




Albuminuria 
minima. 



Fig. 82. — This figure shows the obliteration of same group by high illumination. 

Some observers report them as present in nearly every urine if the centri- 
! fuge be employed, but such has not been the author's experience. Occurring 
alone and unassociated with albuminuria or other symptoms pointing to dis- 
eased kidneys, it must be admitted that their significance is less grave than 
would have been assigned them by the older teaching. It is certainly 
true that they may represent transient and hence often negligible conditions 
or localized rather than general renal changes, but as a persistent constituent 
of the urinary sediment they still demand serious consideration and have lost 
little of their old significance. It is also a much debated question as to whe- 
ther they are ever found without some degree of albuminuria and, according 
to E. S. Wood, the hyaline cast is always associated with the pale very finely 



THE EXAMINATION OF THE URINE 



241 



granular cast.* It rapidly disintegrates in alkaline urine or in that treated 
with acetic acid. 

Significance.— The chief significance of the hyaline and finely granular 
cast, existing alone, is found in its special relation to acute and chronic infec- 
tions, acute or chronic intoxications, chronic passive renal congestion, and the 
early stages of arteriosclerotic kidney, and true interstitial nephritis. 

Infection and Toxemia. — We are but just beginning to appreciate the part 
played by persisting foci of chronic streptococcic infection, and by other 
forms of persistent or recurring toxemia in the etiology of nephritis. 

The readiness with which even a marked albuminuria, associated with hyaline 
cylinder showers, may be induced by heavy drinking is apparently little appreci- 
ated. In the author's practice this has several times led to the detection of 
the " sneak drinker." 

a - 



Hyaline and 
finely granular 
forms. 



Isolated 
findings. 




Fig. 83. — a. Waxy casts, b. Fatty and fat-bearing casts. Fibrinous casts closely re- 
semble waxy casts but are always yellow or brown. 

The Waxy Cast. — This is dense but highly refractile and is usually relatively 
short and of large size. It is either without color or slightly gray, never carrying 
the yellow or brown of its simulator, the fibrinous 'cast, stands out as clearly 
upon the field as does the triple phosphate crystal, and, once seen, is never 
forgotten. 

It points to one of three conditions: amyloid kidney, advanced chronic paren- 
chymatous nephritis and the terminal stage of interstitial nephritis.] 

* This corresponds to the author's own observations as applying to ordinary clinical 
work and to true casts and seems to have a logical pathologic foundation, 
t Ultzmann states that it may be present in tuberculosis of the kidney. 
16 



Alcoholic 
excess. 



Unmistakable. 



Commoner 
associations. 



242 



MEDICAL DIAGNOSIS 



Forerunner of 
death. 



Active or 
subsiding 
inflammation. 



Inflammation. 



Important 
variety. 



Good or bad 
omen. 



Epithelium- 
bearing. 



In amyloid kidney, it appears earlier than in interstitial nephritis. Indeed, 
in the latter it marks the beginning of the end, and cases of contracted kidney in 
which it is found will usually terminate fatally within one year. 

The Fibrinous Cast. — This misnamed cylinder resembles the waxy cast 
save in color. It is always yellow or even brown, deriving its color from blood 
pigment, and, as might be expected, points to an active or subsiding inflammation; 
ordinarily to acute Bright's disease. 

The Blood Cast, and the Brown Granular Cast. — This points to acute 
inflammation as does the brown (dark) granular cast. 

If, as is usually the case, the cast carries washed-out cells (abnormal 
blood) it indicates slow effusion of blood or its high origin; if normal blood, 
more abundant hemorrhage or an origin in the straight tubules or pyramids. 




Granular casts. Light and dar£. 



The dark granular cast is actually a blood-pigment cast. 

The Finely Granular Cast. — The special significance of this common form 
has been discussed together with that of the hyaline cast. 

The Coarse Granular Cast. — This is usually associated with fibrinous 
or waxy casts. 

The Fatty Cast. — This is most frequently seen in convalescent cases of acute 
nephritis, or in chronic parenchymatous nephritis. 

True Epithelial Casts. — These occur only in active or subsiding, acute or 
subacute inflammation, in acute Bright's disease, or the subacute exacerbation 
of a chronic parenchymatous nephritis. 

Many casts carry here and there an epithelial cell and should be so 
described in case reports, yet these cannot properly be called epithelial casts. 

Pus Casts. — These are found in suppurative disease of the kidney or in 



THE EXAMINATION OF THE URINE 



243 



pyelitis extending to the straight tubules and frequently require treatment with 
dilute acetic acid to distinguish them from certain epithelial casts. 

Significance and Associations of Casts. — Hyaline and finely granular 
casts indicate: (a) Interstitial nephritis, (b) Amyloid kidney, (c) Chronic 
congestion of the kidney. 

They are also frequently found in acute and chronic infections and 
intoxications and even in asthenic albuminurias of the orthostatic or adoles- 
cent types, though in many or most of such cases some chronic obscure 
infection exists (tonsils, teeth, nasal accessory sinuses, cryptogenetic tuber- 
culosis, etc., etc.). 

Waxy casts indicate as stated : (a) Terminal stage of chronic interstitial 
nephritis, (b) advanced parenchymatous nephritis, (c) amyloid kidney. 




Fig. 85. — a. Blood cast and hyaline cast carrying red blood cells, b. Leucocyte or pus 
cast. c. Hyaline cast carrying leucocytes, d. Epithelial casts. 



Acute and Subacute Nephritis. — In these ailments one finds: (a) Fibrin- 
ous; (b) blood; (c) epithelial; (d) hyaline; and (e) dark granular casts. 

Convalescence from Acute Nephritis. — rHere one finds fatty, dark granular, 
epithelial and hyaline casts. 

Uncomplicated Chronic Parenchymatous Nephritis. — In this disease one 
finds fatty, hyaline, and finely granular casts, and with any decided disturbance, 
epithelial casts. 

Sources of Error in Searching for Casts. — Cast-like Forms. The amor- 
phous urates are frequently grouped in cast-like forms and similar accumu- 
lations of bacteria and other sedimentary substances may perplex the tyro. 
They will seldom or never deceive the trained eye as they lack the definite 
linear boundaries of the genuine cast. Urates, moreover, are promptly dis- 
solved by heating the preparation. More deceptive still are the cylindroids. 



Indicate 

suppurative 

focus. 



Misleading 
forms. 



Pseudocasts. 



244 



MEDICAL DIAGNOSIS 



Mucous 
cylindroids. 



They are usually longer and more band-like than the hyaline cast, and more 
likely to be convoluted or twisted; usually they take the form known as 
mucous cylindroids which occur in many non-albuminous urines and cannot 
be mistaken for true casts as they appear flattened and ribbon-like, often 
| with frayed ends and faint longitudinal striation. 

Demand Typical Forms. — The author believes that fewer casts would be 
important rule, reported in otherwise normal urines if the observer regarded all doubtful forms 
as disproven until he could find in the same urine a definite cast of the ordinary 
size and form, and with both ends rounded. If of renal origin, the unusual 
will certainly be accompanied by the common form. 

Cylindroid Storms. — In certain cases, periods of mental depression are 
Cast showers. I accompanied by showers of spurious casts without the slightest change in 




Fig. 86. — Spermatozoa and associated substances in urinary deposit, a, a, a, a, 
Spermatozoa, c t c. Spermatozoa, tail out of focus, d, d, d. Amyloid corpuscles, e, 
Prostatic cast. g. Crystals, h. Lecithin-granule cells, k, k, k. Epithelium. 

the chemical constitution of the urine and in convalescence from a toxic 
nephritis of mild grade repeated showers of true casts may be observed. 

"Showers" of short granular cysts may precede the onset of a diabetic coma 
and in the exacerbations of actual nephritis the great and abrupt increase of 
casts in the urinary sediment sometimes justifies the term "shower " though with 
less aptness than in the other instances here detailed. 

Prostatic Plugs. — These may closely resemble the large hyaline or fibrinous 
cast, but usually carry, or are associated with, spermatozoa, and evidence of 
prostatic irritation or inflammation. 

THE GONOCOCCUS— As indicating the infectivity of any persistent 
secretion after urethritis, however remote the original attack, the presence 
of gonococci is important. 



THE EXAMINATION OF THE URINE 



245 



Method. — The usual smear is made, dried in the air and fixed, and, 
indeed, may be made by the patient if no discharge is present save in the 
early morning or at irregular times. Ordinarily Jenner's stain or the alkaline 
methylene blue is sufficient. 

The specific cocci appear like pairs of coffee beans with flat surfaces 
apposed and almost in contact and lie for the most part within the pus cells. 
If in doubt, one should apply Gram's stain, the organism being Gram-negative. 
In rare instances it may be necessary to use cultural methods as it is claimed 
that the micrococcus catarrhalis and the diplococcus intracellularis meningitidis 
are also negative to the Gram stain. 

Shreds. — The so-called urethral thread, though common after gonorrheal 
infection, indicates no more or less than chronic congestion of the deep urethra. 





Fig. 



Gonococcus. 



Fig. 88. — Tubercle bacilli in urine. 
Observe tendency to form groups. 



EHRLICH'S TYPHOID DIAZO REACTION.— This test was intro- 
duced by Ehrlich in 1882, and, after meeting with much overpraise as well 
as . much opposition and criticism born of misunderstanding and mis- 
application, has at last been accepted at its true value in many of the in- 
portant clinics. 

Solution Required.— Solution A . — Hydrochloric acid, 50; distilled water, 
1000; sulphanilic acid, q.s. ad. sat. (It should be thoroughly saturated.) 
Solution B. — Sodium nitrite (not nitrate), 0.5 per cent. (j£ of 1 per cent.) 
solution in distilled water. Solution C. — {Test solution.) — One hundred 
parts of A plus 1 part of B. 

The original test solution of Ehrlich was made by adding to 40 parts of 
solution A 1 part of solution B. This the author has slightly modified by 
using 100 parts of A to 1 of B, with the effect of eliminating many disturbing 
factors and doubtful reactions. Dr. C. E. Simon suggested the ring method 
of testing described below. 

Technic. — Take equal parts of solution C and the urine. Shake thoroughly 
and add aqua ammonia in excess, allowing it to run gently down the tube so 
as to overlay the mixture below. 

If the reaction be present, a deep red band appears at the line where the ammo- 
nia meets the mixture. When shaken, it yields a pink or rose-colored foam, 
and, after standing several hours, a green precipitate forms. 

All-important Rules. — The following rules must be carefully observed: 
(1) Use fresh urine. (2) See that the reaction is acid and the urine filtered. (3) 
Use a freshly mixed test solution. (4) Keep the sodium nitrite solution in a 
black bottle and in a cool place and renew it frequently {the sulphanilic solution 



Usually 
intracellular. 



Gram- 
negative. 



"Tripper 
Faden." 



True value 
established. 



Author's 
modification. 



Terminal 
reaction. 



Strict adher- 
ence to detail 
essential. 



246 



MEDICAL DIAGNOSIS 



Color 
reactions. 



Absurd errors. 



Sources of 
confusion. 



Constant in 
severe typhoid, 



Differential 
value. 



Value in 
negation. 



Exact cause 
unknown. 



Retained 
waste. 



keeps indefinitely). (5) Hold the tube near, but not against, a white background, 
the source of light being behind the observer. Artificial light should not be used. 
(6) Accept no color but a distinct red, and regard no reaction as a true one in 
which the solution when shaken does not yield a pink foam. False or imper- 
fect reactions occur in which the band is of the proper color, but the foam is yellow 
or brown* 

One may oftentimes follow the imperfect but suggestive reaction of early 
typhoid to its typical manifestation a day or two later. 

The most absurd errors have arisen from a failure to observe the exact 
technic and precautions here outlined and adverse reports under high author- 
ity have been based upon the use of sodium nitrate instead of the necessary 
nitrite, or of weak instead of strong ammonia, and indeed one eminent observer 
omitted the end reaction altogether and naturally failed to get consistent 
results. Others have accepted the meaningless yellow and orange reactions 
with confusingly catholic positive results, or have even used a 5 per cent. 
solution of sodium nitrite (10 times the proper strength). 

True Value of the Reaction. — The test is not pathognomonic, as was originally 
maintained by Ehrlich, but is constant in all severe forms of typhoid, appearing 
sometimes as early as the fourth or fifth day, though more generally at the end of 
the first week or ten days, and persisting until the fever begins to decline. 

The importance of the test is at the present time of course greatly 
diminished by the availability and specificity of the agglutination test and 
the even better, but less available, blood-culture method. 

If the test is applied according to the author's method the true and com- 
plete reaction is absent in the ordinary forms of malaria, in appendicitis, 
pneumonia and in the earlier stages at least of miliary tuberculosis. 

According to the author's experience it occurs only in some of the acute 
exanthemata; in certain cases of advanced malignant disease with fever; 
clarifyingly late in miliary tuberculosis and, unfortunately, in its typical form, 
in febrile cases associated with septic absorption. 

Pseudo-reactions are found in a considerable number of diseases and the 
inclusion of the universally obtainable yellow and orange reactions has tended to 
discredit a good test. 

It is of great value in negation, for it is the author 's firm belief that, within 
the period previously defined, it will be found present in all cases of severe typhoid, 
and that its persistent absence in any such case quite certainly negatives the 
diagnosis of typhoid fever .^ 

UREMIA. — Any form of Bright's disease may be associated with symp- 
toms grouped under the head of " Uremia." The exact cause of this Condi- 
tion is still unknown, but its occurrence apparently depends upon the reten- 
tion of certain products of retrograde metabolism distinctly toxic in their 

* Upon one or the other of these reefs, shipwreck apparently has befallen most of those 
who have tried this simple test. 

f Recently Unverricht, in quoting Michaelis, an enthusiastic advocate, has raised anew 
the old question of color and demands a more definite reaction. A deep red band and a 
pink foam should be demanded by every clinician before the individual reaction is accepted. 



UREMIA 



247 



nature, and perhaps, of certain toxic substances (nephrolysins) associated 
with the progressive destruction of renal tissue.* 

Deficient Excretion. — // is a well-known fact that no living organism can 
resist the poisonous effect of its own retained waste products. In the elimination 
of these substances the kidney plays the chief part and in almost all cases of uremia 
the phenomena of relative, or even absolute temporary renal insufficiency, are 
evident. 

The onset of uremia is attended not only by a diminished excretion of 
urinary solids in general, but of urea nitrogen itself, and the molecular con- 
centration of the blood is correspondingly increased, as has been shown by 
the demonstration of a lowering of the freezing-point of the serum. 

It mjist be remembered, however, that during an established seizure, and its 
subsidence, these conditions may be reversed. 

Symptomatic Expression. — The symptoms of uremia are made manifest 
chiefly through the nervous system, although the gastrointestinal and respiratory 
tracts are almost invariably involved in the severer forms. 

No concrete picture is -presented in this curious toxemic state, the symptoms 
being irregular and inconstant in appearance, grouping and duration. Single 
symptoms of every grade of intensity may be the only signs, apart from the con- 
dition of the urine, which seldom fails to show a diminished excretion of solids. 

Nervous Symptoms of Uremia. — Almost every disease of the nervous system 
may be simulated by uremia but the cerebral symptoms are the most interesting 
and important. 

Headache, drowsiness, stupor or coma may be found alone or in transition 
stages. There may be slight twitchings or the more terrible convulsive 
seizures closely simulating epilepsy, while violent outbreaks of acute mania, 
profound melancholia, or the so-called delusional insanity of Bright's disease 
such as occur in certain cases may easily lead to serious error in diagnosis 
or even to the committal of such patients to an asylum for the insane, f 

Sensory Symptoms. — Various disturbances of general sensation may be 
encountered, such as itching, anesthesia, hyperesthesia, formication, and abnormal 
response to heat and cold. 

Vertigo is often a prominent feature and is usually associated with periods 
of high arterial tension or its opposite, marked circulatory depression, 
diminution of total solids or the predominance of the dyspeptic symptoms, 
often so prominent a feature in chronic renal disease. 

* Although all of the older theories have been abandoned, the specific cause of uremia is 
as great a mystery as ever and the subject is, perhaps, even more involved in conflicting 
opinions. At least ten new theories of causation are now before the profession, all unproven. 

t A remarkable case in the author's practice showed the existence of an uremic delusioD, 
single but fixed and dominant, which lasted about three years, during which period the 
patient was converted from the warmest friendship to the most bitter enmity, returning 
abruptly to his first status of exaggerated loyalty at the end of the period. In this case the 
albuminuria was intermittent with frequent periods of marked deficiency of excretion, as 
indicated by estimation of the urinary solids. Several physicians had pronounced the man 
wholly free from disease, because of the absence of albumin from individual specimens of 
urine. 



Chiefly 
nervous. 



Cerebral. 



Insanity of 

Bright's 

disease. 

Varied symp- 
tomatology. 



2 4 8 



MEDICAL DIAGNOSIS 



Transient 
paralyses. 



Blindness and 
deafness. 



Time limit. 



Uremic 

asthma. 



Misleading 
symptoms. 



Minor 
uremias. 



Extreme 
forms. 



Motor and Special-sense Symptoms. — The most remarkable symptoms 
of uremia are those extraordinary attacks of transient paraplegia or hemiplegia 
simulating true apoplexy, and the disturbances of the special senses re- 
sulting in tinnitus aurium, deafness or sudden temporary blindness (uremic 
amaurosis).* 

Various more serious eye symptoms may co-exist with uremia and the 
diagnosis of chronic interstitial nephritis is often first made by the oculist, who 
discovers evidence of a neuro -retinitis of the albuminuric type. Uremic amau- 
rosis usually lasts but one or two days and ordinarily follows some profound 
manifestation of uremia, such as coma or convulsions. 

Cases presenting marked symptoms of actual albuminuric neuro-retinitis 
seldom live longer than one year. 

Respiratory Symptoms. — Cases of chronic nephritis are often peculiarly 
subject to inflammation of the pulmonary structures, but aside from these, 
we have curious disturbances of respiratory rhythm. 

Uremic dyspnea may be continuous, paroxysmal, alternating, or Cheyne- 
Stokes. 

The paroxysmal type is often mistaken for true asthma, the mode and time 
of onset being precisely the same. 

Continuous dyspnea of uremic origin is not uncommon, and medical lit- 
erature furnishes many evidences of the ambulatory Cheyne-Stokes type.\ 

Gastrointestinal Symptoms. — These so closely simulate various independ- 
ent diseases as to render diagnosis impossible, except by recourse to the urinary 
examination and particularly the estimation of blood pressure, the urinary 
solids, and the use of the phenol sulphonephthalein test whenever possible. 

As previously stated, these uremic symptoms may be evident in any 
case of nephritis. They may also be present in minor degrees, at least, in 
the absence of demonstrable nephritis, though many if not all of such 
cases represent probably an early chronic nephritis. In all observed by 
the author the functional activity or permeability of the kidney has been 
temporarily reduced. Its most extreme and bizarre manifestations are en- 
countered in chronic interstitial nephritis, or, even more commonly, in 
chronic parenchymatous nephritisj during periods of low urea excretion. 

The Onset. — The onset of uremia of the severer types is almost invariably 
associated with lessened quantity of urine, excessively high arterial tension, 
and a sharp reduction in total solids and urea, or almost complete impermeability 

* Amaurosis, i.e., blindness usually temporary and removable and without apparent 
lesion may also be encountered in hysteria, migraine, acute severe hemorrhages, tobacco 
and cocain habituation and diabetes. 

t In one case of interstitial nephritis in the author's practice, typical Cheyne-Stokes 
breathing was present at night for over three years before the patient's death and was 
occasionally observed in the daytime during hours of active business. 

% A case under the author's observation for five years showed during that period nearly 
every symptom to which reference has been made in a preceding page, and among these 
were attacks closely simulating hysteria, but promptly removed by radical therapeutic 
measures, while no less than three times before death the patient was found in deep uremic 
coma. 



UREMIA 



249 



to solids as proven by the phenolsulphonephthalein and other tests. In the rarest 
instances decided polyuria precedes the attack. 

Uremic Coma. — This may closely simulate that of apoplexy in which 
condition interstitial nephritis plays so large a part, but is rarely so sudden 
in onset and is more generally preceded by convulsions, a history of which 
should be carefully sought. Such cases are the bete noire of the hospital 
physician on account of the difficulties attending "emergency" differen- 
tiation. 

The following points should be carefully noted: .(a) Examination of 
the urine obtained by catheterization is of the first importance, as it may 
yield evidence of an active or chronic nephritis or show a marked reduction in 
solids, (b) A history of antecedent convulsions or convulsive movements may 
be obtainable, (c) The pupils yield no certain signs, (d) Paralyses are rare, 
though transient hemiplegia is a rare possibility and there may be muscidar 
twitching and rigidity of the extremities if severe convulsions have occurred, 
(e) The temperature may be elevated, but usually it is normal or subnormal. 
(J) Opthalmoscopic examination may or may not show retinal changes, (g) 
The general aspect of the patient may clearly indicate the existence of renal 
disease, (g) No absolute dependence can be placed upon the odor of the breath 
as indicating renal toxemia, yet it is strongly suggestive and helpful. 

High Blood Pressure. — High arterial pressure may prove a most valuable 
and suggestive finding. 

Uremia vs. Acetonemia. — The uremic odor is sweet, nauseating, chloro- 
form-like and may pervade a whole apartment, but is found in connection 
with profound toxemia, resulting from cardiac failure, advanced hepatic 
disease, renal disease and sometimes in connection with malignant growths. 
It lacks the peculiar quality of the breath encountered in diabetic coma, 
in which there is an actual fruity fragrance of the most penetrating 
quality. 

CRYOSCOPY. — The introduction of cryoscopy by Koranyi represents an 
effort to secure more exact information especially concerning renal activity 
and efficiency by determining the freezing point of the blood and urine. The 
greater the molecular concentration of a watery fluid the lower is its freezing 
point, and assuming that the average freezing point of normal blood ranges 
from — 0.56 to — o.58°C, and that of urine between — 0.9 and — 2°C, it is 
evident that the lower freezing point on the part of the blood indicates a 
greater concentration and that a higher figure for the urine indicates a 
lessened molecular content. 

It further appeared that a test of the urine taken by catheterization 
from each kidney might determine the relative functional activity of those 
organs and that the procedure would prove a guide to the surgeon in nephrec- 
tomy as well as to the physician in connection with the so-called uremic 
states and renal inefficiency. 

As a matter of experience the cryoscope has proven a distinct disappoint- 
ment, being wholly untrustworthy in ordinary clinical urinary work by reason 
of its extreme delicacy and the serious errors incident to its use. 



Clinically 
useless. 



Untrust- 
worthy. 



250 



MEDICAL DIAGNOSIS 



No hard and 
fast lines. 



Blending of 
lesions. 



All 

nephritides 

"mixed." 



Diagnostic 
reverses. 



Total nitrogen. 



THE CLASSIFICATION OF RENAL DISEASES.— The student would 
be spared much distress of mind and disillusionment were it more generally 
taught that a rigid clinical classification of renal lesions is an absurdity. 

We may divide the nephritides into acute or chronic and distinguish 
anatomically certain leading types such as the acute and chronic parenchy- 
matous nephritis, chronic primary interstitial nephritis, and amyloid de- 
generation, but neither clinically nor anatomically can we draw hard and 
fast lines. 

We know little of the "real beginnings" of an interstitial nephritis or of that 
vague zone where "functional changes" end and il degenerative changes" begin. 
We do know that there is no "interstitial nephritis" without some degree of 
parenchymatous change, and vice versa. 

Classifications are Artificial. — In the main, all classifications are clinical 
conveniences based upon the preponderance of clinical evidence or of suggested 
anatomic changes, rather than upon clean-cut and convincing data. 

These incontrovertible facts should discourage fine-spun diagnosis, yet 
emphasize the value of thoroughgoing intelligent examination. 

Arbitrary grouping is a teaching necessity hallowed by custom, but let us 
neither forget that no man has defined successfully "physiologic albuminuria" 
in clinical terms, nor lose sight of the fact that all forms of actual nephritis 
are in some degree "mixed." 

Life insurance companies find "physiologic albuminurias" expensive and 
clinicians are sometimes appalled by the scant autopsy findings in apparently 
clean-cut nephritides or, rarely, astounded by the demonstration of an 
acute nephritis in a case yielding no clinical urinary symptoms. 

RENAL INADEQUACY.— Aside from cryoscopy and the estimation of 
urinary solids, many efforts have been made to determine directly and by 
simple means the functional efficiency or inefficiency of the kidneys, espe- 
cially with relation to actual or suspected medical or surgical diseases of 
those organs, but until recently no method had been evolved which was 
free from serious objection and, at times, gross error. 

McLean's method, already described, is not adapted to the use of the 
practitioner (see p. 203). 

The accurate estimation of total nitrogen can hardly be adapted to the 
examination of specimens obtained by ureteral catheterization which repre- 
sents small separate specimens, and furthermore involves an absolute knowl- 
edge of the ingesta, of excretion through channels other than the kidney, a 
complicated chemical estimation, and repeated tests covering a considerable 
period; all of which requirements place it entirely outside the possibilities of 
the everyday clinical work of the general practitioner. 

Rough estimations are of course extremely helpful and at times of great 
value but all medical men have felt keenly the need of some method at once 
simple and accurate. 

Methylene Blue. — Achard and Castaigne some years ago recommended 
and used methylene blue for the determination of the functional activity 
of the kidneys, using intramuscular injections and noting the time elapsing 



RENAL INADEQUACY 



251 



between its administration and the subsequent discoloration of the urine as 
well as the approximate amount of the coloring matter recovered. It has 
been found, however, that the test is of little value as a measure- of renal 
insufficiency, the elimination being unmodified in parenchymatous and 
amyloid nephritis and too widely variable in different cases of interstitial 
nephritis. 

The Relative Toxicity of Urines. — Bouchard's method of determining 
the relative toxicity by injecting urine into guinea-pigs is entitled to little 
respect, nor is it in any way adapted to ordinary clinical work. 

The Phloridzin Test. — It is probable that the sugar excretion following 
the hypodermic use of the glucoside phloridzin furnishes a reasonably accu- 
rate index of renal secretory activity. 

Test. — -i c.c. of a sterile 1 : 200 watery solution of the glucoside, gently 
heated to dissolve any persisting crystals, is introduced into the tissues. 
Sugar should appear in the urine within from thirty to sixty minutes and sugar 
excretion should cease within four hours. The total amount excreted 
varies from 0.5 to 2.5 grams. 

If the functional capacity of each kidney is to be determined, the ureteral 
catheters should be introduced and left in position during the whole test 
period. 

No sugar, or but minimal amounts, will be secreted in acute or subacute 
nephritis and advanced interstitial nephritis. 

As the clinical evidences of the first two forms is almost invariably frank, 
the test can only be of great value in certain rare cases of interstitial nephritis. 

Determination of Electric Conductivity. — This is little more than a 
complicated, and clinically unimportant, method of estimating the mineral 
constituents of the urine. 

THE PHENOLSULPHONEPHTHALEIN TEST.— The Best Procedure.— 
Rowntree and Geraghty have introduced a test of renal functional activity* 
which has maintained its place for several years and represents the highest 
degree of accuracy so far obtained by simple and practical methods. 

The procedure proved of distinct usefulness and value in the author's clinic. 

Drug. — The drug is a non-toxic, bright red powder moderately soluble 
in alcohol and water and readily soluble in the presence of alkalies. 

Normal Excretion. — 77 is excreted with almost incredible rapidity, appear- 
ing in the urine a few moments {five to eleven) after hypodermic injection, and 
being eliminated in normal cases almost wholly within two hours. From 50 
to 60 per cent, of the drug should be excreted during the first hour, and from 70-90 
per cent, by the end of the second. 

Test Solution. — 0.6 gram of the phenolsulphonephthalein and 0.84 c.c. 
of a 2/N NaOH solution (8 per cent.) are added to normal salt solution suffi- 
cient to make 100 c.c. The addition of a few drops more of the 2/N NaOH 

* It should be thoroughly understood that normal excretion does not prove that the 
kidneys are free from disease. It does show that, at the time, the renal function is not 
seriously affected. We do not know what degree of change is required to produce recog- 
nizable impermeability. 



Simple and 
accurate. 



Renal. 



Time limits. 



252 



MEDICAL DIAGNOSIS 



End coloi 
reaction. 



Standard color. 



solution to the injection fluid at the time it is used changes the color of the 
test fluid to a wine red and renders it non-irritating to the tissues. 

Technic. — (a) The patient is given 300 to 400 ex. of water to insure free 
secretion, (b) A catheter is passed into and retained in the bladder after this 
viscus is completely emptied, (c) At a carefully noted time, twenty to thirty 
minutes after the ingestion of the water, 1 c.c. of the test solution (6 mg. of the 
drug) to which 2 or 3 additional drops of the 2 /NNaOH solution have been added 
to prevent irritation, is injected into the upper arm. (d) From this time all of 
the urine is led into a test-tube containing a drop of 25 per cent, sodium hydrate 
solution and the first appearance of a pink color carefully noted. 

This represents the initial excretion period which normally varies between 
five and eleven minutes. 

Obstructive vs. Unobstnictive Cases. — If no obstruction to micturition 
exists the catheter now may be removed, the patient voiding at the end of 
both the first and second hours. 

In obstructive cases the catheter is clamped and maintained in situ until 
two hours have elapsed, the bladder being drained at the end of each hourly 
period. 

Colorimeter. — The amount excreted is measured by a colorimeter.* 
Each hour's voiding, being measured and its specific gravity determined, is 
placed in a 1 -liter volumetric flask and treated with sufficient 25 per cent. 
NaOH solution to alkalinize it and thus develop the maximum color, a brilliant 
purple red. 

Sufficient distilled water to bring the solution to the 1 -liter mark is then 
added, the mixture thoroughly shaken up and a filtered portion taken for 
comparison with a standard solution consisting of 1 c.c. of the test solution in 
1 liter of water, plus 1 or 2 drops of a 25 per cent. NaOH solution. 

The standard solution is accurately adjusted to the 10-mm. mark of the 
scale and compared with the unknown solution, the percentage of drug 
excreted being calculated by the differences in scale required to secure unifor- 
mity of color in the two solutions. f 

Clinical Application. — In renal disease, both parenchymatous and in- 
terstitial, but especialiy the latter, the excretion is retarded and greatly 
diminished if the kidneys are insufficient. 

Advantages Claimed for the Test. — Its originators claim for it the follow- 
ing advantages: 

(a) It represents a non-toxic agent promptly secreted by normal kidneys, or 
by diseased kidneys, while functionally efficient, but retained for suggestively 
longer periods in actual renal insufficiency. 

* Geraghty and Rowntree's recent modification of the Autenrieth-Konigsberger color- 
imeter permits a direct percentage reading by an indicator on the scale of the instrument. 
(See also "Kuttner's colorimeter," described in "Blood" section.) 

t As the standard is 10 it is evident that a reading of 20 for the unknown solution 
indicates the presence of but 50 per cent, as much dye as is contained in the standard 
solution (3 mg.) which represents but one-half the quantity of dye injected for the test 
(6 mg.). Hence the reading of 20 on the scale indicates an excretion of but 25 per cent, 
of the dye and the same proportion will be true for any other readings obtained. 



DISEASES OF THE KIDNEY 



253 



(b) The brilliant red of the solution lends itself readily to colorimetric 
determinations. 

(c) In cardiorenal cases the drug may show clearly the extent of actual 
renal insufficiency inasmuch as simple chronic congestion, save in the most 
extreme degrees of incompensation, affects excretion but slightly as compared 
with actual nephritis. 

(d) It permits better prognosis, forecasts or determines the presence of uremia 
and is oj great importance with relation to proposed surgical procedure, and 
in warning the obstetrician of impending eclampsia. 

(e) Within reasonable limits and in conjunction with ureteral catheteriza- 
tion it permits an estimate of the relative functionating values of the two kidneys. 

Uremic Seizures. — During an actual uremic attack the elimination during 
two hours is almost nil. 

Impending Attacks of Uremia. — In any nephritic patient a showing of 
10 per cent, or less indicates an impending uremic seizure. 

CHRONIC PASSIVE CONGESTION OF THE KIDNEY 

The Kidney of Stasis. — This is always obstructive in the clinical sense, 
whether the primary disease be of the heart or pericardium, lungs or liver, 
pressure on the renal veins by abdominal tumors (including the pregnant uterus 
and ascitic fluid) or the cardiac weakness of prolonged exhausting disease. 

Minor degrees of passive venous congestion are much more common than is 
generally taught or believed. 

Morbid Anatomy. — The kidneys ordinarily show a simple venous hy- 
peremia though in cardiac incompensations of long standing or such as result 
from or are associated with an actual nephritis, both parenchymatous 
and interstitial changes may be manifest. Indeed simple cases of long 
standing may show the well-known "cyanotic induration" kidney in which 
marked atrophy of the secreting structures and some interstitial changes 
may be manifest. 

Symptoms. — There are no symptoms of importance save the urinary find- 
ings and those referable to the primary lesions. 

Urine in Chronic Passive Congestion. — The total amount is diminished, 
the total solids approximately or actually normal. 

Reaction. — Acid. 

Color. — Distinctly high save in diseases characterized by marked im- 
pairment of nutrition. 

Albumin is present only as a trace, except in pregnancy when large 
amounts may be found, as is also the case when decided parenchymatous 
changes co-exist. 

The amount of albumin in simple passive congestion usually varies in- 
versely with changes in the heart strength, and such variations often assist one 
in the diagnosis of the minor cardiac decompensations. 

Microscopic Findings. — An occasional hyaline or finely granular cast, 
together with a few renal cells constitute the usual findings. 



Differential 

value. 



Prognosis and 
prediction. 



Relative 
excretion. 



Venous 
obstruction. 



Often 
"mixed." 



Important fact. 



254 



MEDICAL DIAGNOSIS 



Caution. 



Total solids. 



Faulty 
classification. 



Chief cause. 



THE KIDNEY OF PREGNANCY.— There is no single and distinct 
anatomic type which fits this clinical condition. 

Even though the condition may be one of simple pressure hyperemia, 
the amount of albumin is likely to be larger than in other instances of chronic 
passive congestion, and it must not be forgotten that active hyperemia or 
acute or chronic inflammatory diseases of the kidneys may accompany this 
state, a toxic tubular nephritis is the commoner type. 

In this connection it is of the utmost importance that specimens of urine be 
submitted frequently to the attending physician and that these represent the 
twenty-four hours' urine, and not the individual haphazard specimen. 

Furthermore, the essential feature of the examination, as indicating 
danger to the patient, lies in the estimation of urea, the blood pressure and 
in the use of the Rowntree and Geraghty test when deemed necessary. 
This point is often overlooked by the practitioner, who may mistakenly 
regard the amount of albumin as the important feature. 



ACUTE SEVERE CONGESTION AND ACUTE NEPHRITIS 

Clinically Inseparable. — These conditions should be considered together, 
inasmuch as the causes operating to produce them are essentially identical and, 
further, because no line can be drawn clinically between actual acute nephritis and 
severe congestion, save that based upon the duration of symptoms. 

Mild congestion of the arterial type occurs under many conditions 
of slight potency, and is the antithesis of the severer types, the amount of 
urine being increased, but a small trace of albumin being present, and the 
urinary solids being actually or approximately normal. 

Etiologic Factors. — Irritating Drugs. — Among these are copaiba, cubebs, 
sandalwood oil, turpentine, cantharides, carbolic acid, phenol compounds 
generally, arsenic, lead and mercury. These cause trouble only when ingested 
in excessive doses or for too long a period. 

Insoluble Urinary Constituents. — Uric acid, calcium oxalate, cystin, 
acid urates and phosphates, as constituents of "gravel" or "calculi" are 
the chief factors. 

Toxins. — These may be divided into three groups: (i) Those asso- 
ciated with acute febrile infections and especially with the exanthemata 
and certain virulent tropical diseases, of which yellow fever is the chief. 
(2) Suppuration with septic absorption which should include the acute and 
chronic disease of the tonsils, peridental abscesses, chronic prostatitis, sinus 
diseases and like obscure sources of infection. (3) Chronic diseases, such as 
syphilis, gout, malaria, pulmonary tuberculosis, diabetes mellitus and certain 
of the anemias. Streptococcus infections are especially potent. 

The toxic albuminurias may be extremely mild and transitory, as acute 
clinical conditions, and are best exemplified by the so-called "febrile" albu- 
minuria. Whether such conditions leave'permanent lesions behind them or 
not, depends upon the virulence of the toxemia and the condition of the 



DISEASES OF THE KIDNEY 



255 



patient prior and subsequent to the attack. Clinically, they represent no 
more than a mild renal congestion. 

Nervous Influences. — Formerly it has been customary to place under this 
head the nephritis attending such conditions as acute mania, delirium tremens 
and the so-called ascending or reflex congestions connected with diseases of 
the bladder, seminal vesicles, urethra and the prostate. This is incorrect, 
for the ingestion of large amounts of alcohol is in itself sufficient to produce 
marked albuminuria and reduce resistance to infection from within and 
without the body. 

Add to this the exposure to the elements and the excessive exhaustion 
attending delirium tremens, and acute renal congestion or an actual nephritis 
is readily explained. In many cases of acute mania, nephritis is the ante- 
cedent factor of which mania may be but a symptom. In delirium tremens 
the habits of the individual, the likelihood of preexisting disease, the exposure 
and exhaustion attending a debauch, leave little room for the older classifi- 
cation. In the case of the so-called reflex or ascending congestion, save in 
the rarest instances, we are dealing with an extension of infection. 

Pregnancy. — The acute renal disturbances of pregnancy are associated 
with a marked diminution in the amount of urine, a profusion of casts and 
albumin, and an associated edema of varying degree, often decided or even 
excessive. Toxic symptoms are decided and the condition tends to the 
production of convulsive seizures of an uremic type. Blood cells are present 
in the urine in many or most instances but not to the degree usually observed 
in connection with the actual acute nephritis of the ordinary type. Empty- 
ing the uterus, if timely, is followed by a rapid recession of the symptoms 
and, in most instances observed by the writer, an uneventful and complete 
recovery on the part of the patient. 

General Causes. — Sexual excesses, the excretion of large quantities of 
bile, and extreme concentration of the urine seem adequate to produce mild 
congestion. 

Fatigue, mental or physical, particularly when combined with exposure 
to cold or wet, would seem to be a predisposing cause, but the most potent 
active factors are the chronic infective foci already mentioned. 

Morbid Anatomy. — The complex description and varying terminology 
in use embarrass the student when he approaches the subject of renal pathology. 

Essential Factors. — All renal lesions, acute or chronic, actually fall under 
four heads: 

1. Those in which glomerular changes predominate. 

2. Those in which tubular changes dominate. 

3. Those in which the interstitial changes are most prominent. 

4. Those in which all structures are affected without determinative dominance 
of any one group. 

The finer classification and subdivisions are of pathologic interest only 
and in any severe nephritis, acute or chronic, one finds all structures involved 
in some degree, so that it becomes simply a question of relative predominance. 

Clinical Aspect. — In an acute nephritis or severe acute congestion of the 



Negligible. 



"Reflex" a 
Misnomer. 



256 



MEDICAL DIAGNOSIS 



Variable onset. 



Early edema. 



Hypertension. 



Peculiar facies. 



kidney, any one of the three pathologic types, glomerular, tubular, or interstitial, 
may be primary or predominant. 

Aside from the rare and clinically unrecognizable acute nonsuppurative 
interstitial nephritis, the three fundamental structures are in some degree 
involved and, in any event, no consistently accurate clinical distinction can 
be made. 

Microscopic Pathologic Findings. — We ordinarily find cloudy swelling, 
desquamation, and hyaline, dropsical and fatty degeneration or complete 
necrosis of the epithelium of the tubules, which are crowded with inflamma- 
tory detritus. We are likely to find acute intracapillary glomerulitis, the capil- 
laries being filled with cells and thrombi and the epithelium of the tuft and 
capsule being involved. The latter is crowded with blood cells and leucocytes, 
and interference with the renal circulation and nutrition, no less than with 
the excretion of the urine and contents, is inevitable. Furthermore, the 
loss of integrity on the part of the filtration apparatus must necessarily 
lead to the escape of albumin. In rare instances a portion only of the kidney 
may be involved, or the process may be unilateral. 

Macroscopic Appearance.- — The gross appearance of the kidney varies 
somewhat; it is ordinarily swollen and red, dripping blood on section, having 
a succulent feel and an easily stripped capsule. Rarely it may be pale and 
mottled, exuding on section a milky fluid (acute non-suppurative interstitial 
nephritis). The glomeruli are usually red and prominent, but may be pale 
and indistinct. 

GENERAL SYMPTOMS.— The onset may be sudden and frank, with chill 
and sharp temperature rise, but is usually gradual, afebrile, and insidious. 

There is usually some pain or heaviness in the loins, a dry skin and in- 
creased frequency of micturition, the pulse tension increases, and nausea, 
vomiting, headache and thirst may be present. 

The severity of the initial symptoms bears no definite relation to the 
type of the disease, save that those of simple acute congestion are ordinarily 
milder and more evanescent. In many instances the first thing noted is 
pufiiness under the eyes, the development of general edema, or even uremic 
convulsions or coma. As a rule, however, these two last symptoms occur 
only after several days of illness. 

Arterial Tension. — One of the best guides when nephritis complicates 
other disease is found in the arterial tension, which is usually but not in- 
variably increased in the presence of either severe acute renal congestion or 
inflammation (180 to 200 mm.). 

Fever. — Though ordinarily present, it is seldom high and often is masked 
by that of some primary disease of which the nephritis is a complication. 

Edema. — The edema of acute nephritis is oftentimes extreme and is likely 
to appear first in the eyelids and tissues of the face, the skin being pallid* 
and "pasty." 

* A secondary anemia of considerable or excessive degree may be present but the 
"pallor" does not prove its presence nor conform to the degree of anemia when that does 
coexist. 



DISEASES OF THE KIDNEY 



257 



In the extremities the swelling is comparatively firm, though pitting 
deeply on pressure, and, because of the blue veining on the dead-white back- 
ground which is especially well marked on the child's skin is often termed 
14 marble edema." 

There is a special tendency to secondary complicating symptoms espe- 
cially affecting the serous membranes and the myocardium and to attacks 
of edema of the glottis which, if not immediately relieved, may cause sudden 
death by suffocation. 

Special Precautions. — At least once daily the attending physician should 
by careful examination exclude endocarditis and myocarditis, no less than 
pericarditis and pleurisy, with or without effusion, the condition last named 
often coming on rapidly and insidiously. 

Edema of the glottis with urgent stenotic dyspnea usually demands imme- 
diate recourse to the most radical measures; the free scarification of the 
engorged tissues, prompt application of astringent preparations and, very 
often, an emergency tracheotomy. A few moments of indecision and delay 
has more than once caused death. 

URINARY FINDINGS. — The urinary findings in acute congestion vary 
with its severity, but tend to assume, pari passu, characteristics identical 
with those of acute nephritis. 

// is evident that severe acute congestion can be differentiated from acute 
nephritis only by its shorter duration, but the mildness of the slighter grades 
makes their recognition easy. 

The student should refresh his memory regarding the subject of albumi- 
nuria and the finding and significance of casts before taking up the following 
section. The findings fall naturally under three heads: 

First Stage. — Quantity for twenty-four hours, 100 to 400 c.c. Color, dark 
smoky or black. Specific gravity. This may be high or low for albumin 
may raise it even to 1030. It is invariably low if albumin is removed. Re- 
action, acid or, from large quantities of blood, slightly alkaline. Solids, 
the solids are absolutely diminished, urea being greatly lessened and the 
chlorides absent if dropsy is extreme. 

Sediment. — An abundant dark sediment is present. Casts are abundant, 
the urine containing dark granular, epithelial, fibrinous and blood casts 
with a few T hyaline and fine granular forms. Casts carrying leucocytes, 
caudate pelvic cells, and round cells from calices are present in severe cases. 

Albumin. — This varies from y± to 1 per cent, according to the degree of 
tubal involvement. Red blood cells are abundant, as are leucocytes and 
brown granular epithelial cells. 

Second Stage. — Quantity for twenty-four hours, 600 to 1500 c.c. Color, 
dark and smoky. Specific gravity, 1015 to 1020, Reaction, acid. Solids, 
still diminished. 

Albumin. — This will vary from }£ to ^ per cent, diminishing pari passu 
witfrurine increase. 

Sediment. — Profuse and dark; fatty changes now become evident through 
fatty casts, fatty renal cells and compound granule cells. The amount of fat 
17 



Marble edema. 



Serious 
complications. 



Glottic edema. 



Acute 
congestion. 



Acute stage. 



Lasts 5 to 10 
days. 



5 to 10 dayt 



Improvement. 



Characteristic 
changes. 



25* 



MEDICAL DIAGNOSIS 



in some degree measures both the improvement and the severity of the 
primary attack. 

Third Stage. — Edema if originally present has now disappeared. Urine, 
the quantity is increased (1500 to 4000 c.c.) and the tendency to polyuria 
may last for weeks. Color, pale or slightly smoky. Reaction, acid. Specific 
gravity, 1006 to 1020. Solids, normal or slightly increased by absorption of 
exudate. 

Albumin. — This will vary from a mere trace to ^ of 1 per cent. 

Sediment. — This is scant and of lighter color and contains abnormal 
blood cells (rings) (ghosts) , and occasionally hyaline and granular casts both 
light and dark. Possibly an epithelial, fatty, or fibrinous cast may be found 
and a few renal cells. The casts and renal cells may carry fat droplets or 
abnormal blood cells, but as improvement continues the evidence of active 
degenerative and regenerative changes disappears and the urine at last 
becomes normal. 

Any chronic renal disease may undergo acute or subacute exacerbations and 
a most common diagnostic error lies in the failure to appreciate the fact that in 
adults most of the apparently acute cases are but exacerbations of an unrecognized 
chronic nephritis. 

Prognosis. — The disease is less common and less fatal in dry than in damp 
climates. Children give a large mortality (30 per cent.), especially scarlatinal 
cases. Low tension, extremely high tension, major uremic symptoms, and 
serous effusions are ominous, and lack of any decided improvement after 
ten days means a probability of chronic disease. Persistent profound anemia 
is also a threatening sign but recovery may take place even after one or two 
years. Relapse and multiple relapses are frequent. 

ACUTE FOCAL GLOMERULONEPHRITIS.— These cases are clinically 
undemonstrable as such, and represent focal embolic nephritis, involving 
especially the glomerular capillaries in minute widely scattered areas. 

Albuminuria, a few red blood cells in the sediment, and, sometimes, 
fugitive edemas, constitute the only bases for diagnosis. 

In the presence of " endocarditis lenta," or other conditions of a similar 
sort, this condition may be assumed with some justification if the symptoms 
named above are present. 

ACUTE INTERSTITIAL NON -SUPPURATIVE NEPHRITIS.— This 
interesting pathologic picture is revealed only at autopsy, and, chiefly, in 
fatal cases of scarlatina or, less frequently, acute rheumatic arthritis. As 
stated previously, the change is almost exclusively confined to the inter- 
stitial tissue, in which round cell infiltration is demonstrable. Clinical signs 
of renal involvement may be wholly absent during life. 

CHRONIC PARENCHYMATOUS NEPHRITIS 

Etiology. — An antecedent acute nephritis, prolonged exposure to wet and 
cold under conditions of fatigue, chronic malarial infection, syphilis, alcoholism, 
chronic suppuration and chronic obscure infections are the common factors. 



DISEASES OF THE KIDNEY 



259 



The many sources of streptococcic infection must be considered, for this 
organism plays the chief part in all probability. 

Morbid Anatomy. — Glomerular, tubular, and interstitial changes are present, 
the two first predominating. 

The kidney is large, its capsule may be adherent, but usually strips 
easily from the pale and mottled kidney surface; section shows increased 
resistance and a swollen white cortex with curious areas of opacity. 

Microscopic Findings. — These include obliterative hyaline degenerative 
changes in the vessels of the glomeruli, involving both the cells and the 
vessel walls, and swelling and nuclear proliferation of the tufts is evident. 
There is a tendency to connective-tissue ingrowth and to proliferation and 
desquamation of the capsular epithelium. 

The tubules show degeneration, desquamation, and necrosis of their 
epithelium and edema and connective- tissue infiltration of the intertubal 
tissues. 

Symptoms. — The onset is insidious but the general symptoms usually 
become frank, anemia and edema alike being prominent. 

The various uremic phenomena are common, early, and recurrent, there 
being a special tendency to headache, dyspepsia, intractable neuralgias, 
nausea, vomiting and diarrhea. Pleurisy and pericarditis with effusion are 
frequently observed. Ulceration of the colon occasionally occurs. There is 
constant tendency to general anasarca, and quiet, insidious transudations 
into the pleura, pericardium, peritoneal cavity, and tunica vaginalis testis 
may complicate the case. 

Although edema of the face and pallor are ordinarily the first noticeable 
objective signs, the edema usually appears promptly in the ankles and may 
at this time act much like the cardiac form though far more shifting and 
inconstant with respect both to degree and location. About the face, head, 
and neck it is particularly pronounced in the early morning. 

The circulatory changes are less marked and constant than in interstitial 
cases, though the pulse tension is usually increased and may become very 
high as the disease progresses. The second aortic and apical first sound are 
in such cases markedly accentuated, the left ventricle enlarged and changes 
in the retina are common. In many cases the heart remains throughout a 
weak dilated or readily dilatable organ, the myocardium being persistently 
affected by the toxemia. 

URINARY FINDINGS.— It is customary to separate the urinary symp- 
toms into those of the active, as compared with the inactive stage. It will 
be noted that the essential symptoms are the same under both conditions, i.e., 
a decided albuminuria, the presence of fatty casts, and marked diminution of 
the urinary solids. The disease is especially liable to subacute exacerbations, 
giving to the urinary findings a resemblance to an acute nephritis of the 
early stage of convalescence. 

Active Stage. — Amount, 200 to 800 c.c. Color, high or pale, yellow 
or greenish, often smoky from exacerbation. Reaction, acid. Specific 
gravity, high from albumin, 1026 to 1035; but with this removed, low. 



Misleading 
exacerbations. 



260 



MEDICAL DIAGNOSIS 



A misnomer. 



Essential 
features, like 
interstitial 
form. 



Solids, greatly diminished, especially chlorides and urea as in all dropsical 
cases of renal disease. 

Albumin. — This is profuse and the urine may boil solid. One-half to 
two per cent, is the common variation (5 per cent, has been reported, but the 
average is 1 per cent.). 

Sediment. — This is always considerable and one finds hyaline, granular, 
fatty and epithelial casts, fatty epithelium and compound granule cells. 

Epithelial casts indicate in any form of nephritis a superadded or recent 
acute or subacute trouble. Free fat, fat crystals, cholesterin and waxy casts 
occur in the late stages. Red blood cells are present and may of course be 
very plentiful and associated with blood casts. The number varies with the 
intensity and stage of the active process. 

Inactive Stage. — Quantity, 800 to 1200. Color, pale or greenish. 
Reaction, acid or neutral. Specific gravity, 1010 to 1015. Solids, greatly 
diminished. Albumin, J4 to H P er cent. Sediment, as in active stage. 

Prognosis. — If the disease is strongly intrenched and not merely a pro- 
tracted case of acute Bright's disease, its victims rarely recover, but die in 
a few years of pulmonary edema, general anasarca or uremia, the average 
duration of the disease being a little over two years. 

Cases of Mixed Type. — Cases are frequently observed which present evi- 
dences of marked tubular and glomerular involvement for long periods without 
excessive general edema, and ultimately become clinically almost typical cases 
of interstitial nephritis. 

In these mixed cases the urinary findings much more closely resemble 
cirrhotic kidney than do those assigned to the type described below. 

THE SMALL WHITE KIDNEY (Secondary Contracted Kidney).— 
This misnamed condition is supposed to represent an advanced stage of 
an unusually prolonged chronic parenchymatous nephritis with ultimate 
predominance of the interstitial elements. It represents actually a "mixed" 
nephritis. 

Morbid Anatomy. — The kidney is sometimes small and yellowish but more 
often approximates the size of the large white kidney. Connective-tissue 
hyperplasia is marked, the capsule being thick and adherent, and the kidney 
surface under it rough and granular and on section there is increased resist- 
ance. The cortex is thin, pale, yellow, and covered with yellowish-white 
spots. 

Microscopic Findings. — The interstitial changes are marked, there is arterial 
thickening, and the glomerular and tubular structures are degenerated and 
largely destroyed. 

General Symptoms. — These are essentially those of a combination of 
parenchymatous and interstitial nephritis, changes in the heart and blood 
vessels being more pronounced than in the parenchymatous form. 

Urinary Findings. — Quantity, normal or slightly increased. Color, 
pale. Reaction, acid or neutral. Specific gravity, 1004 to 1010. 
Total solids, greatly diminished. Albumin, Y± of 1 per cent, or less. 

Sediment. — This is like that of chronic parenchymatous nephritis of the 



DISEASES OF THE KIDNEY 



261 



"inactive" stage, save that casts are less abundant, and that, in some 
cases, late in the course of the disease, waxy casts are found in unusual 
numbers. 

FOCAL ARTERIOSCLEROTIC FORM.— This represents the senile 
type of diseased kidney and is characterized pathologically by its tendency 
to maintain an approximately normal size, associated with a certain amount 
of induration. 

The involvement of the vessels is patchy, irregular, and not confined to 
the arterioles. This condition is reflected in the macroscopic "patchy" 
depressions scattered over the surface of the kidney. In nearly every in- 
stance, the condition is associated with decided peripheral arteriosclerotic 
changes throughout the body. Urinary signs are scant, and may be wholly 
absent over long periods. Arterial pressure may be high, low, or inconstant 
and widely variable. Signs of renal insufficiency may be lacking up to the 
time of death. 

CHRONIC INTERSTITIAL NEPHRITIS 

("Gouty" kidney, "contracted" kidney, "cirrhotic," "granular," "sclerotic" 
or "small red" kidney, "chronic diffuse" nephritis, etc.) 

Morbid Anatomy. — The kidneys are usually small, an extreme instance 
having been reported in which their combined weight was but i}^ ounces. 
The capsule is thickened and adheres to the dark red, nodular, granular 
surface, and section shows an increase in resistance. The arteries are 
prominent, the cortex very thin, the pyramids wasted and the pelvic fat 
increased. 

Microscopic Changes. — These are essentially those of connective- tissue 
overgrowth, with atrophy and degeneration of both glomerular and tubular 
structures. Many of the glomeruli and tubules are entirely destroyed. 

Etiology. — Here, as in arteriosclerosis and aneurysm, the worship of 
Venus, Bacchus and Vulcan have long been regarded as the primary factors 
in causation, though to this group one might well add Minerva and also 
Mammon, the non-Olympian. 

In other words, overwork (mental and physical), syphilis, sexual excess, 
exposure and privation, heavy eating and drinking, all play a prominent part. 

The author believes, nevertheless, that with the exception of lues, these are 
merely predisposing factors. 

Chronic foci of infection and the obscure and subtle changes wrought by past 
illnesses are probably the most potent elements. 

Arteriosclerosis is a prominent feature in cases of interstitial nephritis 
and one is not surprised to find what seems like a direct hereditary predisposi- 
tion to the development of the latter disease. Lead poisoning, lues, alcoholic 
excess, chronic malaria, and the various forms of gout are common and promi- 
nent in the case histories. As in the case of arteriosclerosis proper, we here 
find the "young old man," old by virtue of inherited vascular weakness or 
gout, or through sexual excesses, syphilis, or excessive mental strain. It 



A masked 
process. 



262 



MEDICAL DIAGNOSIS 



Incredibly 
slow. 



Often 
unrecognized. 



Urine and 
circulatory 
organs. 

Silent 
hypertension. 



Certain 

hypertension 

symptoms. 



Significance of 

extreme 

hypertension. 



is wholly probable, however, that acute infections or obscure chronic infec- 
tions of the streptococcus type play a large part or the leading role. 

The chronic or remittent toxemia of interstitial nephritis itself doubtless 
promotes and advances arteriosclerotic changes in the general arterial 
system. 

General Symptomatology. — The pallor, edema and the frankly albuminous 
and cast-filled urine of chronic parenchymatous nephritis makes mistaken 
diagnosis in the case of that form of nephritis unpardonable. The reverse is true 
of chronic interstitial nephritis. 

In the earlier clinically recognizable stages of the disease the patient may 
appear to enjoy unusually good health, this being particularly true of the 
sthenic type. Pallor, edema, and pigmentation are late symptoms, and the 
urinary findings are sometimes both variable and obscure. 

Many cases die under other diagnoses and in the case of many others, recogni- 
tion is deferred until autopsy. 

It must be borne in mind also that most of these cases exist for years 
before clinical recognition is possible. We know but little of such ailments in 
their earlier pathologic stages. 

Much dependence must be placed upon the secondary signs in the heart and 
blood vessels, and the urinary examination demands care and the intelligent 
application of a full knowledge of the vagaries of this extraordinary disease. 

Most patients with well-established lesions seem to become habituated 
to, and carry well an arterial systolic pressure of 170 to 180 or 185 mm. of 
mercury, but usually show symptoms if the higher figures are much exceeded. 

Sensory Disturbances. — These symptoms are often obscure and consist 
chiefly of numbness, tingling or a sense of weakness in the extremities. 

The general symptoms are essentially those of arterial hypertension or 
uremia, either or both of which may be present at any time in any of their 
various forms. The severer manifestations of uremia may be postponed to 
the very end of the case, or never occur. (The section dealing with uremia 
should be carefully reviewed.) 

Circulatory Signs. — Advanced interstitial (diffuse arteriolar) nephritis is 
invariably attended by increased arterial tension, at least until the extreme ter- 
minal cardiac incompensation supervenes. 

This hypertension is indicated by the sphygmomanometric readings and 
reflected in the overacting or hypertrophied left ventricle, a hard radial pulse, 
and, usually, marked accentuation of the aortic second sound and mitral first 
sounds, with or without reduplication of the latter. 

In advanced cases with uremic manifestations the systolic pressure, ordinarily 
165 or 170 to 215, may reach 250 or even 300 mm., though the last figure has been 
seen by the author only just before or a few days preceding an apoplectic stroke, 
uremic convulsions or coma. 

Most authorities state that abnormal tension follows rather than precedes 
definite urinary findings, but the author believes this to be an exact reversal of 
the true sequence. 

It should be understood that in many cases of decided arterial hypertension, 



DISEASES OF THE KIDNEY 



263 



the aortic sound is not heard as a sharply accentuated tone. Many errors result 
from the usual teaching with reference to this matter. 

In many cases, early or late, the classic accentuation of heart sounds is lost 
or modified by reason of valvular changes or a weakened myocardium. 

The sphygmomanometer will ultimately give us, in all probability, our 
first knowledge of the true "early stages" of interstitial nephritis and the 
phenolsulphonephthalein test may also aid us. Neither, however, can take 
us back more than a part of the way to the beginnings of interstitial nephritis 
of the common type. 

Arterial tension is often maintained at a high figure even when death is 
impending and cardiac insufficiency extreme, and indeed excessive tension in 
any case is often found to be due in part to stasis and decided amelioration 
may follow brisk cardiac stimulation.* 

Edema. — When marked edema appears in this disease, it is usually due chiefly 
to cardiac failure, and shows the characteristics of a passive congestion edema, 
the most dependent portion being first involved, as is the case in primary valvular 
or myocardial diseases of the heart. 

In many cases of established interstitial nephritis, however, one may see 
for years a curious fullness of the eyelids, especially the lower. In the 
morning the skin appears thinned, pearly, and almost translucent, whereas 
later in the day the fluid may disappear and the delicate integument 
subsides into fine wrinkles. 

Some of the cases come under the head of u mixed.nephritis" and in these 
the renal facies is likely to be more marked and unmistakable, owing to the 
presence of parenchymatous degeneration and glomerular changes. 

Traube's Heart. — In the case of the heart of long established renal dis- 
ease and arterial hypertension the whole organ may be affected, indicating 
quite clearly an underlying general toxemia. 

This is not always the case, however, and in many instances observed by the 
author the left ventricle only has shown change during many years. 

The Fundus Oculi. — In these as in other forms of renal disease, the eye 
changes may be pronounced and important; indeed, many cases are referred 
by the oculist to the internist under a correct diagnosis without urinary 
examination. The usual changes consist of flame-shaped hemorrhages, 
papillitis, retinal edema, or peculiar fawn-colored patches, radiating from the 
macula lutea. Glaucoma is not uncommon, and uremic amaurosis may 
occur. As a rule, these eye changes indicate a fatal termination in a short 
period, yet the author has observed one case in which the original diagnosis 
was made by the oculist, and a subsequent glaucoma led to enucleation of 
the affected eye; yet the patient is still living after fifteen years of apparent 
good health. The rule admits few exceptions nevertheless. 

Respiratory Tract. — It is important to remember the special liability of 
renal cases to attacks of bronchitis, pleurisy, asthma, edema of the glottis, and 
dyspnea in its various forms. 

* Probably because of the varying degrees of asphyxial irritation of the vasomotor 
center. 



A mis- 
conception. 



Stasis 
hypertension. 



Usually 
cardiac. 



A suggestive^ 
sign. 



Mixed cases. 



Warning. 



Readily 
recognized. 



Prognostic 
value. 



Pleurisy, 
asthma, and 
glottic edema. 



264 



MEDICAL DIAGNOSIS 



Scant findings. 



Nightly 
increase. 



Often 
important. 



Variable. 



Valuable 
warnings. 



Watch urea 
excretion. 



Deceptive 
findings. 



A massive pleural or pericardial transudate may come on so quietly 
as to attract no attention save through the embarrassment in respiration. 
In a case recently observed the acute edema of the laryngeal tissues, that 
followed a sharp attack of tonsillitis, proved to be due to the acute toxic 
congestion superimposed upon an old nephritis associated with passive con- 
gestion due to a weakened myocardium. 

The inflammation of serous membranes which may complicate Bright's 
disease are for the most part, doubtless, mere streptococcic infections which 
attack by preference a weakened body. 

URINARY FINDINGS. — The essential symptoms in the typical case consist 
in the increased amount of night urine, attended by increased frequency of 
micturition; a total increase for the twenty-four hours; a more or less persistent 
and extreme tendency to diminution in the total amount of solids; traces of 
albumin, and a few hyaline and granular casts. 

Increased night frequency may be due to causes other than nephritis, 
such as enlarged prostate, chronic irritability of the neck of the bladder, or 
cystitis, but when the symptom is associated with a marked disturbance 
of the normal ratio between night and day, the symptom becomes one of 
primary importance. 

Diminution of Solids. — Urea Variations. — A man with interstitial nephritis 
may during years pass a normal or nearly normal amount of urinary solids the 
greater part of that time, though unrecognized periods of retention undoubt- 
edly occur. 

In the later stages of the disease the excretion of solids will almost in- 
variably fall below normal, and this is especially true of urea. Valuable 
information is often given by sudden drops in urea excretion, associated with 
heightened arterial tension and in many such cases, under close observation, one 
may avert an impending attack of uremia or apoplexy through these warnings. 

Albumin. — Albumin may be present continuously or intermittently, at 
one time of the day and not at another, but in uncomplicated cases will be 
found only in small traces. The specimens least likely to show it are those 
passed in the early morning, those most likely being the ones voided several 
hours after a full meal taken in the middle of the day or after a heavy dinner 
at night. Exposure to cold, slight infection, physical exertion and the process 
of digestion seem to increase the albumin output. 

A negative examination of the single specimen, even of the twenty-four 
hours' urine, proves no man free from interstitial nephritis. 

Briefly we may summarize as follows: Color, usually pale. Specific 
gravity, low — 1002 to 1014. Total amount, 2000 to 4000 ex.; may reach 
7000 or 8000 c.c. Reaction, faintly acid or neutral. Urinary solids, 
diminished, coloring matter diminished, except indoxyl, which is usually 
increased. Albumin, usually a trace, rarely reaches J^ of 1 per cent, 
in the later stages. 

Sediment.; — This is usually slight or absent macroscopically in undecom- 
posed urine. 

Casts. — The casts are chiefly the hyaline and faintly granular varieties. 



DISEASES OF THE KIDNEY 



265 



Cells. — A few renal cells may be found and some cases are associated 
with cylindroid storms. Even with the use of the centrifuge casts may 
be very few in number. 

Note. — All urinary findings may be modified by a superadded passive 
congestion due to a failing heart or by a subacute exacerbation, though the 
latter is unusual in the straight interstitial type. 

Defective elimination, as shown by the phenolsulphonephthalein test, 
is especially marked in this form of nephritis. 

Blood-pressure. — It is wholly probable that an abnormal arterial ten- 
sion is the earliest sign available for the practitioner. 

Symptoms of the Terminal Stage. — Cardiac and Renal Symptoms. — 
There may be passive congestion due to a failing heart, resulting in an 
increased amount of albumin, and, as a rule, more numerous casts showing 
coarser granules and an occasional waxy cast. The amount of urine is dimin- 
ished, the total solids are low, though the specific gravity may be relatively 
high. The general appearance of the patient is that of a cardiac edema 
and such cases offer great therapeutic difficulties especially to those who 
undervalue the need of supporting the weakened heart. 

Uremic symptoms usually become prominent and such cases may ter- 
minate in pulmonary edema or uremic coma. 

Prognosis. — Duration Indefinite. — Inasmuch as we know little or nothing 
of its beginnings, we cannot say for how long a period the individual may 
endure changes of interstitial nephritis nor can we recognize its earliest 
stages. It is safe to assume that cases have endured in some instances for 
forty years, and that the average duration is a long one. 

Through inheritance of cases, the author has been able to follow certain 
patients through a known period of at least twenty-five years, and is pre- 
pared to believe that some of them will add several years more before the 
end comes.* 

Such represent, however, the few surviving out of a large group observed, and 
in most instances of interstitial nephritis, as in chronic myocardial disease, a 
patient is far advanced before the disease is recognized or even encountered. 

Subacute Attacks. — Some cases, and especially those of the "mixed" 
type, are greatly jeopardized by the occasional occurrence of subacute 
attacks which may be sufficiently severe to produce symptoms of acute 
congestion or be so mild as to show little more than a few blood cells or 
epithelial casts. 

Prognostic Factors. — The occurrence of certain characteristic retinal 
changes, symptoms of marked and persistent or decidedly resistant cardiac 
incompensation and the appearance of waxy casts usually mean that the terminal 

* One patient whose case seemed very definitely to represent the consecutive small 
white kidney, died a short time ago in uremic coma after being under observation for 
twenty-four years. Strangely enough he had lived the life of a bon vivant for the greater 
part of that entire period upon the old theory of "a short life and a merry one." The old 
physician who attended him during his original attack twenty-six years before gave him two 
years to live and he proposed and proceeded to make the most of them according to his 
lights. 



Watch the 
heart. 



Support the 
heart. 



Extreme 
chronicity. 



Belated 
recognition. 



Intercurrent 
exacerbations. 



Heralds of 
death. 



266 



MEDICAL DIAGNOSIS 



stage has been reached though death may be postponed for a year or two in favor- 
able cases. 

Apoplexy. — As might be expected an apoplexy is a very common event, 
terminal or otherwise. 

TRENCH NEPHRITIS.— The attention of military authorities was 
directed to nephritis during the Great War of 19 14-18 because of the extent 
to which this disease played a part in the morbidity of attending Army 
service especially at the front, although there seems to have been nothing in 
the types of the disease occurring which would permit any separate classifica- 
tion or demand detailed consideration here. 

The term "trench nephritis" is not an accurate one, inasmuch as the 
disease occurred amongst men in all branches of the service though naturally 
to a greater extent amongst those whose duties were especially arduous and 
who were exposed most to cold, wet, and profound fatigue. 

The conditions of service at the front throughout the war were peculiarly 
trying, as all men know; minor infections were frequent and the relighting of 
hidden foci extremely common. Hence every condition suited to the 
redevelopment of an old nephritis or the excitation of an acute congestion 
or an actual acute nephritis was present. 

By far the greater number of cases were of such a nature as to suggest 
apparently the presence of a relatively severe degree of acute congestion 
or an actual acute nephritis. 

It would appear that for the most part the duration of these attacks was 
relativelv short and the mortalitv low. 



Diagnosis by 
association. 



Significant 
syndrome. 



Spleen and 
liver. 



Valuable 
guide. 



Bimanual 
palpation. 



AMYLOID KIDNEY 

Urinary Findings Indeterminate. — From the urine alone the diagnosis can- 
not be made in this disease, but the presence of conditions with which it is known to 
be associated, viz., chronic suppuration, chronic ulcerative tuberculosis, or inveterate 
syphilis, is suggestive, particularly if hepatic and splenic enlargement co-exist. 

Symptoms.— Polyuria with a large amount of albumin, hyaline casts in 
variable numbers, associated not infrequently with granular and occasionally 
fatty and waxy casts, constitute the urinary findings. 

The most significant diagnostic feature is the combination of polyuria, 
low specific gravity and a large albumin content in a patient showing the amyloid 
changes in the spleen and liver which usually occur in this form of nephritis. 

Edema and effusions occur as in other forms and cachectic fades is common. 

Other Differential Factors.— The urinary findings vary greatly and the 
total solids are usually little affected. The consequent absence of marked 
toxic hypertension and cardiac changes is of some diagnostic significance. 

MOVABLE AND FLOATING KIDNEY.— The normal kidney may or 
may not be palpable, but usually, in the female, its lower border may be 
detected under proper conditions of muscular relaxation and correct technic. 

Technic of Palpation. — To palpate the kidney, one hand should be placed 

over or just below the floating ribs behind, the other below the costal margin 

I on the outer side of the rectus abdominis border. By steady firm pressure 



DISEASES OF THE KIDNEY 



267 



Caution. 



Useful 
postures. 



Movable vs. 

floating 

kidney. 



the two hands should be approximated, during a forced full inspiration and 
allowed to separate slightly, when the movable kidney may be felt to pass 
between them and may be directly engaged and palpated during the maneuver. 

No attempt should be made to grasp the kidney primarily, and in any event 
it sJwuld be engaged between the fingers of the two hands by simple approxima- 
tion rather than by any grasping or clutching movement such as is sometimes 
recommended. 

Patient's Attitude. — Though ordinarily such an examination can be 
carried out when the patient is in a dorsal position, it is often useful to 
examine them in a position between the dorsal and the lateral, the arm on 
the side under observation being allowed to hang loosely forward and the 
patient receiving some support to relieve the abdominal tension. So also 
one may often rind that the organ is most readily reached when the patient 
is standing and bent forward or even when in the knee-chest position. 

Degrees of Renal Displacement. — The palpable kidney is one whose 
lower edge can just be felt by the examiner. Such a kidney is not abnormal; 
the movable kidney is that which slips back and forth like a "pea in a pod," 
or one which can be fixed by passing the examining fingers above its superior 
border during full inspiration. 

The term floating kidney is applied to those having more than a vertical 
displacement, or such as are vertically displaceable to a lower level than 
the umbilicus. The range of mobility is often extraordinary and in some 
instances the kidney may be found in the pelvis. 

Important. — Not infrequently albumin may be found in the urine after 
the kidney has undergone such manipulations and may lead to a faulty con- 
clusion. It is trivial, transient and unimportant. 

Etiology. — The disease is ordinarily congenital and but a part of what 
Stiller has justly called "asthenia universalis congenita." 

Almost without exception a floating kidney is associated with gastro ptosis, 
splanchnoptosis, a narrow, mobile, readily dilatable, low-lying, modified or 
typical, u drop heart," a more or less " phthisical" bony conformation of the chest 
and a more or less decided tendency to nutritional instability which may or 
may not be present at the time of examination. 

There is in such cases a congenital delicacy of structure and unstable func- 
tional and nutritional equilibrium of the utmost importance to both diagnostician 
and therapist. 

It is far more common in women than in men and most marked in multi- 
paras and in poorly nourished individuals. About three-fourths of the cases 
occur on the right side and in about one-seventh the condition is double. 

Congenital relaxation of the ligaments is primary, tight lacing and re- 
peated pregnancies, the wasting of the peritoneal fat of the capsule, trauma- 
tism or muscular strain increase the mobility and failure or marked de- 
pression of nutrition invites symptoms. 

In most cases a combination of these causes may be operative. A curious 
relationship, possibly associated with the enteroptosis, sometimes seems to 
exist between floating kidney and the occurrence of appendicitis. 



Manipulation- 
albuminuria. 



Usually 
congenital. 



Important 
associated 
conditions. 



Functional and 

nutritional 

instability. 



Increase of 
mobility. 



268 



MEDICAL DIAGNOSIS 



Production of 
symptoms. 



Symptomless 
cases. 



Ascending vs. 

blood-borne 

infections. 



Fever of 

infection. 



Acid urine. 



Rarely a colic 



Symptoms. — In well-nourished phlegmatic individuals extreme ptosis 
may exist without symptoms, while slight cases may contribute to the general 
discomfort in the undernourished individual. 

In view of the exaggerated importance attached to this condition by the laity 
it is often wise to withhold informatio?i from the patient where no symptoms 
seem to be present or where the condition is incidentally or casually encountered. 

When symptoms are present they vary from those of "nervousness," 
dyspepsia, troublesome psychasthenia, or hysteria, chiefly attributable to 
the general state of the patient, to the remarkable pain crises, first described 
by Dietl. 

Dietl's Crises. — These are attacks, sudden in onset, characterized by severe 
abdominal pain, nausea, vomiting, and in extreme cases, by chill, fever, and 
even symptoms of collapse. 

The utmost care should be observed in diagnosis, as errors are aston- 
ishingly frequent. 

The author ventures again to express the opinion, founded upon somewhat 
extensive observations, that true Dietl's crises are extremely rare; and that the 
appendix, gall-bladder, gastric ulcer, renal calculus, and especially gastroptosis 
with pyloric spasm are vastly more likely to prove the essential factors. 

PYELITIS AND PYELONEPHRITIS 

Definition. — By pyelitis is meant an inflammation completely or chiefly 
confined to the pelvis of the kidney; by pyelonephritis, an inflammation 
involving both the kidney substance and the pelvis. The former can hardly 
exist without a slight invasion of the kidney texture. 

Etiology. — Various microorganisms are capable of causing these condi- 
tions. Among these are: the pyogenic streptococci, staphylococci, typhoid 
and colon bacilli, gonococci and tubercle bacilli. 

Infection in some cases is ascending, the bladder or ureter being the pri- 
mary source. They arise also in connection with certain virulent acute in- 
fections or in those of the chronic sort, and under these conditions the infect- 
ive agent would appear to be brought directly by the circulation. Renal 
calculus is a potent cause, yet stones may exist for years in a kidney without 
causing any marked disturbance. 

Symptoms of Pyelitis. — An acute pyelitis is ushered in by fever, pain in 
the back, or tenderness in the region of the twelfth rib, and is usually marked 
by frequent micturition. The urine in acute, severe cases is diminished in 
amount, contains pus in quantity and is usually acid in reaction in primary 
pyelitis. 

The reaction is largely dependent upon the microorganism present. 
The colon bacillus, gonococcus, and tubercle bacillus are, fortunately, as- 
sociated with acidity. The staphylococcus, streptococcus and proteus cause 
an alkaline fermentation. 

The pain which is usually more or less severe at the onset even in simple 
suppurative pyelitis may be so extreme when, as sometimes happens, com- 
plete or even partial temporary blocking of the ureter occurs, as to simulate 



DISEASES OF THE KIDNEY 



269 



renal colic and may radiate in the same way to the groin, inner side of the 
thigh or testicle. 

Chill and fever may occur at any time during the course of an acute attack 
and certain' cases have been mistaken carelessly for malarial fever on this 
account. Occasionally in unilateral cases, the ureter or an affected kidney 
becomes blocked, and retention on the part of the unsound kidney permits a 
misleading secretion of normal urine from the sound side. In such cases 
a pyonephrotic tumor is evident on the affected side. So also masses of 
stringy pus and debris may produce obstruction at the neck of the bladder 
and pain simulating that of stone in the bladder. 

Sediment. — The urinary sediment shows large quantities of pus, a vari- 
able amount of blood, usually of the slightest quantity, and the more or less 
characteristic cells of the renal pelvis. Ordinarily one will rind also a few 
renal cells and an occasional cast. Under prompt and efficient treatment 
these symptoms rapidly subside so that in a period varying from a few days 
to two or three weeks, an uncomplicated simple case may recover. 

Symptoms of Pyelonephritis. — These are essentially the same as those 
of pyelitis, save that the amount of pus is usually larger and the sediment 
shows a decidedly greater number of renal elements. 

The characteristic features of the typical case are: (a) An acid urine, 
(b) containing pus, (c) yielding a sediment showing characteristic elements, 
i.e., casts and renal and pelvic epithelium. 

The picture may be much obscured by the presence of a complicating 
or primary cystitis, in which case the urine may be ammoniacal, and the 
sediment be so profuse and with such predominance of the cystic elements 
as to greatly obscure the diagnosis unless modern methods of direct exami 
nation are employed. 

RENAL TUBERCULOSIS 



Misleading 
findings. 



Cystitis vs. 
Pyelitis. 



Miliary. 



Its Two Forms. — This occurs in two forms — the acute miliary, which is 
merely a part of a general tuberculosis, and invariably obscured by the other 
manifestations of the disease, and, the so-called "tuberculous infiltration" 
{caseous form), which is of great clinical interest. The latter commences c 
usually as a miliary or larger nodule which undergoes much the same changes 
as would occur in other portions of the body. Either one or both kidneys 
may be affected and the process frequently involves the whole urinary tract, 
including the urogenital apparatus. 

Etiology. — Predisposing influences such as trauma, chronic cystitis, 
pyelitis, urethritis, and the congestion of pregnancy may play a part and 
it is unquestionably most frequent in persons of the congenital asthenic type 
who afford a favorable soil for the tubercle bacillus. 

Tuberculosis of the kidney is now regarded as primary rather than as- 
cending and we know that it tends to confine itself for long periods to a single 
kidney and spare the ureter and bladder. It is, therefore, a blood-borne 
infection and from the standpoint of actual origin is secondary to some pri- 
mary focus elsewhere in the body. 



Primary and 
blood-borne. 



270 



MEDICAL DIAGNOSIS 



Frank vs. 
latent case. 



Examine for 
t. b. elsewhere. 



Dysuria. 



Not always 
progressive. 



Scant 
findings. 



May or may 
not be 
symptomless. 



Diagnosis. — The diagnosis may be extremely easy or surprisingly difficult, 
the development being in some instances that of a frank tuberculous pyelitis 
or pyelonephritis. In others it pursues a latent course with no symptoms 
save those of irritation. 

In every case attention should be given to the organs so often secondarily 
affected, such as the spermatic cord, testis, prostate, and in the female the 
ovaries and tubes. 

So also persistent dysuria without signs of bladder disturbances sufficient 
to account for the condition will oftentimes prove to be of tuberculous origin. 
In most cases there is a slight elevation of temperature and, in a goodly 
number, tuberculosis present or past or a suggestive family history is made 
evident. Symptoms of lithiasis may co-exist and complicate the picture. 
The affected kidney may or may not be movable primarily and in some 
instances becomes greatly enlarged and readily palpable. 

According to the author's experience the caseous chronic tuberculosis 
of the kidney acts much as does tuberculosis elsewhere and may go 
rapidly to the bad, recover temporarily or even become permanently 
arrested, under the same general conditions as apply to tuberculosis of 
the lungs. Spontaneous healing under rest, improvement of nutrition 
and favorable environment is certainly more common than is generally 
believed. 

He cannot, therefore, coincide with the opinion expressed by some of our 
best surgeons that the tuberculous change is of necessity and invariably a pro- 
gressive and destructive one, however great the comfort and increased sense of 
safety conferred by nephrectomy in unilateral cases. 

In a considerable number of cases of slight involvement occurring in 
patients who declined operation and in a number who presented a double 
tuberculosis so advanced as to forbid operation, the process has shown the 
same or indeed a greater tendency to arrest than is observed in the lungs when 
proper conditions were obtainable. 

Finally, the diagnosis must depend upon the findings of the tubercle bacilli 
in the urine and their differential staining by proper methods and the localiza- 
tion of lesions by means of modern procedure. It must be remembered that they 
may be found in urines showing but the slightest traces of pus* 

In some instances the diagnostic use of tuberculin is justifiable and may 
be followed by the appearance of the bacilli in a urine from which they 
were absent previously. 

RENAL INFARCT. — This common condition may produce no symptoms 
sufficient to attract attention though in rare instances there may be localized 
pain and tenderness, chills, fever and vomiting associated with albuminuria 
and perhaps hematuria, f 

* In several cases recently observed the urine was almost clear and the only subjective 
symptom was a slight dragging pain over the kidney. 

t In case the urine is being closely watched, the author believes that even though 
subjective symptoms are lacking albuminuria will usually be present and hematuria more 
frequently than is taught at the present time. 



DISEASES OF THE KIDNEY 



271 



Such emboli may be suppurative, in which event renal abscess promptly 
follows, but they are usually non-infective and the irregularly contracted kidney 
of repeated infarction is a common finding in the autopsy room in connection 
with valvular disease and myocardial degeneration of the left chambers 
of the heart. A positive clinical diagnosis of renal infarction can rarely 
be made but their frequency in diseases involving the left heart should be 
held in mind. 

RENAL TUMORS. — Their general characteristics have already been 
described and the subject is one for surgical rather than extended medical 
discussion. 

The malignant hypernephroma is of congenital origin and springs from the 
suprarenal tissue. It and primary renal sarcoma are peculiarly frequent 
in children under ten years of age. Otherwise the tumors of the kidney are 
of the usual types. 

Malignant disease of the kidney occurs chiefly in children under ten 
and in adults over fifty years of age. An apparently causeless renal hemor- 
rhage should always suggest it as a possibility for it is present as an early 
symptom in from 80 to 90 per cent, of renal tumors and as the first sign in 
three-fourths of such cases. 

If tiny clots are present in urine which is but lightly blood-tinted and 
they are pale red, yellow or white, and of the size of maggots or tripper 
shreds, the probability of their origin in a malignant growth is somewhat 
strengthened. 

Such early hemorrhages as have been described in the preceding paragraphs 
may be wholly unassociated with pain. 

If the growth primarily affects the renal pelvis, large hemorrhages are the 
rule. 

Preoperative differential diagnosis of the different varieties of renal tumors 
is usually quite impossible. 

RENAL SYPHILIS. — Nephritis associated with the secondary stage of 
syphilis is bilateral and differs in no respect from other forms of Bright's 
disease save in its response to prompt antiluetic treatment. 

The rare cases of renal gumma are more likely to be unilateral and may 
exactly simulate a malignant new growth. 

In such cases even though the process seems far advanced, vigorous medi- 
cation will often result in prompt amelioration. 

RENAL CYSTS.— Classification.— We may divide renal cysts into four 
forms, viz.: (1) Simple solitary cysts. (2) Paranephric cysts. (3) Echino- 
coccus cysts. (4) Cystic degeneration. 

Simple Solitary Cysts. — These are simple hemispherical retention cysts, 
occurring chiefly in the aged, sometimes reaching a large size, and are caused 
probably by the blocking of certain renal canals, the formation of multiple 
small cysts and their ultimate fusion to form a single cavity. 

Differential diagnosis as between such a cyst and a hydronephrosis is often 
impossible before exploration. 

The use of the ureteral catheter is, of course, helpful and often decisive 



A surgical 
topic. 



Hyper- 
nephroma. 



Age incidence. 



Renal 
hemorrhage. 



Clots. 



Secondary 
bilateral. 



Tertiary 

unilateral. 



272 



MEDICAL DIAGNOSIS 



Usually 
escape 
diagnosis. 



Characteristic 
syndrome. 



Variable 

urinary 

findings. 



May produce 
cyst -like 
tumor. 



as to hydronephrosis. Aspiration yields indefinite results, should be always 
extraperitoneal and is no safer than an exploratory incision. 

The fluid from all renal cysts is practically the same, inasmuch as the urinary 
characteristics pertain to all. 

Paranephric Cysts. — These are clinical curiosities and their diagnosis 
from a differential standpoint is likely to be made only by the pathologist. 

Echinococcus Cysts. — These are relatively rare even in established echino- 
coccus infection. 

Small cysts must escape diagnosis unless they discharge their contents 
into the renal pelvis and large cysts seldom yield the pathognomonic hydatid 
thrill. 

If extraperitoneal aspiration or formal incision reveals the hydatid hooks 
or peculiar membrane, the diagnosis is positive. 

The content of the cyst is rich in chlorides, poor in albumin, alkaline in 
reaction, clear as water and of medium weight (specific gravity, 1007 to 1016). 

CYSTIC DEGENERATION OF THE KIDNEY.— This interesting con- 
dition is a polycystic degeneration honeycombing the parenchyma of the 
kidneys which are present as bilateral tumors and are found to consist 
of a multitude of small cysts varying from the size of a pea to that of a 
cherry. 

Diagnostic Signs. — If certain clinical facts are kept in mind the diagnosis 
of some of the cases of this interesting and relatively rare condition may be 
rendered reasonably definite. 

If one encounters bilateral tumors in the flanks associated with high arterial 
pressure together with uremic manifestations and cardiovascular signs of chronic 
nephritis, the diagnosis of congenital polycystic kidney is practically the only 
one fitting the symptoms. 

The urinary signs are not dependable but in many instances the clinical 
picture is that of an interstitial nephritis complete, with urinary casts and 
albumin, plus bilateral renal tumor. Hemorrhage is not uncommon and 
may be profuse. Leucin-like colloid bodies (Beckmann's rosettes) may ap- 
pear in the sediment. These show from two to five concentric rings and 
radiate striae. 

The tumors representing the degenerated kidneys need not be equal in 
size and unilateral cases are reported. 

Summary. — In the presence of such cases as show (a) bilateral tumors of 
renal origin, (b) high arterial pressure, (c) accentuation of the aortic second and 
mitral first sounds, (d) hypertrophy of the left ventricle, (e) uremic manifestations, 
(/) polyuria, (g) albuminuria and (h) the presence of hyaline casts, the diagnosis 
of polycystic congenital kidney may be made with some certainty. 

Even in the absence of distinct urinary findings, the cardiovascular signs 
and the bilateral tumors with or without distinct uremic manifestations make 
such a diagnosis wholry justifiable, the high arterial tension being especially 
suggestive. 

HYDRONEPHROSIS— Definition.— By hydronephrosis is meant an over- 
accumulation of urine within the kidney due to an obstruction in some portion 



DISEASES OF THE BLADDER 



2 73 



of its ureter, or, to a less degree, to persistent bladder retention. A persist- 
ence of this condition may result in a conversion of a kidney into a large cyst. 
If persistent the condition is characterized by the large cyst-like tumor 
which occupies the renal site and may fill and empty in intermittent 
obstruction. 

Etiology. — The condition may be temporary or permanent, persistent or 
intermittent, and it may be either congenital or due to disease. Among the 
causes are stricture of the ureter or urethra, calculi, clots, a twisted or com- 
pressed ureter, and in short any blocking of the urinary channel. The con- 
dition is commonly temporary and intermittent, but due in most instances 
to temporary torsion, pressure or removable obstruction. 

ACUTE CYSTITIS.— Etiology.— An acute inflammation of the mucous 
membrane of the bladder may be due to direct or hematogenous infection, to 
injury or irritation from calculi, foreign bodies, wounds and the introduction 
of sounds, or may be associated with urethritis, tuberculosis, prostatitis or 
mere exposure to cold and wet, sexual excess or the toxemia of infectious 
diseases. 

Symptoms. — The onset may be sharp with a decided febrile reaction. 
Dysuria with increased frequency and marked cutting, burning tenesmus 
are the chief symptoms, though pain may be severe and radiate, to the 
perineum, the glans, hypogastrium or thighs; fever is usually slight and may 
be absent. The urine is scant, strongly acid or variable, usually of high 
specific gravity and contains an approximately normal amount of solids, 
albumin, blood and pus in variable quantity. The sediment consists of pus 
and blood cells in quantity with much bladder epithelium and numerous 
round cells. 

CHRONIC CYSTITIS.— Etiology.— This may result from an acute attack 
or may insidiously develop as the result of an enlarged prostate, a stricture, 
the frequent use of the catheter, infection from the genitals (female), or from 
calculi, growths or tuberculosis affecting the viscus. Like every other hollow, 
muscular organ, the changes may be either atonic or hypertrophic and in 
many cases of long standing the bladder is greatly contracted and tends to 
become incrusted with urinary salts. 

Symptoms. — These are those of the acute form, usually in a milder degree 
both as to subjective symptoms and urinary findings, though in the latter 
blood is less often present in quantity, and the reaction is more likely to be 
ammoniacal. The solids are little affected and the sediment will show triple 
phosphate and often ammonium urate crystals if the urine is ammoniacal. 

Comment. — It should be noted that these cases, if primary, lack all evidence 
of renal involvement and that the albuminuria present is usually in direct pro- 
portion to the blood or pus from which it is derived. 

TUBERCULOSIS OF THE BLADDER.— A chronic cystitis presenting 
no symptoms of stone, stricture, or enlarged prostate, should always suggest 
tuberculosis. It usually involves primarily the trigone and the urethral 
orifices. The seminal vesicles and prostate should always be examined for 
nodular infiltrations and weight should be given to recent hemorrhages. 
18 



Persistent or 
intermittent. 



Dysuria and 
tenesmus. 



Contracted 
bladder. 



Source of 
albumin. 



274 



MEDICAL DIAGNOSIS 



Acid chronic 
cystitis. 



A cause of 
hematuria. 



Symptoms. — The appearance is that of a severe or mild chronic cystitis, 
with or without hemorrhage, but associated usually with acid urine. The 
diagnosis depends upon the finding of the tubercle bacilli, the use of the cysto- 
scope and in some instances the tuberculin test. 

TUMORS OF THE BLADDER.— These fall properly under surgery, 
and it need only be said that papillomata are the most frequent, aside from 
malignant growths of advanced age, and that they produce chiefly symptoms 
of chronic cystitis associated with marked intermittent hematuria. Occa- 
sionally bits of the growths may appear in the sediment, together with shreds 
of tissue and caudate cells from the villi of the growth. 

ACUTE PROSTATITIS.— This may result from the same causes that 
lead to an acute cystitis and is recognized by the swelling, heat and tender- 
ness of the gland, associated with throbbing, pain in the back and legs, 
dysuria and constant urgency, both rectal and vesical, with marked cutting, 
burning pain and tenesmus and increase of pain attending the end of urina- 
tion. Casts of the prostatic ducts may be present in the sediment and 
occasionally spermatozoa as well, otherwise the urinary picture resembles 
occasionally acute cystitis. 

Complications. — Prostatic abscess may develop and is usually associated 
with known symptoms of sepsis and may cause mechanical retention of 
urine. 

CHRONIC PROSTATITIS.— This is most frequent at advanced ages in 
connection w r ith chronically enlarged prostate, but may also follow acute 
attacks or be associated with chronic posterior urethritis. The association 
of modified symptoms of the acute form with palpable hypertrophy or 
swelling of the prostate associated with tenderness and the symptoms of 
chronic cystitis make the diagnosis. 

Chronic urethritis need not be considered in this volume. 

URINARY CALCULUS.— This most commonly occurs in the bladder or 
renal pelvis, but stones may also occupy the ureters. They vary in number 
from one to several hundred, and in size from a mere grain to that of a large 
orange. They also differ greatly in form, usually assuming the shape of the 
cavity in which they lie and occasionally being polished by attrition when 
several lie in contact. Uric acid, cystin, and phosphatic stones present usually 
a relatively smooth surface and the calcium oxalate stone is lobulate and rough 
(mulberry calculus). Uric acid and urates vary in color from pale yellow to 
deep brown, phosphatic stones are grayish or wmite, those of calcium oxalate 
deep brown, of cystin, yellow. Section should always be made to determine 
the constituents, as several concentric layers may be found. As to frequency, 
uric acid and urate stones predominate. In all forms the urinary sediment is 
likely to furnish suggestive findings during the stage of stone formation, con- 
taining the characteristic crystals of uric acid, ammonium or sodium urate, 
! calcium oxalate, or triple phosphate crystals, etc., according to the nature 
of the process. 

Tests for Urinary Calculi. — The concentric layers should be sawed through 
and tests made from the scrapings of the different layers and of the powdered 



URINARY CALCULI 275 



nucleus. The following table is taken from Dr. J. B. Ogden's admirable 
book.* 

CHEMIC EXAMINATION OF URINARY CALCULI 

1 . Preliminary Examination. — Heat on platinum foil : 
Albumin = a flame with odor of burnt horn. 
Urostcalith = a flame with odor of shellac and benzoin. 
Cystin = a blue flame with odor of S0 2 . 

Xanthin and uric acid = char without a flame. 

Alkaline urates = alkaline residue soluble in H 2 0. 

Earthy phosphates = a residue soluble in acetic acid without effervescence. 

Calcium oxalate and calcium carbonate = a residue soluble in acetic acid 
with effervescence. 

Calcium carbonate = original powder soluble in acetic acid with effer- 
vescence. 

Calcium oxalate = original powder insoluble in acetic acid. 

Silica = residue insoluble in HC1. 

Murexid Test for Uric Acid. — Original powder + HNO3 and evaporate 
= pink residue + NH 4 OH = purple color = uric acids and urates. 

Original powder + HN0 3 and evaporate + KOH = violet color, which 
disappears on heating = uric acid. Violet increases on heating = xanthin. 

2. Systematic Examination. — Presence of uric acid shown by (1). Boil 
in H 2 and filter. 

A. Filtrate +HC1. Let stand 24 hours = crystals of uric acid. Bases 
in solution. Concentrate. 

Calcium urate = 1 drop of solution + solution ammonium oxalate = 
crystals calcium oxalate. 

Magnesium urate = 1 drop of solution + NH 4 OH + Na 2 HP0 4 = crystals 
ammonio-magnesium phosphate. 

Sodium urate = 1 drop of solution + Pt.CU = after concentrating, prisms 
of sodioplatinic chloride. 

Potassium urate and ammonium urate = 1 drop of solution + Pt.CU = 
duodecahedra of potassioplatinic chloride and ammonioplatinic chloride. 

'Potassium Urate. — Evaporate solution and ignite on mica. Residue -|- 
HC1 + Pt.CU = potassioplatinic chloride. 

Ammonium Urate. — Evaporate solution and ignite on mica. Residue 
= no crystals with'Pt.CU- 

B. Portion insoluble in H 2 0. Add HC1. 
Uric acid = insoluble. 

Calcium carbonate = soluble with effervescence. Filter + NH 4 OH = 
precipitate of calcium oxalate, calcium phosphate, and ammonio-mag- 
nesium phosphate. Wash. Calcium oxalate = insoluble in acetic acid. 
Filter -f- ammonium oxalate to filtrate. Calcium phosphate gives precipitate 
of calcium oxalate. Filter + NH 4 OH to filtrate = precipitate of ammonio- 
magnesium phosphate. 

* "Clinical Examinations of the Urine and Urinary Diagnosis." 



276 



MEDICAL DIAGNOSIS 



Seek the 
normal. 



Incentive to 
accuracy and 
thoroughness. 



Serious 
mistakes. 



The greater 
achievement. 



Economy of 
time. 



"Harking 
back." 



Fundamental 
knowledge and 
technic. 



Genius 
dispensable. 



METHODS AND MEANS EMPLOYED IN THE DIAGNOSIS OF 
THE DISEASES OF THE THORACIC VISCERA 

Methods of Chief Importance. — The elicitation and interpretation of the 
physical signs of disease chiefly depend upon: (a) Inspection, (b) Palpa- 
tion, (c) Percussion, (d) Auscultation, (e) Auscultatory percussion. (J) 
Fluoroscopy and X-ray photography. 

To a less degree in practice, one may employ certain other auxiliary 
methods depending upon special procedures or specially devised instruments 
of precision such as the polygraph and electrocardiograph* 

Proper Mental Attitude. — To establish the presence of normal conditions 
should be the primary aim of the examining student or physician. 

This makes both for accuracy of observation and thoroughness of ex- 
amination and the study of the physical signs of health, of normal breath 
sounds and heart tones, together with the character and extent of normal 
variation, is of the utmost importance to every student of physical diagnosis. 

Many damaging and even fatal errors result from the opposite attitude which 
leads one to seek primarily for rales or heart murmurs and, in their absence, 
fail entirely to note less obtrusive departures from the norm though these may be 
matters of even greater importance. 

To detect the weakened or modified heart sounds of acute or chronic 
myocardial weakness, a failing pulmonary second tone in pneumonia, the 
significantly widened area of a murmurless but rotten heart, are far more 
creditable achievements than the discovery of some frank murmur. 

Thoroughness. — Superficial examinations are fatal to reputation and 
prestige. True economy of time depends upon a correct and systematic technic, 
quick perception, and intense concentration. 

Avoidance of Multiple Repetitions. — As one avoids asking the same 
question twice, so should he try to fix firmly in his memory the physical signs 
as they are elicited, and the well-trained student will make a complete and 
thorough examination and draw his conclusions, while the poorly trained one 
is still running in circles. 

Essentials. — A knowledge of topographic anatomy and of the physiology 
and pathology of the structure under examination, a good technic and a practised 
hand, good eye sight and hearing, must be combined with an accurate knowledge 
of the physical signs of health and disease. 

Anyone who possesses his quota of members, normally acute special senses, 
and a combination of diligence and ordinary intelligence, can become a skilled 
diagnostician. 

* The polygraph, and electrocardiograph are very valuable instruments, adding much 
to the exactitude of cardiac diagnosis in the hands of a specialist, but their use by the 
general practitioner is limited because of the time required for special training and the 
considerable expense involved in their purchase and maintenance (see "Electrocardio- 
graph" and "Polygraph"). Mensuration is also used but is of comparatively little 
value and spirometry and pneumometry are of little use.. 



THE EXAMINATION OF THE CHEST 



2 77 



THE PREPARATION OF THE PATIENT.— Proper Light.— The chest 
surface should be adequately exposed and flooded with light having its source 
behind the physician who is thus aided in his search for physical signs, his 
study of physiognomy and the play of the patient's emotions. Being in 
the shadow he can, in some measure, avoid betraying surprise, disappointment 
or dismay.* 

Interest, cheerfulness, encouragement and calm are the only emotions which may 
be reflected in the face of the physician whether in the office, wards, or sick room. 

The Arrangement of the Clothing. — This must depend somewhat upon the 
sex of the patient. In dealing with women or young girls it is usually possible 
to conduct a satisfactory examination while some thin, soft garment loosely 
enfolds the patient save for that portion directly under examination. This 
should be so arranged as to enable one to shift it at will and expose any 
required area of the chest or abdomen while still preserving a comforting 
illusion of protective covering. In the male the chest should always be uncovered, 
and so also in the female if any real necessity exists or if by greater exposure some 
doubt may be resolved. /j" 

A Common Source of Error. — No proper examination can be made through 
heavy or starched clothing. 

Crepitations in lung apices or heart murmurs may be simulated by the 
crackling, rustling, or rubbing of superimposed material and their conduction 
obscured or lost from the same cause. 

Attitude of Patient and Physician. — Whether in or out of bed, a patient 
should, whenever possible, be in an easy, unconstrained position, the tissues 
relaxed and the shoulders square. In the examination of the lung apices 
especially, both face and chest should be squarely to the front and the head 
quiet; otherwise deceptive differences in percussion may result from muscular 
contraction. 

The physician, himself, should adopt the easiest and most unconstrained 
position possible for both percussion and auscultation. 

Changes of Position during Examination. — Whenever practicable and safe, 
patients should be examined both when recumbent and when sitting or erect, 
because of the peculiar postural variations of cardiac murmurs referred to further 
on. the modification of physical signs occasionally encountered in some of the 
pulmonary lesions and the effect of attitude upon pulse rate and rhythm. 



Important 
details. 



Women. 



Men. 



The patient. 



The physician. 



Important 
landmark. 



THE TOPOGRAPHIC ANATOMY OF THE CHEST 

Regional Divisions. — The "sternal angle," or " angle of Louis," is a ridge ^^- M - 
marking the junction of the manubrium with the gladiolus of the sternum. 

77 indicates the lower border of the aortic arch, the bifurcation of the trachea, 
the junction of the borders of the right and left lung, and the second costo-sternal 
junction. 

* A matter of some moment in relation to sudden and unexpected revelations affecting 
intimate friends or relatives especially, as every physician of experience can testify. 

t Such is the confidence placed in professional honor and clean mindedness that the 
readiness to comply with such requests is usually a measure of the woman's refinement 
and real modesty. 



278 



MEDICAL DIAGNOSIS 



A useless 
landmark. 



2nd rib above, 
7th below. 



Interlobar 
fissure. 



Regional 
divisions. 



Topography. 



Apex 
resonance. 



Lung borders. 



Superficial 
cardiac area. 



Mid-clavicu- 
lar line. 



The Nipple. — The nipple indicates, ordinarily, the fourth interspace, but 
is subject to marked variation, both vertical and lateral, particularly in the female, 
and should not be used as a fixed landmark. 

The Great Pectoral. — The lower border of the pectoralis major should 
correspond to the upper border of the sixth rib. 

The Scapula. — With the arm at the side, the upper border of the scapula 
corresponds to the second rib; its inferior angle to the seventh or its interspace; 
the root of its spine to the third rib and to the starting point of the right interlobar 
fissure. 





Fig. 89. Fig. 90. 

Figs. 89 and 8. — Illustrating the absurdity of the mammillary (nipple) line as a landmark. 

The discrepancies of location encountered in the male are almost as marked. 

This fissure follows the vertebral border of the scapula when the corre- 
sponding hand is carried forward and across to the opposite shoulder and 
represents a region most important in connection with the primary line of 
invasion by the tubercle bacillus as first detectable by physical signs. 

The modern regional divisions and orientation lines necessary to verbal 
or written description are shown clearly by the plates. 

THE THORACIC VISCERA 

With Especial Reference to the Lungs, Pleurae, and Bronchi 

"Contained" vs. "Sheltered" Viscera. — The heart with its great vessels, 
the lungs and their primary bronchi, are contained viscera. The liver, spleen, 
and kidneys, and even a part of the stomach are sheltered viscera, though 
actually subdiaphragmatic and abdominal. 

The Lungs. — The lungs occupy nearly all of the upper chest, their 
apices extending usually to the level of the seventh cervical spine behind and 
1 to 1 3^ inches above the clavicle in front. The right apex is slightly higher 
than the left, and their resonance may be elicited over the whole of the 
supraclavicular and suprascapular regions. The anterior borders of the two 
lungs meet at the sternal angle and, in contact, pass vertically downward to 
the level of the fourth cartilage. At that point that of the left lung passes 
outward, leaving a portion of the heart uncovered and forming the left border 
of the superficial cardiac area. That of the right continues downward to 
the sixth cartilage. 

Lower Borders of Lungs. — In the mid-clavicular line both lower borders are 
represented by the sixth rib and, from the axillary line outward, the lower borders 
of both lungs are practically horizontal. 



THE THORACIC VISCERA 



279 




Fig. 91. — Regional divisions of the chest 
(anterior surface-verticals). The various 
divisions are plainly indicated, a, a. Sternal 
lines, b, b. Parasternal lines. c, c. Midcla- 
vicular lines. 



In m id-axilla they cut the eighth 
ribs; in the scapular line, the ninth; 
and near the spine they reach the 
level of the tenth spinous process. 

Hence a line drawn from the 
sixth chondro-sternal articulation 
on the right side, or from the sixth 
rib in the parasternal line on the 
left side, to the spine of the tenth 
dorsal vertebra, indicates the in- 
ferior lung border in each instance. 
Sheltered Viscera. — Below the 
midriff, as before stated, is an 
important area including the liver, 
spleen, stomach and kidneys. 

The Liver. — The liver y lying 
beneath and adapting itself to the 
dome-like surface of the dia- 
phragm, rises into the thorax to a 
much greater degree than is shown 
readily by percussion, but absolute 
thoracic liver dulness begins at 
the lower border of the lung and extends downward to the costal margin. 
Its lower border crosses the epigastrium from the tip of the tenth right 
cartilage to the tip of the eighth 
left and meets the left extrem- 
ity of the organ in the fifth left 
intercostal space at a point 
closely approximating the loca- 
tion of the normal heart apex. 
Traube's Semilunar Space. 
— This is included between the 
lower border of the left lung, 
the spleen, the inferior costal 
margin, and the left lobe of the 
liver, and is normally hyper- 
resonant because of the under- 
lying stomach. 

Loss of resonance means 
pleural effusion or adhesions, 
enlargement or tumor of the liver 
or spleen, or massive growths of 
the stomach, kidney or bowel. 
The Pleurae. — The inferior 

folds of the pleural extend practi- _ n . a . ,. . . e ,, a , . , 

J J r r Fig. 92. — Regional divisions of the chest (posterior 

cally to the costal margin and, surface-verticals), a, a. Scapular lines. 



Axillary and 
scapular lines. 



Inferior lung 
border. 




Absolute liver 
dulness. 



Tracing the 
border. 



Normally 
tympanitic. 



Clinical value. 



28o 



MEDICAL DIAGNOSIS 




Fig. 93. — Percussion areas, normal chest 
(anterior surface). Lungs — red. Liver — 
horizontal black lines. Relative cardiac 
dulness — vertical black lines. Absolute 
cardiac dulness — cross-hatching. Stomach 
tympany — oblique red lines. This repre- 
sents the incomplete cardiac area obtain- 
able by flat-finger percussion in the normal 
heart. The more modern methods closely 
approximate the x-ray outline and should 
be used^exclusively. 



Fig. 94. — Percussion areas (normal 
chest, posterior surface), a, a. Lungs. 
b, b. Pleural space, c. Spleen, c'. Liver. 
d, d. Kidneys. Area b, b yields percus- 
sion dulness from spleen, kidneys, and 
liver, unless lungs are- distended. 





Fig. 95. — Traube's space. Bounded 
by the lung, spleen and liver and the 
costal margin. Shows region of pleural 
sinus in which movable dulness may 
appear in left-sided pleural effusion. 



Fig. 96. — Lung boundaries (anterior 
surface). (Modified Panch-Fowler.) 



THE THORACIC VISCERA 



28l 



therefore, lie much lower than the lung margin, being 2 inches inferior in the 
midclavicular line, reaching a maximum of 4 inches in midaxilla, and of 1% 
inches in the scapular line. 

It will thus be readily seen that any small e fusion of fluid into the left pleural 
sac will, if free, produce an area of movable or shifting dulness in Traube's 
space, and that any increase in the size of the left lobe of the liver or of the spleen 
may reduce its lateral dimensions. 

Furthermore, the flat note of free e fusion will extend lower than any form of 
lung dulness. 

The Lobes of the Lung. — Delineation. — A line drawn about the chest from 
the second dorsal spine through the armpit to the middle of the sixth costal 
cartilage, indicates the division of the lung into its upper and lower lobes. 

On the right side a second line drawn from the middle of the first line to 
the fourth chondro-sternal joint marks the upper boundary of the middle 
lobe. 

Relation to Surface. — The front of the chest, largely represents the upper — 
the back, the lower — lobe of the lung, the apex being accessible both anteriorly 
and posteriorly. The right middle lobe occupies a portion of the upper axilla 
and of the anterior surface of the chest. 



Important 
boundaries. 

Pleural 
sinuses. 



Upper and 
middle lobes. 



Right 
mid-lobe. 



Anterior vs. 
posterior. 



Right median 
lobe. 



282 



MEDICAL DIAGNOSIS 



The first 
glance. 



Certain 

negligible 

factors. 



EXAMINATION OF THE CHEST, WITH ESPECIAL REFERENCE TO 
THE LUNGS AND PLEURA 

INSPECTION. — A glance reveals the general contour, nutrition and muscu- 
lar development of the chest, the symmetry of the two sides, equality of expansion, 
the presence of scars, pigmentations, skin eruptions or abnormal growths, 
local bulging or retraction and the absence of normal or the presence of abnormal 
pulsations. 

Essential Points. — Inspection is a procedure of great value and its import- 
ance is too generally underestimated. In order that it should be properly 
done it is absolutely necessary that the source of light should directly face 
and illuminate the surface under examination. Furthermore, both anterior 
and posterior surfaces should be inspected not only in the usual manner but 
also from above downward and in profile, the patient sitting, the physician 
standing. 

In a bedfast patient these rules cannot always be fulfilled but should be 
observed whenever possible. 

The utmost care must be observed in the case of very sick individuals to 
avoid exhausting them by prolonged examinations or throwing an undue 
strain upon a weak heart by forcing the assumption of a sitting posture. 

General Form of the Chest. — Absolute symmetry is unusual because of 
slight lateral curvature of the spine, right- or lef t-handedness, or, the occupa- 
tion of the individual, and many variations in chest outline are trivial and 
negligible. 

Wasting and Deformity. — A slight wasting of muscle in the region of the 
lung apex is often more immediately important than some gross deformity. 




Fig. 97. — 1. Unilateral retraction. 



2. Spinal curvature. Outline of horizontal section. 
{Gee; modified.) 



The kyphotic, scoliotic or scoliokyphotic deformities need no extended 
visceral discussion, but the student who has seen the bodies of markedly deformed 

crowding and ., , , , . _ . . ... .. . 

displacements . persons (hunchbacks) upon the autopsy table will realize the importance, to 



THE EXAMINATION OF THE LUNGS AND PLEURA 



283 



diagnosis and prognosis, of the extraordinary displacement and crowding of 
their thoracic viscera. 

Unilateral Enlargement or Shrinkage. — Unilateral enlargement may be 
due to vicarious emphysema, tumors, effusions, or congenital or juvenile 
heart disease. 

Unilateral shrinking indicates pleuritic adhesions, cirrhosis, pulmonary 
collapse or cancer. 

Harrison's Grooves. — These are zones of retraction frequently encountered 
in delicate asthenic children who, by reason of congenital asthenia combined 
with the obstructive effect of adenoid disease or hypertrophied tonsils, have 
persistently imperfect lung expansion leading to partial atelectasis (air- 
lessness) of the lung margins and chronic retraction of the chest along the line 
of the diaphragmatic attachment. 




Fig. 98 — 1. Normal chest. 



2. Pigeon breast. 3. Rickets. 
{Gee; modified.) 



4. Emphysema. 



General Deformities. — (Chiefly congenital.) — Among these are the rachitic 
chest, the transversely constricted chest, the flattened chest, pigeon breast 
and the "trichterbrust" (funnel breast). 

Emphysema. — The true " barrel-shaped " chest of advanced emphysema 
is ordinarily manifest only when the compensatory curve of the spinal column 



A common 
stigma. 



The barrel 
chest. 



284 



MEDICAL DIAGNOSIS 



Obscurant 
spinal curve 



Chest of forced 
inspiration. 



Overdistended 
inelastic lungs. 



The winged 
chest. 



Opposite of the 
barrel chest. 



Common 
forms. 



Rachitic 
rosary 



"Funnel' 
breast. 



is straightened out by placing the patient in the dorsal recumbent position 
on a table or firm mattress. Such a chest often appears flattened anteriorly 
when the patient is erect, the shoulders being rounded and slightly stooped. 

The chest outline in emphysema is that of permanent forced inspiration, 
the epigastric angle being broad, the neck short, the sterno-mastoid muscles 
prominent, the ribs unusually rigid and the movement more lifting than expansile. 

In such cases the lung borders are low; the range of their excursion lessened; 
the superficial cardiac area partially or more often wholly obliterated; the expira- 
tory element of the breath sounds is prolonged and the lungs unusually bright in 
the X-ray picture. 

The "Alar" Chest.— This, called also the "pterygoid," "paralytic" or 
11 phthisical chest" has a small anteroposterior diameter, long vertical measure- 
ment, broad interspaces and narrow epigastric angle. If the patient is thin 
the neck is long and slender and the projecting scapulae give it its somewhat 
fanciful name. Of itself the possession of an "alar" chest or one of its 
modifications does not prove the existence of a tuberculosis but is rather one of 
the expressions of "congenital asthenia" which offers to the tubercle bacillus 
the most favorable soil for its development. 

The most striking examples are seen in cases of advanced tuberculosis with 
extreme emaciation, yet the same skeletal type of chest may be observed 
in plump individuals. 

Various Deformities. — The rachitic chest is best exemplified by the "pigeon 
breast," and the "transversely constricted thorax" indicates the coincidence of 
deficient nutrition and some chronic obstruction to breathing in childhood, 
usually adenoids. The line of retraction is that of the diaphragmatic at- 
tachment indicating its close relation to imperfect chest expansion. 



^Rg T "'$SS£'' * ' ' - jfl 




IM&S>~'s-'f-;.'-.^ 






^^" 


I*.. 




■PSf 


-■'^■' 




Fig. 99. — Pigeon breast (rickets). 



Fig. 



100. — Funnel breast (trichterbrust) . 
In this case congenital. 



A "beading" of the ribs at the chondro-costal articulations is well known as 
the "rickety rosary." 

"Trichterbrust" is of little importance in diagnosis, though an interesting 
and striking phenomenon. It is represented by a groove involving chiefly 
the median inferior portion of the chest deepening from above downward and 
corresponding to the second portion of the sternum, the ensiform often point- 



THE EXAMINATION OF THE LUNGS AND PLEURAE 



285 



ing sharply forward. Usually congenital, it may be occupational in those 
who in early life have performed work necessitating continuous pressure over 
this region. 

The " thorax en bateau" observed in certain cases of syringomyelia shows 
a deep anterior median groove of less limited vertical extent. 

Localized Changes in Outline. — These are of much more significance than 
general deformities, and marked retraction of one side or localized retraction in 
any area nearly always means an old pleurisy, fibroid phthisis, tuberculosis or 
injury. 

Apex Retraction. — Symmetrical retraction of the apices due to chronic nasal 
or tonsillar obstruction is common, is of slight importance in the absence of 
physical signs of disease and, even in adults, may promptly disappear after 
its cause is removed by operation. 

Unilateral supraclavicular, infraclavicular, or suprascapular hollowing 
suggests existing or past disease of the lung or pleura. 

CHEST MEASUREMENTS.— The life insurance requirements in regard 
to dimensions and freedom of expansion are extremely simple. They demand 
that the circumference of the chest at the level of the armpits shall equal one- 
half the height of the individual and that the difference between full inspira- 
tion and forced expiration shall not be less than 2 inches. 

As a test of lung capacity this last requirement is an absurdity, for one who 
under proper instruction cannot expand one-tenth his chest circumference in 
inches can hardly be considered normal* 

In measuring chest expansion, one should draw the tape very closely at 
the level of the nipple, especially in fat individuals. 

Abdominal measurement should show the maximum girth with lightly 
drawn tape and for full life insurance eligibility should never materially ex- 
ceed that of the chest in full inspiration, inasmuch as statistics show that such 
"bow-windowed" persons furnish a heavy early mortality. 

Marked unilateral variations in expansion, shown by measurements or 
visible to the eye, suggest retraction due to fibroid phthisis; pleural adhesions or 
spinal deformity; or the bulging caused by pleural effusions, aneurysm, congenital 
or youthful cardiac enlargement, or new growths. 

CHEST MOVEMENTS.— Normal breathing is of two types: (1) costal; 
(2) abdominal. The first predominates in corset-wearing women, the second 
in men. That of women is largely superior-costal, that of men combined in- 
ferior-costal and abdominal. 

In normal breathing, the ratio of respiration to pulse rate is about as 1 to : 
4, its rate in the new-born being 40 to 45; at the age of five, 22 to 26. It 
should be symmetrical, easy and quiet, and the two sides of the chest should 
move equally and synchronously. 

Counting Respiration. — The respiration is best counted by watching the 
rise and fall of the epigastrium coincident with the action of the diaphragm or, 

* Oddly enough, athletes, and consumptives not too far advanced, usually show the 
highest figures in chest expansion, because both have been especially instructed and the 
latter practice deep breathing as a therapeutic measure. 



Congenital 
usually. 



Usually 
important. 



Symmetrical. 



Unilatc? al. 



Insurance 
requirements. 



An absurdity. 



Correct 
method. 



Ascertain 
maximum 
girth. 



Bow-windowed 
risks. 



Unilateral 
variations. 



Costal vs. 
abdominal. 



Normal 

respiration. 

ratios. 



A useful 
expedient. 



286 



MEDICAL DIAGNOSIS 



Phantom 
shadow. 



Cause. 



Normal range. 



Technic. 



Clinical 
significance. 



Subdiaphrag- 
matic abscess. 



A valuable 
adjunct. 



Wide range. 



in women, the rhythmic lift of the upper chest. If, at the bedside, one 
ostensibly counts the pulse, keeping the eye on the proper area, neither cloth- 
ing, nor bed covering prevents the use of this method nor does the patient's 
self-consciousness interfere. 

Litten's Diaphragm Phenomenon. — This is a phantom shadow of inspira- 
tory rhythm passing downward from the antero-lateral aspect of the sixth rib 
and vanishing just above the costal margin. 

It corresponds to the slight drag exerted upon the intercostal spaces by 
the rhythmically recurring separation of the costal and pulmonary layers 
of the pleural fold coincident with the descent of the diaphragm and the 
inferior border of the lung. 

In the normal chest its movements in forced inspiration and expiration 
should range from 2 to 4 inches. 

To elicit the sign the patient should be placed upon the back facing the 
light, the shoulders being somewhat elevated. The observer should stand 
with his back to the light 5 or 6 feet away, opposite the patient's knees. 
The illumination should come from one window only, and be not too intense. 

This is readily seen in all normal chests not heavily overlaid with fat, but 
is lost or interrupted in pleural adhesion. It is absent in effusion, pneumonia 
of the lower lobe or tumors occupying the lower chest, and 
absent or of lessened range in incipient or advanced 
tuberculosis and emphysema. All lesions involving 
the lung or pleura which check expansion diminish the 
range of the shadow and it is of special value in 
relation to the diagnosis of adhesions. 

On the other hand, tumors or fluid below the 
diaphragm may not entirely obliterate it, and as a 
differential factor in the diagnosis of subphrenic 
abscess it has not borne out its early promise. 

Fluoroscopic Method. — As the descending dia- 
phragmatic shadow accurately determines the relative 
range of excursion of the lower border of the lung, 
this constitutes one of the most definite methods of 
deficiencies of lung excursion due to the 





Fig. ioi. — Litten's sign. 

(a) Reduced excursion in 
pulmonary tuberculosis. 

(b) Normal excursion. 

presence of adhesions, 
emphysema and incipient tuberculosis, even a small area of tuberculous in- 
filtration often checking to a marked degree the movement of the affected lung. 
(See Roentgenography.) 

PALPATION 

Scope of Procedure. — Palpation as applied to pulmonary disease has chiefly 
to do with the detection of fremitus, abnormal pulsation and lung expansion; 
but also determines the form, consistence, extent, mobility and sensitiveness of 
morbid growths; the nature of swellings, the presence of abnormal heat, the loca- 
tion of painful areas, the presence or absence of moisture and the quality, fit 
and elasticity of the skin. 



THE EXAMINATION OF THE LUNGS AND PLEURAE 



287 



Friction sounds, coarse rales, the hydatid thrill or the crackling of a subcu- 
taneous emphysema may also reveal themselves to the fingers. 

Respiratory Movements. — In this connection, palpation confirms, cor- 
rects and amplifies the result of inspection. In deep breathing, expansion 
of the two sides should be uniform, coincident and equal. One notes: 

1. Generally increased or diminished movement. 

2. Unilaterally retarded inspiration (inspiratory lagging). 

3. Unilaterally retarded expiration (expiratory lagging). 

Technic. — The hands are placed fairly upon the chest, palm down, and 
the patient sits facing the light while the physician, standing behind him, 
views the chest obliquely from above. Two pencils, toothpicks, or matches, 
placed vertically between the fingers better show the extent of the move- 
ment. For the upper lobe it is well to place the thumbs in the supraclavicular 
space and the fingers in the infraclavicular region. In examining the back 
the patient should be turned about. 

Justifiable and Necessary Departures from Formal Methods. — The 
examination of very sick patients must be conducted with whatever of adherence 
to strict form and rule the circumstances permit and no more. 

In some instances the physician's examination may be of so thoughtless 
a nature as to actually injure the patient or jeopardize his life. 

This statement is particularly applicable to the common custom of rais- 
ing very sick persons to a sitting posture in an attempt to examine the 
lung bases, when the same knowledge might be gained by having an attendant 
turn the patient on the side either wholly or partially as conditions may 
permit. 

In the routine examinations of known pneumonia patients sufficient access 
is usually obtainable with very little disturbance of one to whom sitting up in 
bed is a positive danger. The same may be said of victims of massive pleural 
effusions or the dilated heart of diphtheria. 

The author has witnessed two sudden deaths directly attributable to a 
failure to recognize the fact that if a patient is too ill to "sit up" he also may 
be too ill to be "set up." 

When the lungs of any person in the lateral decubitus are examined a 
slight allowance must be made for the compression of the thorax on the side 
in contact with the bed. This tends to slightly dull the percussion note, 
increase vocal fremitus and intensify the breath sounds. 

Deficient Expansion. — General bilateral lack of expansion may be due to 
pain, deficient lung capacity, emphysema, a rigid chest wall, or a lack of skill 
on the part of the patient. 

Many persons cannot breathe or cough to order and some do not know 
how to expand their lungs. 

Unilateral defects of expansion indicate a crippled lung or diseased pleura, 
be the cause what it may, the lesion ancient or recent. 

Pleurisy, pleuritic effusions, pneumonia, tuberculosis, pleuritic adhesions, 
a permanently retracted^wall, painful or obstructive lesions of the thoracically 
sheltered abdominal viscera, myalgia of the intercostals, and new growths, 



Proper light. 



Calamitous 
results. 



Often trivial. 



Important. 



Important 
associations. 



288 



MEDICAL DIAGNOSIS 



Significance of 
reversal of 
type. 



Epigastric 
movement. 



One cause of 

shallow 

breathing. 



Invaluatle in 
diagnosis. 



Counting. 



Normal 
predominance. 



Reversal of 

normal 

variation. 



Voice. 



Density of 
structure. 



Reinforce- 
ment. 



constitute the chief and most frequent of the causes of unilateral deficiency 
of expansion. 

Deficient upper-chest expansion in women, even if bilateral, suggests apex 
lesions or naso-pharyngeal obstruction, for costal breathing is the normal 
feminine type. 

Conversely, superior costal breathing in men should lead one to examine the 
lung bases and abdomen, and any lack of the normal inspiratory fullness in the 
epigastrium, unilateral or bilateral, such as is seen in diaphragmatic paralysis 
and painful abdominal affections should be carefully noted. 

The breathing of one who has a painful growth or inflammation involving a 
movable subdiaphragmatic organ is likely to be shallow and of the feminine type. 

Tender Areas. — In the detection of tender thoracic areas, the expression 
of the face is the safest guide. 

Vocal Fremitus.* — Vocal fremitus, that vibration of the chest wall and 
pulmonary structures caused by the vibrations attending the production of 
sounds at the glottis, is best detected by simultaneously placing the palmar sur- 
faces of both hands firmly upon the chest at corresponding opposite points. 

The patient is then asked to enunciate slowly, clearly, evenly, and repeatedly 
the word "ninety-nine, " the resultant vibration of the chest under the hands being 
noted and that of one side carefully compared with that of the other. 

It is a useful procedure alternately to raise and lower the palpating hands, 
thus rendering the contrast in fremitus more distinct, or to apply the same 
hand, first to one side and then to the other. 

Palpation often involves the use of one hand only, in unilateral localized 
lesions. 

There is normally a perceptible difference in fremitus as between the right 
and left side, especially in the region of the upper lobes, that of the right being 
the stronger. 

This difference is due in part to the larger size and more direct course of 
the right bronchus but also to the closer and more direct relationship of the 
right apex to the trachea. 

A marked difference is a suspicious sign, especially if the fremitus of the 
left side exceeds that of the right, and even an equality of fremitus should suggest 
an especially critical examination of both lungs. 

Laws of Fremitus. — Vocal fremitus conforms to the laws of sound 
conduction. In general it follows therefore: 

i. That, if free bronchial communication exists, the louder and deeper the 
voice, the greater is the fremitus. 

2. The denser the conducting material, the greater the fremitus, e.g., con- 
solidated lung yields increased fremitus provided that it is in proper relation 
to a patent bronchus. Conversely the fremitus is relatively diminished over 
emphysematous lung or areas of pulmonary relaxation. 

3 . The transmission of the sound through a tube and into an air chamber causes 

* The palpable vibrations attending cough ("tussive fremitus") and those due to 
stenosis of the air passages or their obstruction by exudate ("rhonchal") or "stenotic" 
fremitus) are of slight importance. 



THE EXAMINATION OF THE LUNGS AND PLEURA 



Structural 
homogeneity. 



Sound 
dampers. 



conservation and reinforcement of the sound waves and thus increases fremitus, 
e.g. } a cavity communicating with a bronchus causes increased fremitus. 

4. The more homogeneous the conducting medium-, the greater is the intensity 
of transmitted vibration (fremitus). 

5. The interposition of substances of a diferent molecular structure between 
the source of vibration and the conducting body or between the latter and the 
palpating hand acts as a damper and interrupts the conduction of vibrations — 
e.g., absence of fremitus in extensive pleural effusion, liquid or gaseous, or 
diminished fremitus in pleural adhesions, save in the case of bands or cords 
carrying vibrations to the chest wall from consolidated or compressed lung 
or patent bronchi. 

In the rare "massive" pneumonias the larger bronchi tributary to the area 
involved are filled with exudate which acts as an interposed barrier or damper 
to vibrations.* 

Deductions. — The following points are to be borne in mind: (a) Markedly 
increased fremitus points to consolidation of lung tissue or cavity formation. 

(b) Markedly diminished fremitus suggests emphysema, pleural adhesions, 
pleural new growths, pleural ejfusions, pulmonary edema or an obstructed 
bronchus. 

It is evident that the strength and pitch of the voice and the presence of fat 
and muscle modify fremitus. 

Any bilateral increase or decrease in corresponding chest areas is of com- 
paratively slight significance in the absence of otherwise demonstrable bilateral 
lesions, such as tuberculosis, emphysema, or hydrothorax. 

Pressure Palpation. — By a mere thrusting pressure of the finger-tips, or a 
thrusting stroke, decided resistance areas may be quite easily defined by the 
specially trained finger, and the resistance felt by the pleximeter finger is 
used, more or less unconsciously, as an auxiliary to percussion in outlining 
organs, detecting exudates and large areas of infiltration. 

PERCUSSION 

The Finger as a Pleximeter. — The body may be directly struck with the "immediate' 
tips of the fingers {immediate} or a pleximeter, such as the finger, an oblong percussion, 
piece of hard rubber, or a pencil, may be struck by the finger or by a percus- 
sion hammer {mediate). 

It matters little what the physician uses as a pleximeter provided he adheres 
to one method, but the finger is something which cannot readily be lost or left 
behind. 

The percussion stroke is best made with the middle finger, and should be 1 
delivered with a loose wrist as if striking a single note on the piano. 

Whether it be "staccato" (quickly rebounding), a mere dropping of the 
hand, or, sustained, depends upon the structure percussed and the direct 
purpose of the individual stroke. 

* The interposition of a lead joint constitutes a common device for cutting off sound 
conduction in an iron pipe circuit. 
19 



Massive 
pneumonias. 



Increase. 



Decrease. 



Variable 
factors. 



Bilateral 
variations. 



Unconscious 
use of method. 



290 



MEDICAL DIAGNOSIS 



"Staccato" vs. 
sustained. 



Avoidance of 
technical error. 



Accurate 
comparison 



Concentration 
upon tone. 



Direction of 
stroke. 



Defining 
boundaries. 



Respiratory 
stages. 



Important. 



Seldom 
needed. 




Fig. 102. — Percussion of apex. 
One of several faulty methods. 
The pleximeter finger is not 
flatly applied to the chest. 



Over hollow air-containing organs or pulmonary cavities or under any 
conditions where hyperresonance or tympany is present or suggested the 
"staccato" stroke is preferred. A sustained stroke best brings out resist- 
ance and if exaggerated becomes a form of palpatory percussion. 

It is useless to get a special plexor and pleximeter, for two pencils, a coin 
and a pencil, etc., etc., are sufficient even for the rod pleximeter percussion. 

Vital Points in Technic. — (a) The strokes should be of equal strength 
over corresponding bilateral areas. 

(b) The pleximeter finger should be placed accurately, firmly and exactly 
but not too forcibly upon the chest and the pressure 
exerted should be equal over all areas under com- 
parison.* 

(c) Exactly the same areas on each side should 
be alternately percussed. 

(d) No change in position that involves sus- 
tained muscular action upon one side only should 
be permitted. 

(e) The attention should be so concentrated 
upon the tone elicited as to render unnecessary a 
prolonged tapping of the same region, with its 
resultant loss of time and dulled perception. 

(/) The direction of the stroke should be 
perpendicular to the surface percussed, except in 
defining the right or left heart border, in which instance one should maintain 
the same vertical plane throughout, regardless of the lateral curvature of the 
chest ("orthopercussion"). See percussion of the heart. 

(g) The force of the stroke should be determined by the nature of the underlying 
structures. 

(h) In outlining an organ, the pleximeter finger should be kept parallel to 
the edge of the object percussed. 

(i) The more forcible the stroke, the firmer should be the pressure of the 
pleximeter finger. 

(j) In critically comparing pulmonary tones, the same respiratory stage 
should be observed. 

(k) Percussion should be practised both after full expiration and deep held 
inspiration. (The lung note is normally more resonant and of higher pitch 
in the latter stage, the lung borders low and the superficial cardiac area 
diminished.) 

The nail of the plexor finger should be cut short so that only the pulp of the 
tip meeets the pleximeter finger, and as in golf, billiards or driving a nail, the eye 
should be fixed upon, and the stroke fall at, the exact center of the pleximeter. 

The finger is by far the best pleximeter for ordinary purposes and may be 
perfectly adapted to every useful type of percussion. 

Strong Percussion. — This may sometimes be useful when the chest wall 
is very fat or muscular or when one wishes to detect some non-resonant body 

* This "flat-finger" percussion should never be used to determine the heart outline. 



THE EXAMINATION OF THE LUNGS AND PLEURA 



291 



lying beneath one that is resonant, but should be avoided when possible 
as too greatly extending the area of vibration and confusing the results. 

A stroke loud enough to be heard throughout a large classroom is always 
faulty and the term- "strong" is relative and does not mean a pounding stroke. 

Light or Moderate Percussion. — This is the more generally useful form 
and especially so when one has to deal with children, a thin wall, or with a 
non-resonant body overlying a resonant one. 

Auscultatory Percussion. — The combination of auscultation and percus- 
sion is a valuable procedure in competent hands and especially so in deter- 
mining the boundaries of thoracic or abdominal organs, the detection of 




Fig. 103. — Normal chest. This figure shows the. conditions affecting percussion of 
the normal chest, a. Variation in shape and volume of the two lungs, b. Modified 
resonance due to ribs and sternum overlying pulmonary tissue, c. The uselessness of 
percussion near the spinous processes of the vertebral column. 

cavities, or the elicitation of the "coin sound" of pneumothorax. It may be 
practised by the "rod pleximeter" method with a small coin as plexor and a 
lead pencil as pleximeter, or, in pneumothorax, two coins. 

The stethoscope is placed over the part to be tested or bounded and an 
assistant percusses lightly, gradually receding until a point is reached at which 
the specific note is lost or abruptly and decidedly changed in pitch and quality. 

Mere gradual decrease of intensity is not definitive. It must occur 
abruptly* 

The heart, liver, spleen, lung apices, stomach and intestines are more 
or less readily and accurately differentiated, and, save the two latter struc- 
tures, delineated, by this method. 

Position of the Patient. — For percussion of the anterior surface of the 
lungs the hands should hang loosely at the side; for axillary percussion they 
should be placed upon the head; for percussion of the posterior surface they 
should be lightly folded in front, not placed upon opposite shoulders, inas- 
much as the latter position necessarily involves muscular tension that 
interferes with the elicitation of the true note. In auscultation, however, this 
position is useful in determining the condition of the interlobar region. 

* Much the same results may be obtained by stroking the surface, or by using a vibrat- 
ing tuning fork. 



Don't pound. 



Most used. 



A valuable 
subsidiary 
method. 



Abrupt 

transition 

important. 



Selective 
postures. 



292 



MEDICAL DIAGNOSIS 



Descriptive 
terms. 



Practice on the 
normal body. 



PERCUSSION SOUNDS.— It is customary to describe the percussion 
notes as "resonant," "hyper resonant" "tympanitic" "dull" or "flat." 
Nothing but practice will serve to differentiate these sounds but any one of them 
may be elicited and studied through percussion of some portion of the normal 
body. 

Normal Areas Available for Comparative Study. — The typical normal 
pulmonary resonance is that of the upper axilla, and its pitch, intensity and 
duration should be carefully noted and compared with that normally elicited 
over the apices, interscapular spaces and lung bases. 

Dulness. — A didl note is yielded by the liver below the lung margin and 
modified dulness just above this point, where only the thin wedge-shaped lung 
border intervenes. 




^r 




Fig. 104. — a. Normal. d. Hyperreso- 
nance (emphysema) . b. Heavy and c, light 
percussion over consolidation. 



Fig. 105. — a. Dulness from thick wall. 
b. Pleural adhesion, c. Normal, d. New 
growth. 



tff 



-> Normal Resonance. 



-4fj(|J] * Increased Resonance. 

-4 > Dulness. 

Both are extremely valuable for training the ear and acquiring an apprecia- 
tion of "resistance" to the pleximeter finger. 

Flatness. — The flat note may be elicited by percussing the thigh or the 
deltoid muscle. 

Tympany. — The tympanitic note is yielded by the stomach or intestines as 
in Traube's semilunar space, and an extremely important modification, viz., 
dull tympany is heard over the main bronchi close to the sternum or over the 
upper sternum itself. 

Characteristics of the Percussion Sounds. — All percussion notes possess 
certain well-recognized characteristics and ordinary percussion also de- 
termines resistance as felt by the pleximeter finger. 

Cardinal Factors. — Each sound has a certain quality, intensity, pitch and 
duration. ■ 

Intensity depends upon the energy and amplitude of vibrations. 

Pitch rises with increase of the rapidity of the vibrations, varying with the 
tension. 

Quality depends upon the material. 



THE EXAMINATION OF THE LUNGS AND PLEURA 



293 



Duration varies with the strength and amplitude of vibration and the density 
and tension of the structure. 

Increased resistance goes hand in hand with dulness, and guided by this 
alone a stone-deaf man might make a very fair percussor. 

In general, the more air the organ contains and the greater its deep diameter 
the more marked is its resonance. 

THE NORMAL PERCUSSION SOUNDS.— It is important that the 
normal variations peculiar to (liferent areas of the chest should be held clearly 
in mind, and these standard notes can be learned only by painstaking practice 
upon a sound chest. 

The Apices. — The apices yield normally a resonant note, clear but not 
intense and tending to rise in pitch and shorten in duration (dulness or "im- 
paired resonance") as the pleximeter ringer approaches the vertebral line 
posteriorly, or the trachea, anteriorly. 

The Infraclavicular Region. — The mid-infraclavicular space is typically 
resonant, the pitch of the percussion note being slightly higher upon the right 
than upon the left side. 

Primary Bronchi. — As stated, any tendency to approach the region of 
the trachea or a primary bronchus results in a note of heightened pitch, 
increased resistance, and shortened duration (impaired resonance or 
modified dulness). 

The Hepatic Area. — Below the right second rib anteriorly there is increased 
resonance until the fifth rib is reached, when the pitch rises because of the 
underlying solid tissue of the liver. 

At the sixth rib resonance normally ceases and a line of absolute dulness 
marks the lower limit of the lung and the upper border of the uncovered 
surface of the liver. 

The Axillary Region. — In the axillary region typical pulmonary resonance 
persists until the seventh interspace or eighth rib is reached (lung border). 

The cardiac area markedly modifies the percussion note of the aspect of 
the left chest anteriorly from the lower border of the third rib downward 
within the mid-clavicular line. Anteriorly along the whole internal boundary 
of the lung the note rises as one approaches the sternum. 

Clavicular Percussion. — The clavicle is usually utilized as a pleximeter 
and directly percussed and its center yields a markedly resonant note. 
Internally and externally, pitch and resistance rise rapidly, but as a 
pleximeter the author believes it to be extremely fallible and often 
misleading. 

Posterior Surface. — Here the height and mobility of the apices are best, 
determined by carrying percussion upward during a forced and held inspira- 
tion, marking the limit of resonance, and repeating the procedure during 
forced and held expiration. Mere increase of intensity in the pulmonary tone 
in inspiration over that of expiration proves nothing. // is the extension, and 
diminution of the area of resonance that is important. The heavy muscles 
covering the back make necessary the use of greater force and the note is 
less clear and satisfactory than in front. This is particularly true of percus- 



Air content. 



Study the 
normal. 



Typical, 
resonance. 



Modifiers 
of tone. 



Modified 

hepatic 

dulness. 



Absolute 

hepatic 

dulness. 



Heart dulness. 



Unreliable. 



Apex 
percussion. 



Resonant area. 



294 



MEDICAL DIAGNOSIS 



sion over the scapula itself and a glance at a transverse section of a chest 
shows the general futility of percussion near the spine, save for the determina- 
tion of Grocco's triangle. Passing downward, the superficial liver dulness 
marking the lower border of the right lung is encountered at the ninth rib in 
the scapular line. 

Auscultatory Percussion of the Apices.— By placing the stethoscope bell 
over the suprascapular space and making direct percussion upward over the 



Liver dulness 



Valuable but 
fallible. 





Fig. 106. — Normal apex resonance. 
Kronig's method. 



Fig. 



>7. — Retracted left apex. 
Kronig"s method. 





Fig. 108. — Anterior surface. Lung 
borders. Forced inspiration. 



Fig. 109. — Lateral surface. 
Forced expiration. 



apex one may mark the upper limit of resonance in full inspiration and 
expiration. Then without moving the stethoscope the summit along the 
suprascapular space should be directly percussed from the center outward 
to right and left to determine the lateral boundaries of transmitted 
resonance. The use of this method with the stethoscope well below the 
clavicle will determine approximately the anterior upper level of the apex and 



THE EXAMINATION OF THE LUNGS AND PLEURA 



2 95 



the breadth of the resonance zone in the upper subclavicular region. This 
method, though fallible, is of great value in detecting obscure apex lesions. 

Kronig's Method. — Kronig uses a light, ringer to finger, percussion mak- 
ing firm pressure with the pleximeter finger and outlining the whole field of 
apex resonance. He lays much stress upon, what might seem to many, 
minor details.* 





Fig. no. — Anterior surface. Lung 
borders. Forced expiration. 



Fig. in. — Lateral surface. Lung 
borders. Forced inspiration. 




Fig. ii2. — Posterior surface. Lung 
borders. Quiet breathing. 



Fig. 113. — Posterior surface. Lung 
borders. Forced inspiration. 



The Lung Borders. — The position and mobility of the lung borders are 
affected in every serious chronic disease of the lung. 

In tuberculosis, they show a decided lack of mobility, both at apex and 
base. 

* See Deutsche Klinik., Band ii, 1907. 



Important 
sign. 



296 



MEDICAL DIAGNOSIS 



Compressed 
lung bases. 



Of limited 
utility. 



In true emphysema, and to a less degree in vicarious emphysema, in 
pulmonary engorgement and obstructive dyspnea of any type, they are lower 
than normal at the base, and markedly lacking in range of movement.* 

In fibroid phthisis, chronic pneumonia and pleural adhesions the change in 
position and movement is a striking symptom. In Figs. 108 to 113 the 
respiratory changes of the lung borders are clearly shown. 

// must be borne in mind that all sound lungs cannot be held to the same limits, 
that equality of movement as between the two sides is the real test and that a 
i considerable displacement accompanies mere change of posture. 

High Inferior Lung Borders. — The lung may be crowded upward or aside 

by pericardial exudates, a dilated heart, malignant growths, pleural exudates, 

I meteorism, ascites, or abdominal tumors, and thus an atalectasis may be pro- 

1 duced in cases of long standing sufficiently complete to yield a misleading 

dulness at the bases, though the commoner finding is the hyperresonance of 

relaxed lung tissue. 




Fig. 114. — a. Pleural effusion, b. Hyper- Fig. 115. — a. Hyperresonance over re- 

resonance above fluid exudate, c. Normal laxed lung surrounding tubercular focus, 
lung. (Some vicarious emphysema.) b. Normal, d. Superficial cavity, e. Thick- 

walled cavity. 



*fH|{ > Normal Resonance. 

•♦tfiffl — > Increased Resonance. 
•4 » Dulness. 



Spinal Percussion Zones. — The spine yields a peculiar note susceptible 
of division into dulness, osteal resonance, modified resonance and fiat tympany 
(Fig. 115). 

The osteal tones are so affected by the adjacent structures as to yield 
some information of value in certain thoracic and abdominal lesions. Thus, 
"A" would be lengthened in mediastinal tumor and shortened in hyper- 
trophic emphysema. "B" would be affected by adjacent pulmonary con- 
solidation or pleural effusion (see page 291). "C" may be affected by 
hepatic renal, pancreatic or gastric growths. 

Most painstaking practice is necessary if one would obtain much 

* In vicarious emphysema the loss is less marked. 



THE EXAMINATION 01 IIN' LUNGS AND PLEURA 



297 



information from these areas and it seldom offers diagnostic information 
which is not elsewhere and otherwise obtainable by more reliable signs. 

Hyperresonance. — This, a note of lower pitch, relatively longer duration 
and greater intensity than that yielded by normal pulmonary tissue, is heard 
listended, relaxed, or emphysematous lung tissue. 



Low pitch and 
long duration. 



Dulness 

(1st to 4th D.). 




Ostial 

Resonance 

(5th to 12th D.). 



Flat Tympany 
(Sacral/ 



Fig. 116. — Spinal percussion zones. {Koran yi — DaCosta.) 




Fig. 117. — Emphysema. The distended air-cells and voluminous lung are clearly shown. 

In some cases of senile (atrophic) emphysema it is replaced by a note 
that is distinctly high-pitched and somewhat lacking in resonance. Well- 
defined hyperresonance may be encountered at the lung bases in cases 
where extreme intra-abdominal pressure exists with upward displacement 
of the diaphragm and the sheltered abdominal viscera or, as previously 
stated, the inferior lung margins may be dull and silent under such con- 
ditions, if of long standing, because of complete marginal atalectasis. 



Intra- 
abdominal 
pressure. 



298 



MEDICAL DIAGNOSIS 



Drum-like 
note. 



Cavity or 
hollow viscus. 



Pitch of note. 



Excessive 
tension. 



Misleading 
dulness. 



Free exudate. 



The "jug 
sound." 



How imitated. 



Effect of 
tension. 



How imitated. 



When normal. 



Cavity sign. 

Necessary 
maneuver. 



Other 

associations. 



Sign of 
"open" cavity. 



Effect of 
posture. 



Tympany. — Tympany is characterized by its clear, hollow, drum-like 
quality which is most typically shown in percussion over large, smooth, 
elastic, thin-walled, empty cavities. The intensity and pitch of a pulmonary 
tympanitic note varies greatly with the size of the cavity in which it is 
produced, the thickness of its walls, its proximity to the surface, and the 
size of the communicating bronchus. 

The larger the cavity the lower the pitch; the greater the size of the communicat- 
ing opening, the higher the pitch; and, lastly, the pitch of the percussion note 
varies directly with the tension of the walls. 

The tympanitic quality of any note may be lost if tension reaches a certain 
point. 

Tympanitic Note in Pneumothorax. — In open pneumothorax the percus- 
sion note is extremely drum-like over the air-filled pleural cavity, but it 
should not be forgotten that in certain of the cases of valvular or closed pneu- 
mothorax the percussion sound is quite distinctly dull because of extreme 
high tension. 

It may be metallic, but is never flat, as in the case of liquid effusion, save 
at the base where a small associated free exudate is usually present. 

Amphoric Percussion Note. — This relatively high-pitched, hollow, metallic 
note indicates a large, superficial, thin-walled, smooth, tense cavity, either 
wholly closed or not freely communicating with a bronchus and so formed as 
to produce selective reinforcement of vibrations. This tone can be closely 
imitated by snapping the cheek with middle finger and thumb when it is 
strongly distended and the mouth closed. 

It will be noticed during such a test that certain degrees of increase of 
tension tend to increase the metallic quality of the tone. 

SPECIAL MODIFICATIONS OF THE PERCUSSION NOTE.— The 
Bruit de pot fele. — This is precisely like the " chinking" produced when 
the borders of the palms of the hands are placed transversely together so as 
to leave a central air space free and struck sharply against the knee. 

It may be present normally in the thin, elastic chests of children percussed 
while they are crying. In the adult chest it can be obtained most readily, 
in the infraclavicular region if there be a superficial cavity with thin walls and 
either a stenotic or "slit-like" opening. The mouth should be open and the 
heavy percussion applied during expiration. 

This sign may be, but rarely is, present in open pneumothorax; in the 
vicinity of pneumonic areas; or above a pleural effusion. 

Friedreich's Phenomenon. — The percussion note over a cavity may be 
higher during deep inspiration than in expiration. 

Wintrich's Phenomenon. — The pitch of the tympanitic percussion note 
over an open cavity is higher and clearer when the mouth is open. 

The changes are best appreciated when the examiner's ear is kept close 
to the wide-open mouth of the patient inasmuch as the amplification and 
reenforcement of the percussion vibrations transmitted by the bronchi and 
trachea are amplified by the pharyngeal and buccal walls. 

If the cavity contains fluid, change of posture may block the opening of 



THE EXAMINATION OF THE LUNGS AND PLEURAE 



299 



bronchial communications by closing the cavity and abolish the sign until 
another position is assumed. 

High-pitched trachea! tympany of the same type as regards its tonal changes 
sometimes occurs over infiltrated or compressed lung tissue of the ordinary type 
{William's tracheal tone); or over the manubrium in certain cases of mediastinal 
new-growth, aneurysm or massive pericardial effusion (Hoover). 

Biermer's Sign. — In hydropneumothorax the percussion note is higher 
pitched when the patient is in the erect or sitting posture than in recum- 
bency because of the distribution of the fluid in the latter position which is 
such as to increase the long diameter of the pleural cavity and lengthen the 
vibration of the overlying chest wall. 

Gerhardt's Sign. — This term is applied to the well-known postural 
variation in the percussion note over a cavity, and is, of course, dependent 
upon the presence of movable fluid in a vomica freely communicating 
with a bronchus and possessing unequal axes. // is a Biermer's sign in 
miniature. 

Coin Sound. — This is described under " Auscultation." 

Skodaic Resonance. — This hyperresonant or tympanitic note is heard 
over relaxed lung tissue, as, for example, in pleuritic effusion above the level 
of the fluid; in the neighborhood of an advancing pneumonic consolidation; 
in early edema of the lungs; to a lesser degree, in certain stages of incipient 
apical tuberculosis, and in pressure upon lung tissue by massive pericardial 
effusions, new growths or aneurysmal tumors. 

In tuberculosis it may prove puzzling and lead the physician into a futile 
search for a lesion in the less resonant sound lung. 

Diminished Resonance. — As resonance varies directly with the amount of 
air in the underlying structures accessible to a percussion stroke, deep-seated 
areas of consolidation covered by air-containing lung tissue yield a mixture 
of the vesicular and dull note, such as is well illustrated by the relative dul- 
ness of the liver an inch or two above the inferior lung border. Large areas 
of consolidation at the surface of the lung yield a dulness exactly like that 
of the liver just below the lung border. 

Forms of Pulmonary Dulness. — It is obvious that subtle or decided 
differences must exist in the so-called "dull" percussion note and that these 
will depend upon the density and degree of airlessness of the tissue yield- 
ing it, as well as its depth from the surface, its size, its relationship to other 
more resonant tissues or organs and the condition of the neighboring or 
possibly enveloping lung tissue. 

Lobar Pneumonia. — If central, one may find primarily a hyperresonance 
which undergoes a gradual transformation to frank dulness as the process 
becomes superficial. So also in the stage of congestion our first percussion 
may elicit hyperresonance due to the disturbed tension of the tissues (relaxa- 
tion) and, for the same reason, as the process of consolidation advances, a 
band of hyperresonance may precede it. 

In frank established pneumonia the note is of a dulness comparable to that 
of the liver just below the lung margin and it is usually definitely limited by 



William's 
tracheal tone. 



Postural 
change of 
pitch. 



Miniature of 
Biermer's sign. 



Relaxed 
tissue. 



Associated 
conditions. 



A misleading 
sign. 



Deep vs. 

superficial 

lesions. 



Modified vs. 
true dulness. 



Variants. 



Misleading 
hyper- 
resonance. 



Important 
points. 



3oo 



MKDICAL DIAGNOSIS 



Apex 

pneumonia. 



Hyper- 
resonance 
the nile. 



Effect of 
emptying. 



known lobar boundaries, most commonly being found posteriorly and, in the 
larger number of instances, on the right side. 

The upper lobes are often involved secondarily or even primarily, the 
latter locus being not uncommon in influenza and in the misleading tubercu- 
lous lobar pneumonia. If the bronchi leading to a pneumonic area are blocked 
{massive form) fatness results and the entire involved area becomes silent. 

Broncho -pneumonia. — Dulness does not characterize this form and if 
present is usually due to the fusion of lesser areas which may previously have 
been hyperresonant and are usually represented by strips of interscapular 
dulness or anterior zones along the lateral lung margins. These are usually 
best defined by light percussion but in exceptional cases a frank lobar consolida- 
tion is closely simulated. 




Fig. 118. — Lobar pneumonia (left); Central pneumonia (right). The lobar consolida- 
tion on the right side would present the classical signs of complete solidification with 
patent bronchi. The central area of consolidation might yield no percussion signs, or, 
hyperresonance, and be chiefly denoted by distant tubular breathing obscured by the 
vesicular murmur of over-lying lung-cells. 

Lung Cavities. — All pulmonary cavities may yield a dull, or if very large, 
a flat note when filled with secretion and one often finds a sudden transition 
from dulness to tympany after free and copious expectoration. 

Atelectasis. — The percussion note of a beginning compression atelectasis 
is hyperresonant because of tissue relaxation but when carnification occurs 
the airless tissue yields a dull note. (See pages 383 and 384.) 

Tuberculosis. — This ailment otters every variant of dulness calculated to 
perplex the physician. In early cases the patches are likely to be small and 
relaxation of surrounding tissue and vicarious emphysema add to his 
difficulties. Miliary cases of the pulmonary type offer as a rule only an 
extreme and significantly generalized hyperresonance.* Cavities may show 
central tympany or its modifications together with the marginal dulness of 
infiltration. 

* The author has never seen this sign given the prominence it deserves. The hyper- 
resonance is usually decided throughout on the lung but may be intensified over certain 
areas. Cyanosis is usually marked and the combination is of decided clinical value in the 
presence of fever. 



THE EXAMINATION OF THE LUNGS AND PLEURAE 



30I 



Pulmonary Edema. — The primary percussion note of lung edema is 
hyperresonant but in prolonged cases the areas may become airless and the 
bronchi rilled with liquid, in which event dulness or even flatness may be 
present as in the case of massive pneumonia. 

Flatness. — This characteristically dead or toneless note indicates dense 
adhesions, liquid pleural effusions or solid growths in close contact with the 
chest wall. The sound is of great assistance in differentiating the puzzling 
cases of pleural effusion in which the breath and voice sounds have almost 
precisely the character of those heard in pulmonary consolidation. It is 
by no means a difficult matter to distinguish between dulness and flatness. 

The cardiohepatic angle is represented by the resonant area in the right 
fifth interspace bounded by the cardiac right border and the hepatic 




Fig. 119. — Various forms of pulmonary cavities; incipient tubercular deposits; area of 

softening. 

dulness below. Its angular outline is lost to percussion early in pericardial 
effusion* ("Rotch's sign") right-sided pleural effusions and adhesion, and 
right-sided basal pneumonia. 

AUSCULTATION 

Unilateral vs. Bilateral Variations. — The first law of auscultation demands 
that the test of symmetric breathing shall precede inference. In other words, 
before concluding that a slight departure from the type of breathing on one side 
represents a pathologic change, the corresponding opposite area should be 
investigated. Slight symmetric departures from the normal are often transient 
and negligible. 

Basis of Auscultatory Phenomena. — The art of auscidtation rests upon 
the same laws of sound as underlie palpation and percussion. The sound heard 
when the ear is applied to the chest is chiefly produced in the glottic chink, 
but transmitted and modified by the bronchial tubes, lung tissue and chest wall. 

The nearer the ear approaches the glottis, the greater is the predominance 
of a tubular element in the sounds heard and if the normal pulmonary structure 

* This, despite the fact that the profile X-ray picture may show preservation of the 
angle with outward displacement. 



Growths'and 

liquid" 

exudates. 



Rotch's sign. 



Fundamental 
rule. 



Rationale. 



Glottic 
proximity 



302 



MEDICAL DIAGNOSIS 



Variants. 



Broncho- 
vesicular 
type. 



Bronchus 

caliber. 



Reinforced 
vibrations. 



Cavernous or 
amphoric. 



The voice. 



Diminished 
conduction. 



A huge cavity. 



is replaced by consolidation, the glottic sounds are transmitted almost unmodified. 
All degrees of shading may occur according to the situation of the areas of 
induration and their relation to the bronchi. 

If the patch of thickened lung be remote from the surface, a vesicular sound 
due to overlying pulmonary tissue will be superadded to, and modify the tubular 
sound. 

Again, the larger the bronchus that is in direct communication with the in- 
durated area and the more superficial the patch, the more intense will be the sound. 

Cavities. — Lung cavities in communication with a bronchus yield modifica- 
tions of the same glottic sound, and follow the same general law. 

In them we have a definite air chamber surrounded by more or less rigid 
walls of consolidated lung tissue. 




Fig. i 20. — Pleural effusion. 



Especial attention should be directed to the compressed 
lung of the larger effusion. 



If cavities communicate with an unobstructed bronchus, are wholly or partly 
empty, and if the communicating tube itself be unobstructed, the glottic sounds 
take on a hollow, metallic or even muscial quality from the walls of the cavity 
and thus modified will be transmitted to the surface of the chest. 

The intensity of conducted sound varies directly as the depth and intensity 
of the voice and inversely as the thickness of the chest wall. 

Interposition of Air or Fluid Between Lung and Chest Wall. — Any form 
of pleural effusion, liquid or gaseous, acts ordinarily as a damper to transmitted 
vibrations from the glottis. 

Hence, in any form of pleurisy with effusion, breath sounds are likely to 
be diminished or lost below the level of the fluid. Certain exceptions to this 
rule will be considered later (see "Pleurisy"). 

Open Pneumothorax. — It will be readily understood that in some cases 
of pneumothorax a free opening between the pleural cavity and lung may be 
present and that in such a case the physical signs would be those of a very 
large cavity. 

Mediate and Immediate Auscultation. — Auscultation may be either 
mediate or immediate at the pleasure of the auscultator. 



THE EXAMINATION OF THE LUNGS AND PLEURA 



303 



The Stethoscope. — As to stethoscopes, it matters little what one is 
used if the examiner is competent to interpret what he hears. 

Essentials. — The chief essentials in any stethoscope are: (a) That it 
shall clearly conduct sound in proper volume from the chest wall to the ear. 

(b) That its chest piece or bell shall be of a size adequate to the purpose of 
the instrument, yet not too large or of such a form as to make it impossible to 
examine thin chests or those of children. 

(c) That the ear-tips are of a form and size that will properly fit and com- 
pletely close the external auditory canal without exerting undue pressure. 

Many of the modern stethoscopes have a diaphragm and are especially 
useful in auscultatory percussion. The diaphragm intensifies breath sounds, 
heart sounds and murmurs but often obscures certain faint vibratory mur- 
murs, such as may be present in certain cases of mitral stenosis. 




Fig. 121. — Pneumothorax (left); encysted pleurisy (right). 

The author carries an instrument having a reversible chest piece, one side 
of which, the larger, carries a diaphragm while the other, of lesser area, is 
freely open, the original diaphragm having been removed. The chest piece 
revolves upon the branched, metal conduction tube in such a manner as to 
leave but one opening patent when either chest piece is employed. 

He uses also, on all stethoscopes, the frame devised by the late Dr. Arthur 
Sansom which is perfectly adjustable, being made of malleable metal that has 
a trifling but adequate resiliency and can be bent to any degree desired. 
These arms are so jointed as to close quite compactly for the pocket. The 
more complicated stethoscopes have not proven useful in the author's hands, 
nor does he believe that it is wise to use those which excessively magnify 
sound. 

After all, there is no stethoscope that equals the unaided ear, if that has been 
properly trained. 

High-pitched feeble sounds are often lost if the stethoscope alone be used and 
furthermore, one's ears are always li brought along.' n 

Familiarity with both mediate and direct methods is an absolute 
necessity. 



Cerebration 
the chief 
factor. 



Advantages 
and dis- 
advantages of 
diaphragm. 



Excessive 

magnification 

useless. 






MEDICAL DIAGNOSIS 



Study them. 



Avoid 
overpressure. 



Varying 
pressure. 



"Losing" 
extraneous 

sounds. 



Pre cautionary 
measure. 



The "Sandow 



Commoner Sources of Avoidable Error. — Every student should study care- 
fully the sounds produced by muscle contraction, joint motion, stethoscopic 
rubbing, the presence of hair or remnants of the almost inevitable porous 
plaster on the chest and also the curious crackles which may be heard over 
the female breast when this is fat and is subjected to firm -stethoscopic 
pressure. 

Muscle sounds, illary tremor or stethoscopic 

continue after breathing is stopped. 

If due to other muscular activity or joint motion associated with re 
effort, it will usually be evident that the patient is breathing over :!y* 

The presence of h demand the use of water or soap, and the peculiar 

superficiality of tlie breast crackles, their direct response to stethoscopic pressure 

the absence of re; dge of their 

occurrence over that region will prevent error. 

Stethoscopic Pressure. — The careless or inexpert frequentl much 

unnecess ■:.'- pain by applying forcible stetlwscopic pressure to tend: 
forgetting that only such :eed be applied as will accurately an zbly 

adapt the whole c: nee of the bell to the chest wall. 

In the- auscultation of heart murmurs, however, it is necessary to vary 
the contact, as systolic' murmurs are intensified and presystolic murmurs 
diminished by pressure, but painful, excessive pressure is seldom or never 
red. 

Quiet Necessary. — Whatever the form of stethoscope or the ph; 
natural or acquired power of concentration, a quiet place is essential to good 
work. 

Absolute quiet is usually unattainable however and the faculty of uncon- 
sciously "losing" extraneous sounds while detecting internal abnormalities may 
be developed to a remarkable degree : ~ be acquis 

Instruction of Patient. — It may be necessary to show the person under 
examination just how he should breathe, and ordinarily the mouth should 
be open and the respiration be thoracic, deep, uniform, regular and free both 
from blowing and purring on the one hand and extreme deliberation and 
Sandow-like i: pouter pigeon protrusion" on the other. If these precautions 
are not observed, accidental sounds will be abundant, disturbing and mis- 
leading. 

! Extreme deliberation kills the pulmonary sounds, which should be dis- 
tinctly heard, whereas excessive straining procv:r- the misleading murmurs 
of muscular contraction. 

In any event it is well to observe and listen to a few of the patient's inspira- 
tion: before applying :?pe to the chest. 

Effect of Cough or Crying. — In broncho-pneumonia, or in early apical- 
tuberculosis, cough, or, in the child, crying, may develop well-dehned, 
pathologic breathing or suggestive modifications in areas previously silent. 

* The true source of such sounds oftentimes may be determined by having the 
patient go through the act of inspiration and expiration with the nostrils stopped and 
the lips tightly closed. 



THE EXAMINATION OF THE LUNGS AND PLEUR.E 









"- 



Attitude of Patient during Auscultation. — The position of the patient 
during auscultation should vary with the different areas under investigation, 
precisely as in percussion, save that the most effective examination of the 
region of the posterior interlobar space requires that the hand should be 
carried across the chest to the opposite shoulder. 

The scapula is thus carried forward and outward, and by its posterior 
border very nearly defines the posterior line of division between the upper and 

Pulmonary Areas Demanding Special Attention. — Fowler, of London, 
has emphasized the necessity for a special examination of certain auscultation 

areas. He shows that the physical 
of tuberculosis nearly always 
first appear at the apex; not the ex- 
treme tip. but a point nearer to the 
posterior than the anterior surface 
and somewhat external, and that 
they follow a definite "'line of 
march/' with respect to audibility, 
passing downward and into the 
upper portion of the lower lobe along 
the interlobular fissure. 

Regions Most Important. — With 
reference to tuberculosis the most 
important areas are: 

(a) Posteriorly, : oppo- 

site, the second dorsal spine but 
toward the scapula. 

(b) Anteriorly, at, or just below the middle of the clavicle. 

(c) The supra- a ~:dar spaces. 

(d) Along the inner border of the scapula, when the hand of that side rests 
upon the opposite shoulder. 

(e) The upper part of the axillary space. 

VESICULAR BREATHING.— Its characteristics are a peculiar, 

. rustling quality, low pitch, moderate intensity, and no definite break or 
silence interval between inspiration and expiration. 

The latter has no more than one-third the duration of the former, has less 
of the typical quality, and may be inaudible in ordinary auscultation. 

The sound is closely imitated in the prolonged after-sound of the soft, whis- 
pered enunciation of'F." 

PUERILE OR HARSH RESPIRATION.— Normal.— In the chest of a 
normal child, or when listening over a lung that is performing vicarious 
duties, one hears the so-called puerile breathing, which is practical". 
tensifed vesicular respiration. 

TJie prolonged after-sound of a loudly whispered "F" fairly represents it. 

Pathologic. — It constitutes in adults an important sign of broncho- 
pneumonia or vicarious overactivity and may be heard over the unaffected 





Fig. 122. — An important area. 
Fouler.) Position for auscultation of inter- 
lobar region. 



Posterior 
interlobar 
region. 



Tuberculous 
invasion. 



"Line of 
march." 



Normal 
breathing. 



-stated. 



Children. 



Broncho- 
pneumonia. 

Vicarious 

activity. 



306 



MEDICAL DIAGNOSIS 



Early 
tuberculosis. 



Of obstruction, 



Impaired 
expulsive 
power. 



Suggested 
ailments. 



Various 
causes. 



Incipient 
phthisis. 



Overrated. 



Spurious form. 



Title faulty. 



Impaired 
expansion. 



Normal over 
7th cervical. 



side in phthisis, lobar pneumonia, or pleurisy with effusion and over the 
healthy portion of a diseased lung. 

It is, moreover, an early, important and suggestive sign of incipient 
tuberculosis when properly supported by other evidence and may of 
course be heard in certain pulmonic and extrapulmonic dyspneic states. 

Prolonged Expiration. — Aside from the stridor of obstructive or spasmodic 
dyspnea, a respiratory sound possessing this as its most marked characteristic 
is frequently heard on auscultation, and suggests at once a delayed ex- 
pulsion of air from that portion of the lung yielding the sign. 

If the expiratory note be high-pitched, a small area of infiltration is indicated; 
if the pitch be low, one thinks of distention or relaxation of the lung tissue, such 
as occurs in emphysema, chronic bronchitis, or 
in areas immediately surrounding an incipient 
tuberculous deposit. 

Absent or Suppressed Breathing. — Ab- 
sence of the breath sounds over any part of the 
lungs indicates feeble breathing, the interposi- 
tion of some substance between the lung and 
the chest wall, an obstructed chief bronchus or 
certain types of atelectasis. 

Senility, profound exhaustion, shock or 
collapse represent the first; pleurisy with 
effusion, closed pneumothorax, superficial 
filled cavities, and pleural growths or thick- 
ening, the second; and the rare cases of 
massive pneumonia prolonged pulmonary 
edema, pressure of growths or aneurysm, or 
occlusion by foreign bodies, the third. 

Suppressed or feeble breathing is common 
at the apex in incipient tuberculosis, when small multiple foci are enclosed 
by relaxed lung tissue. Such scattered foci are oftentimes too small to 
yield signs of infiltration. 

Cog-wheel Breathing. — Much stress has been laid upon this as a symptom 
of early phthisis. It is overrated and one should remember that mere 
nervousness may produce marked overaction of the heart, irregular and 
unequal inspiration, uneven muscular contraction and, therefore, "mislead- 
ing pseudo-cog-wheel breathing." 

The Genuine Cog-wheel Breathing. — // genuine, it should be heard 
when the breathing is regular and deep, and the heart action neither unduly 
violent nor greatly accelerated. The term "cog-wheel" is not descriptive. The 
breathing is wavy, and marked by distinct breaks and the change almost wholly 
pertains to inspiration. When genuine it indicates imperfect or irregular 
expansion of some portion of the lung. 

BRONCHIAL BREATHING.— Normal.— If a stethoscope be placed over 
the seventh cervical spine, bronchial breathing is heard normally. 

It differs from vesicular breathing in almost every particular. Both inspira- 




Fig. 123. — Selective points for 
manifestation of physical signs in 
pulmonary tuberculosis. 



THE EXAMINATION OF THE LUNGS AND PLEURA 



307 



Hon and expiration arc Hgk-pitched; between them is a distinct break. Expira- 
tion is greatly prolonged, its intensity being equal to or even greater than that of 
inspiration and its pitch usually higher. 

Pathologic— Such breathing indicates consolidation, cavitation or com- 
pression of lung tissue in close relation to a patent bronchus. 

Thus it is heard in pneumonia and established or advanced phthisical 
infiltration, over lung compressed by mediastinal or other tumors or by 




Fig. 124. — Malignant growth (left) and pulmonary abscess (right). The larger mass on 
the left side involves a bronchus, and would yield signs of consolidation. The anterior 
superficial mass would present only dulness, diminished voice and breath sounds, with 
defective lung movement on the affected side. Such abscesses as are here shown present 
few recognizable physical signs and are often overlooked. Malignant growths of the type 
shown are usually marked by hemorrhagic effusion. 

massive pleural or pericardial effusion, but still maintaining communication 
with a patent bronchus. 

Because of such compression probably, the locally intensified voice and 
breath sounds and especially the whispered voice are fairly well conducted 
from the condensed lung in some cases of effusion. In such instances the flat, 
toneless percussion note and usually (though paradoxically) a markedly 
impaired or wholly absent palpatory voice fremitus over the area of flatness 
suggests the correct diagnosis. The breathing is, moreover, usually distant 
though tubular in such cases. Occasionally, tense adhesion bands may act 
as transmitters of these sounds in cases of effusion. 

Broncho-vesicular Breathing. — Normal. — If the stethoscope be placed 
over the second intercostal space at the sternal border or is applied to the 
upper interscapular region of the normal chest, the sound conducted to the 
ear in a curious mixture of vesicular and bronchial breathing, the latter element 
being more marked in the expiratory phase. 

Pathologic. — There is no more important clinical study than this modi- 
fication, as it frequently represents early tuberculosis, compressed lung 
tissue, disseminated areas of infiltration or deep-seated central consolidation. 

TUBULAR BREATHING.— Normal.— Tubular breathing is that heard 
normally over the glottis and difers from bronchial breathing in being more 
intense and possessing a peculiar whiffing quality. 



Infiltration,, 
compression, 
or cavitation. 



Misleading 
variation. 



Corrective 
value of 
percussion. 



Heard nor- 
mally at 2d 
sterno- 
chondral angh 



Deep or 

disseminated 

consolidation. 



Normal over 
glottis 



3 o8 



MEDICAL DIAGX 



Cavity or 

superficial 

consolidation. 

Caution. 



Hollow and 
low pitched. 



Requisite 
conditions. 



Hollow 
metallic and 
musical. 



Indicates a 
cavity. 



Veiled 



Pathologic. — Its significance when heard over pulmonary areas is / 
in its association with cavity formation, bronchiectasis, and superficial consolida- 
;' lung tissue. It is important that this breathing should be carefully 
studied, because of its intimate association with, or near likeness to, cavernous 
and amphoric breathing. 

Cavernous Breathing. — The sole important ' c between cavernous 

and tubular breathing lies in the fact that in the former the pitch is rel I 
■:d the quality distinctly hollow. 

For its production a pulmonary or bronchiectatic cavity is necessary 
not less than an inch (2 cm. + ) in diameter, empty or partially so, with 
resilient walls, and free bronchial communication. 

Amphoric Breathing. — Amphoric breathing is exactly the same as : 
save that it possesses a distinctly metallic or musical quality, the sound resembling 
that produced by blowing across the mouth of an empty bottle. 

It is Jieard over very large superficial cavities and in open pneumothorax and 
approximates in quality its more complex equivalent, the exquisitely bell-like 
tone of the coin sound as heard best in pneumothorax. 

In all cases of cavity, free bronchial communication is necessary : 
production of the typical sound. 

Seitz' Metamorphosing Respiration. — Either or both elements in the 
cavernous or amphoric breathing may carry a simple tubular or bronchial 
element at its beginning which is transformed into the proper hollow or metal- 
he tone before the phase is completed. 

Bruit Voile. — Over infiltrated lung the breath sound may start as a 
cular sound and become broncho-vesicular or pure bronchial as it proceeds. 



Cardinal facts. 



Modified 
in disease. 



An important 
variation. 



VOCAL RESONANCE 

Normal. — If the ear or stethoscope be applied to the axillary region of a 
healthy chest, and the patient slowly and clearly repeats the word '•'ninety- 
nine," in the lowest range of his speaking voice, the voice is heard but the 
words cannot be distinguished; moreover, the ear recognizes the fact that 
the sound is produced at a point some distance from the stethoscope. 

Such normal vocal resonance is associated with a vesicular murmur and a 
normal percussion note, but in disease we find variations in vocal resonance to 
fit every variety of abnormal breath sounds and percussion tones. 

Important Precaution. — The head of the patient should be turned aside as 
the test words are spoken, or the misleading external sound may be further muffled 
by a handkerchief or towel held over the mouth. 

DIMINISHED VOCAL RESONANCE. — The following conditions 
usually result in diminution or loss of the normal vocal resonance : 

Normal Causes. — (a) Weak voice, (b) Excessively thick chest wall. 

Pathologic Causes. — (a) Emphysema or relaxed pulmonary tension from 
any cause, (b) Effusion into pleural cavity (liquid or gaseous), (c) Pleural 
growth or thickening, (d) Massive pneumonia (large bronchi blocked), (e) 
Occluded bronchus due to foreign bodies or to pressure. (/) Certain phases of 
atelectasis and prolonged pulmonary edema. 



THE EXAMINATION OF THE LUNGS AND PLEURAE 



309 



Increased Vocal Resonance of Heightened Pitch. — Vocal resonance may 
be only slightly increased in intensity but show a rise in pitch in cases of imper- 
fect or incomplete infiltration, or over cavities that are not surrounded by con- 
solidated lung tissue. 

BRONCHOPHONY ("Bronchial Voice").— "Normal— Bronchophony is 
normally heard best over the manubrium. At this point the voice or whisper 
seems to be directly at the mouth of the stethoscope and the sense of remoteness, so 
marked in normal resonance, is altogether lost. 

Pathologic. — Bronchophony is heard in varying degrees under the same 
conditions that produce bronchial and broncho-vesicular breathing. Namely, 
consolidation cavitation or compression of lung tissue directly connected with a 
patent bronchus. 

A faint bronchophony is sometimes termed a "bronchial whisper," but 
should be called "distant" or "faint" to avoid confusing it with "whispered 
bronchophony." 

PECTORILOQUY. — {Tracheal Voice) . —Normal.— Pectoriloquy corre- 
sponds to the normal voice as heard over the trachea. It differs from bronchophony 
in that the words seem to be distinctly articulated and spoken directly into the ear. j 

Pathologic. — -It is heard over superficial cavities, compression and 
consolidation. 

"Whispered pectoriloquy" is the term applied when the whispered voice is 
thus transmitted and is always pathologic* 

EGOPHONY. — Pathologic— Egophony is a peculiar modification of the 
voice sound that gives it a bleating or distinctly nasal character. It is most 
frequently heard at the upper level of pleuritic effusion, and, sometimes, just 
above the area of advancing consolidation in pneumonia. 

Attention is not infrequently directed to small pleural effusions, acute or 
subacute, by encountering egophony at the inferior angle of the scapula. 

Bell Tympany (Gairdner's Coin Test). — The coin sound proper is a peculiarly 
beautiful ringing bell-like note heard over the affected side in pneumothorax or 
some very large smooth-walled tense cavities when a coin is placed upon the chest 
and lightly struck with another. 

In eliciting it in pneumothorax the auscuitator usually applies his ear or 
stethoscope to the back and an assistant manipulates the coins upon the 
anterior surface of the chest. 

In certain cases representing either very low or extremely high tension the 
coin sound may be absent in pneumothorax until the tension is changed, f 

Amphoric Voice and Heart Sounds. — Metallic or amphoric resonance of 
the voice and heart sounds may be heard under conditions similar to those 
producing the corresponding breath sound and also at times because of the 
close proximity of a distended stomach. 

Metallic Chink {" Signe du Sou").— A metallic "clicking" or "chinking" 

* The whispered voice is not of glottic production and is almost inaudible over the 
normal lungs; wholly so as syllabic speech. 

t The author has never encountered such an instance in high pressure cases, even though 
the dulled percussion note was present. 



Heard nor- 
mally over 
manubrium. 



Distant 
broncophony. 



Normal over 
trachea. 



Superficial 
lesions. 



Whispered 
pectoriloquy. 



Nasal 
character. 



Accidental aid. 



Bruit d' airain. 



Technic. 



Misleading 
variant. 



3io 



MEDICAL DIAGNOSIS 



Pleural 
effusion. 



Dry and moist. 



Sibilant and 
sonorous. 



Musical. 



Modifying 
factors. 



Significance. 



Obstruction or 

glottic 

paralysis. 



Cardinal 
points. 



Causes. 



may be elicitated over pleural effusions by the Gairdner coin test but is 
wholly different from the exquisite bell tone of pneumothorax. 

Over a pneumonic consolidation the sound is usually merely a dull thud. 

D'Espine's Sign. — This somewhat discredited sign is heard occasionally 
over the upper dorsal vertebrae in cases of tuberculosis of the tracheo- 
bronchial lymph nodes. It consists merely in a w T hispered prolongation of 
the final "e" of such words as "we" "three" or "tree" after the voice stops. 

RALES 

Their Genesis and Varieties. — Rales are either dry or moist, and a considera- 
tion of the anatomic structure of the lungs and pleura makes it easy to understand 
the mode of their production, their significance, and the varying qualities depend- 
ent upon the condition of the lung itself and the character of respiration. 

DRY RALES. — Aside from the friction rale, dry rales may be divided into 
two groups: (a) Sibilant or whistling, (b) Sonorous, "at one time resem- 
bling snoring, at another the sound of a bassoon, and very frequently it is 
like the cooing of a turtle-dove." 

They occur in all grades of pilch and intensity and in passing from the very 
feeblest wheeze or whistle {sibilant) to the most raucous sonorous rdle, the dif- 
ferences depend upon the size of the tube in which they are produced; its proximity 
to the surface; its relation to the consolidated areas; and the depth and character 
of the respiration itself. 

Such dry rdles alone or in association with others are most frequently found 
in bronchial obstruction, bronchitis, asthma and emphysema, but persistent dry 
rdles are common in incipient tuberculosis and may be distinctly resonant or 
consonating in the presence of consolidation. 

Consonance refers to the peculiar quality by virtue of which the striking 
of a certain note upon a musical instrument will produce sympathetic vibra- 
tions in other sonorous bodies as seen in the strings of a piano. Rales of 
various kinds take a higher pitch and changed quality in the presence of 
consolidation or modify their qualities to accord with the peculiarities of 
vibration encountered in cavities. 

Stridor. — Stridor is the loud, whistling sound heard when the trachea 
or a primary bronchus is obstructed by aneurysm, tumor or a foreign body, 
or in spasm or obstruction of the glottis by new growth, edema, false mem- 
brane, catarrhal swelling, abscess, or a foreign body. A similar sound is 
heard in paralysis of the abductors, such as may result from pressure upon 
the recurrent laryngeal nerve.* 

Moist Rales. — In the consideration of moist rales the chief points to be 
noted are: their character, "size," pitch, and resonance. 

A moist rale may be produced by respiration at any point from the glottis 
to a terminal alveolus and may be due to a, tracheal " death rattle;" to the inflow 
and outflow of air through bronchi filled with the thin, serous exudate of edema; 
to the mucous or mucopurulent secretion of bronchitis; the thick tenacious sputum 
of pneumonia, or the purulent fluid of a pulmonary cavity or pyopneumothorax. 

* See also "Stertorous" breathing. 



THE EXAMINATION OF THE LUNGS AND PLEURAE 



311 



Being oftentimes associated with consolidation of all kinds or cavity of any 
degree and originating in tubes of any caliber from that of the primary air 
passages to that of the terminal alveolar openings, it must vary with its surround- 
ings in pitch, quality, size and intensity. 

Crepitation. — This, the "smallest," "finest," "tiniest," of all moist rdles-, 
is usually a "shower" of tiny sounds like the crackling of burning salt or the 
crepitations produced by rolling between the fingers a lock of the hair in front of 
tlie ear. It is heard characteristically at the end of a full inspiration. 

Crepitation is not truly a liquid rale, but signifies merely that air is enter- 
ing into a collapsed vesicle and, at the end of inspiration, i.e., at the moment of 
maximum pressure, is forcing apart the collapsed and slightly agglutinated 
infundibular and vesicular walls. The exact period for each of the group of 
vesicles affected varies by the fraction of a second and thus is produced the 
"showers" of crepitation. 

The crepitant rale is one of the early physical signs of lobar pneumonia {crepi- 
tus indux); is not infrequently present in pulmonary edema, hemorrhage, 
infarction and incipient tuberculosis. It occurs as a precursor of resolution 
(crepitus redux) in pneumonia, and together with subcrepitant rales, or 
alone, may normally be heard with the first deep inspirations at the apex in 
persons who are habitually shallow breathers. It is present oftentimes at 
the base of the lung, when the first deep inspirations are taken, and, with 
considerable persistence, in persons suffering from exhausting disease, espe- 
cially if they have been lying for some time in the dorsal position. Such 
rales are also heard persistently at the lung bases early in pulmonary edema 
and the hypostatic congestion of cardiovascular insufficiency and constitute 
then a sign of importance. 

It should be borne in mind that they are heard only at the end of deep inspira- 
tion, for at first they may be confounded by the student with a more superficial 
pressure crepitation produced by his own ear or stethoscope but lacking the specific 
timing of the true crepitant rale. 

Both crepitant and subcrepitant rales may be closely simulated by modified 
friction sounds. 

Friction sounds are unmodified by cough, peculiarly fixed in their apparent 
point of origin, and are usually distinctly superficial. Oftentimes they are mani- 
festly intensified by firm stethoscopic pressure which may also reveal tenderness. 

"Crackling" Rales. — Three varieties of crackles are recognized by the 
diagnostician. 

The Subcrepitant Rale. — The fine crackling or subcrepitant rdles are pro- 
duced in the bronchioles, heard chiefly but not exclusively in inspiration and 
indicate, as a rule, commencing infiltration. 

Heard at the apices, they always strongly suggest an incipient tuberculous 
process; at the base, temporary atelectasis, pneumonia, congestion, or incipient 
pulmonary edema. They are heard early in resolving lobar pneumonia and are 
the dominant finer rales of broncho-pneumonia. 

Medium Crackling Rales. — These are of the same general nature as the 
foregoing, but coarser. They are heard over softening tuberculous areas, broncho- 



"Smallest' 
rale. 



How imitated. 



Probable 

rationale. 



Showers.' 



Associated 
lesions. 



Significant. 



Time 
important. 



Source of 
error. 



Modified 
friction. 



Differentia- 
tion. 



Not limited to 
inspiration. 



Bronchiolitic. 



Significance. 



Occurrence. 



312 



MEDICAL DIAGNOSIS 



Consonance. 



Resonant 

consonating 

rales. 



Cavity or 
pneumothorax. 



Tiny musical 
echoes. 



Pneumothorax. 



Rare source 
of error. 



A rub, squeak, 
creak or 
crackle. 



pneumonia, and resolving lobar pneumonia, change of pitch and quality due to 
consonance being marked in the presence of infiltration. 

Large Crackling Rales. — These are still coarser and more distinctly fluid 
than the foregoing and, if consonating, point usually to extensive softening in a 
tuberculous infiltration area. 

Mucous Click. — This sound stands midway between the crackling and 
the bubbling or gurgling rales. Its name is its best description and it is 
usually single and oftenest heard at the apices in tuberculosis. 

Bubbling Rales. — These liquid rales are true to name; may be small, 
medium, or large, and are usually readily recognized. 

Gurgling Rales. — These, also sufficiently described in the title, are usually 
heard over large pulmonary or bronchiectatic cavities during cough or forced 
inspiration, occasionally in bronchitis'with profuse exudate, and also over the 
drowning lungs in advancing pulmonary edema. 

Pitch and Resonance of Rales. — All varieties of rales have a certain pitch 
and degree of resonance, directly attributable to their surroundings. 

One that is produced in a bronchus or cavity surrounded by consolidated lung 
tissue or atelectasis will have many of the qualities of tubular or amphoric breath- 
ing, hence we speak of resonant rales, echoing rales, consonating rdles, etc., 
and these may be either moist or dry and at times metallic or ringing* 

SOUNDS APART.- — There are certain special sounds of great interest, 
and chief among these are "post-tussive suction," "metallic tinkling," and 
" succussion." 

Post-tussive Suction. — This interesting physical sign is pathognomonic 
of cavity formation and has been aptly termed "the india-rubber-ball 
sound." It is an inspiratory moist " sucking" sound supposed to attend the 
expanding of a "collapsed thin-walled cavity communicating with a bronchus. 

Water-whistle Sound. — A coarse, gurgling sound either inspiratory or 
expiratory may be heard in pneumothorax if communication with the lung 
exists (pulmonary fistula)-. 

Metallic Tinkling. — This term is applied to the exquisitely delicate and beau- 
tiful musical sounds sometimes heard over a very large wet cavity with dense 
smooth walls and, more commonly, in pyo- or hydro pneumothorax. 

The phenomenon is really due to the production of echoes, and when 
low-pitched is often termed amphoric tinkling. 

Hippocratic Succussion.— This is the well-known " swashing" or "slosh- 
ing" sound, often metallic, usually elicited by. the somewhat heroic measure 
of shaking the victim of a pyopneumothorax or hydro pneumothorax, or rarely, 
of some huge lung cavity containing fluid. 

A mere change in the patient's position or a gentle rocking of the body 
is usually a sufficiently effective maneuver. A similar sound may be heard 
over the stomach but is seldom so transmitted to the thorax as to cause confusion. 

FRICTION SOUNDS.— True friction is produced by the attrition of the 
I apposed pleural surfaces when rendered dry and harsh by inflammation; is 
usually unmistakable and often palpable. 

* As stated, it is well to remember that an overdistended stomach or colon may some- 
times thus influence rales produced over or near the inferior boundaries of the lungs. 



THE EXAMINATION OF THE LUNGS AND PLEURAE 



313 



pleura. 



It is quite closely simulated as to its common phases by the sound heard How imitated, 
when the palm of the hand is pressed firmly against the ear and the dorsum 
rubbed by the flat of the finger pulp under varying pressure. 

Distinctive Features. — The quality of the sound is creaking, rubbing, 
shuffling, rustling, or, more rarely crackling. It is ordinarily distinctly super- Superficial. 
ticial; commonly best heard in the axillary and inframammary regions and 
at the anterior lung margins; is usually jerky or interrupted in rhythm, associated 
with pain in deep inspiration in acute or subacute cases and unmodified by cough. Unmodified by 

If friction disappears from some site previously detected it may sometimes 
be elicited by flexion of the body, or raising the arm of the affected side. < 
Care should be taken lest a friction-like sound due to movement of the shoulder 
joint or scapula be confused with true friction. Perez has described mid-sternal 
friction sounds associated with movements of the shoulder joints. The important 
dependence of these pseudo-friction sounds upon movement and their ready 
localization will usually prevent serious error. 

Friction rales may persist at the margins of the flatness due to a pleural 
exudate. Reappearance after disappearance indicates absorption. 

Pleural Crepitation. — This often occurs early or midway in the inspiratory 
phase of the individual breath sound, whereas true crepitation is late, but this 
distinction is not always possible. 

Pleuro-pericardial Friction. — A friction murmur of cardiac rhythm heard 
over the area of superficial cardiac dulness, or along its borders, synchronous Pulmonary 
with the heart beat but disappearing in forced expiration, suggests inflam- 
mation of the pulmonary pleura and apposed pericardium. 

A similar murmur disappearing with full inspiration suggests inflamma- Costal pleura, 
tion and attrition of the pericardium and costal pleura. 

Such friction may also be persistent and yet vary in intensity with the 
respiratory phases. It is not a very rare sign in cases of pneumonia and 
indicates direct extension of the inflammatory process. 

Pneumocardial Crepitations and Crackles. — These sounds of cardiac Show cardiac 
rhythm, with or without coincident or incidental friction sounds, are oc- 
casionally heard over the inner edges of the lung adjacent to the heart if 
infiltration is present. 

Pure crepitations along the anterior lung borders may also be associated 
with the fringes of air cells seen in advanced emphysema. 

BRONCHOSCOPY. — The same apparatus can be used for bronchoscopy 
and esophagoscopy, and the instruments described elsewhere in this volume 
are suitable for this purpose. 

The tubes carry a centimeter scale and measure for adults 7-10 mm. in 
diameter and 30-45 cm. in length; for children, 5-6 mm. in diameter and 15- 
25 mm. in length. 

Thorough local anesthesia or in resistant individuals and in children 
general anesthesia will be found indispensable. 

The position is practically that described under " Esophagoscopy " and 
" Gastroscopy," and the expert can render visible and obtain access to the 
interior of the tracheobronchial tree as far as the subdivision of the main 
bronchi into those of the second class. 



314 



MEDICAL DIAGNOSIS 



Appearance of 
thoracic field. 



Obsolete 

tuberculous 

foci. 



Hilus 
radiations. 



Fluoroscopy. 



Stereoscopy. 



Defines 
relationships. 



Swollen 

peribronchial 

glands. 



INTRATHORACIC RADIOGRAPHY AND FLUOROSCOPY 

THE ROENTGENOGRAPHS EXAMINATION OF THE LUNGS AND PLEURA 

Frank S. Bissell, M. D., 
Minneapolis, Minn. 

A Region of Sharp Contrasts.— The thoracic cavity lends itself advan- 
tageously to roentgen investigation, the air within the lung affording the 
necessary contrast of the lung structure with the more dense tissue of the 
other viscera. 

A sagittal view, on the fluoroscopic screen, is that of two large light fields, 
separated by a wedge-shaped shadow. The lateral areas are the lung fields 
and the central shadow is formed by the spinal column, sternum, mediastinal 
structures, heart and great primary arteries, and the venous trunks. 

The Hilus Shadows. — On either side of the median shadow, within the 
lung fields, are the ''hilus shadows" produced by the large blood vessels, 
bronchi, and the lymphatics, supplying the lungs. Usually, within the 
hilus areas, even in persons not actively tuberculous, there may be several 
large nodules of greater density, evidences of some earlier but ineffectual 
tuberculous invasion. 

Radiating shadows, some short and broad, others fine and long, extend in 
ail directions from the hilus toward the lung periphery. These, like the hilus 
shadows, are composite, being produced by bronchi, blood-filled vessels and 
lymphatics. 

Method of Examination. — While the fluoroscopic method is excellent for 
the study of respiratory movements, the stereoscopic roentgenogram reveals 
the greater wealth of lung detail, and takes first rank in the roentgen diagnosis 
of lung diseases. In the stereoscopic roentgenogram, superimposition of the 
shadows of various structures lying in the axis of a given ray does not occur 
as it does on the single plate. Thus, with each shadow appearing in its 
proper relation to every other shadow, the factor of error in interpretation 
is greatly reduced. 

In the study of the roentgenogram, it is necessary to bear in mind that 
the objects appearing dark on the fluoroscopic screen are light on the photo- 
graphic plate, while the lateral areas, light on the screen, appear dark in 
the roentgenogram. 

Tuberculosis. — Mottling of the Pulmonary Field in Early Cases. — 
Normal peribronchial glands do not obstruct the rays sufficiently to cast a shadow, 
but when they become swollen, as the result of bacterial invasion, they appear as 
fine nodules, which, increasing in number, tend to give the lung field a mottled 
appearance. 

While this mottling is observed early in many cases of tuberculosis, it 
is by no means characteristic of this disease but points only to some infection 
or irritation of the bronchi. 

Tuberculosis of the adult type tends very early to involve the parenchyma 



ROENTGENOGRAPHS EXAMINATION OF LUNGS AND PLEURA 315 



of the lung, peripheral to the terminals of the bronchial tree, and it is here 
that the most characteristic roentgen signs of the disease become manifest. 
The engorgement of the Lymphatic and blood vessels which is an early reac- 
tion to the tuberculous invasion, produces in the stereoroentgenogram small 
cone-shaped areas of increased density, the apices of which are directed 




Fig. 125. — Interlobar empyema (right) with infiltration of left lung, closely simulating 
that of tuberculosis. {Dr. Frank S. Bissell.) 

toward the hilus. The anatomical explanation of the "cone" is that each 
primary lung lobule (the anatomical unit) is triangular or cone-shaped and 
has its own complement of blood and lymph vessels. 

Since, however, it is not always possible, even in known cases of tubercu- 
losis to clearly delineate the "cone" it becomes necessary to rely upon less 



316 



MEDICAL DIAGNOSIS 



typical areas of increased density, pointing to congestion or beginning infiltra- 
tion in the periphery of the lung field. The more characteristic site of such 
areas is that beyond the extremities of the first and second interspace bron- 
chial trunks. It is fortunate for differential diagnosis that these areas usually 




Fig. 126. — Unilateral Pulmonary Tuberculosis. Note marked infiltration of right 
upper lung field. Pleuro-diaphragmatic adhesions. {Dr. Frank S. Bissell.) 



remain clear and uninvolved until late in the progress of other chronic 
infections. 

Basal tuberculosis, while it has the same general characteristics, is much 
more difficult to differentiate from other chronic infections. Tuberculosis 



ROENTGENOGRAPHS EXAMINATION OF LUNGS AND PLEURAE 317 



of the base, however, without concomitant involvement of the apex of one or 
more lobes, is relatively rare. 

Advanced Tuberculosis. — Paradoxical as it may seem, the more advanced 
stages of tuberculosis sometimes present a roentgen picture less typical 
and hence less easv to differentiate than the earlier ones. 




Fig. 127. — Apical Tuberculosis — Healed or Latent. Note that lesions are closely cir- 
cumscribed by apparently normal lung. {Dr. Frank S. Bissell.) 

This is true because the more characteristic changes tend to become 
masked by the effects of fibrosis and mixed infections. Usually, however, 
the distribution of the lesions points the way to a correct diagnosis or some 
area of slight involvement is found where the changes are more typical. 

Compensatory emphysema frequently exists in some degree, manefesting Emphysema. 



3i8 



MKDICAL I)IA(;\OSIS 



itself chiefly by increased translucency of the area so affected. This trans- 
lucency, when the emphysema is extensive, aids materially in the study 
and recognition of the tuberculous foci by lending sharper contrast to them. 
Thus the clinician's handicap becomes the advantage of the roentgenologist. 
In advanced tuberculosis the greatest value of the roentgen examination 




Fig. 128. — Pulmonary Tuberculosis with Cavitation. {Dr. Frank S. Bissell.) 

lies in the accuracy with which may be demonstrated the extent of the 
disease, the presence and nature of complications, as well as other factors in 
prognosis. The extent of involvement of a lung is usually found greater than 
physical signs or symptoms would lead one to suspect because so many of the 
lesions lie in the deeper portions of the lung where they escape the detection of 
the keenest clinician. 



ROENTGENOGRAPHS EXAMINATION OF LUNGS AND PLEURA 310 



Cavities.- -Cavita lion is easily recognized although one must be careful 
not to interpret all ring-like shadows in the lung field as cavities. There 
must be a total absence of normal lung structure within the ring and special 
care must be used to differentiate from bronchiectasis or partial pneumo- 
thorax. Areas of lung consolidation surrounding a cavity filled with exudate 




Ftg. 129. — Chronic Pulmonary Tuberculosis with extensive fibrosis in both upper 
lung fields. Tendency is toward recovery but the determination of activity in this type 
of case must be made upon clinical evidence. (Dr. Frank S. Bissell.) 

or pus may render its recognition temporarily impossible. Rarely, however, 
is a cavity so completely filled with fluid that it cannot be diagnosed. 

Resolution. — In the process of recovery from a tuberculous invasion, the 
lung may return to normal or nearly normal in its roentgen appearance. 
An old focus which has become calcified, an apex more dense than normal 



Cavity'signs. 



3 20 



MEDICAL DIAGNOSIS 



Caution 
required. 



"Woolly" foci. 



Isolated apex 
regions rare. 



Aids in 
prognosis. 



The "Drop 
Heart." 



Confusing 
factors. 



(thickened or retracted pleura) or a pleuro-diaphragmatic adhesion may 
alone remain to tell the tale of a previous infection. 

There are, however, many cases clinically cured which show roentgen 
signs closely simulating those of active tuberculosis. Here both experience 
and caution are required and final conclusions as to activity should be based 
upon clinical, rather than roentgen evidence. 

The shadows of inactive foci are more definite and circumscribed, while 
foci of active disease are softer in appearance and the lung immediately 
surrounding them is more dense than normal. This gives them a " woolly" 
appearance, their density shading progressively into the relative translucency 
of the normal air-filled alveoli. 

Apical Tuberculosis.— The roentgenologist meets with apical tuberculosis 
as described in text-books and at the bedside with comparative infrequency. A 
marked increase in the density of one or both apices may indicate consolidation, 
fibrosis, or thickened retracted pleura. When an active tuberculosis exists, 
however, the more characteristic signs previously noted are usually present. 

Prognostic Data. — Roentgen data which may aid in making a prognosis 
are: (i) the extent of involvement; (2) the amount of fibrosis; (3) the presence of 
healed lesions; (4) cavitation; (5) the size of the heart. 

1. If the process shows a tendency to limit itself to one or two restricted 
areas, healing there as it spreads to others, the disease may continue active 
for many years without causing the lung tissue to "break down." If, on 
the other hand, many areas are involved in one or both lungs and these 
tend to become confluent, the prognosis is much more grave. 

2. Extensive fibrosis, especially without cavitation, is a favorable 
indication. 

3. So too, the presence of healed lesions, associated with the active ones, 
is evidence that the patient has an established immunity of some degree. 

4. Cavities are always of grave prognostic importance. A case may 
become symptomatically cured, only to die with hemorrhage into a cavity 
which has escaped obliteration. 

5. There is apparently a close association between the atrophic (drop) 
heart and a low degree of resistance on the part of the patient. Conversely, 
a large heart is a favorable factor in prognosis. 

Differential Diagnosis. — Certain chronic infections of the mediastinal and 
pulmonary lymphatics, secondary to tonsillar, peridental, and antrum or sinus 
infections, may closely simulate the roentgen picture of tuberculosis. 

The lesions, however, are prone to be more diffuse throughout both lung 
fields; there is not so much tendency to fibrosis and there is complete absence 
of any of the complications of tuberculosis such as cavitation, pleurisy, and 
the like. Some of these cases cannot be differentiated roentgenologically 
from miliary tuberculosis. 

Pneumonoconiosis, Chalicosis, Anthracosis. — Men engaged in certain 
occupations, of which marble-cutting is the most conspicuous example, 
frequently show lung changes in the roentgenogram which so closely resemble 
those of tuberculosis that differentiation is impossible. That these are not 



ROEXTGEXOGRAPHIC EXAMINATION OF LUNGS AND PLEURA 3 21 



actually tuberculous is proven by the fact that the lungs regain their normal 
appearance when a temporary change of occupation is made. 

Syphilitic Pneumonia. — Certain cases of tertiary syphilis show lung 
changes closely resembling chronic pulmonary tuberculosis. The history 
and other clinical evidence must be relied upon for differentiation. 

Malignant Metastases. — Metastases from malignant tumors of the 
mediastinum and elsewhere produce shadow changes in the lung fields not 
greatly unlike those of advanced tuberculosis. The individual lesion, how- 
ever, is usually much more conspicuous and massive in appearance. 

CHARACTERISTICS OF OTHER PULMONARY LESIONS.— Chronic 
Bronchitis. — In many cases of long standing, one notes the marked trans- 
lucency of basal emphysema in distinct contrast to the increased density 
of the poorly aerated lung above. An accentuation of the normal lung mark- 
ings may be observed and the bronchial tree shadows may have a broken 
appearance, like the network described by certain authors as characteristic 
of tuberculosis. 

Bronchiectasis. — Demonstration of bronchiectatic cavities is relatively 
easy when they are empty and surrounded by thickened lung tissue. The 
examination should be made in the morning after the paroxysm of coughing 
has emptied the cavity or cavities. Repeating the roentgenization on the 
succeeding day, one may note that a light center has appeared in certain 
areas w r hich were homologous shadows the day before, the secretory contents 
of the cavity having been coughed up in the interim. The entire lung field 
may be sponge-like in appearance, at first glance, but upon more careful 
study in the stereoscope we may differentiate a multitude of small bean- 
shaped cavities, connected together by dense strands of tissue. 

Tumors. — Primary carcinoma of the bronchial mucous membrane has been 
difficult to diagnose by percussion or auscultation because its usual location is at 
the hilus, whence as a dense fan-shaped shadow it spreads toward the periphery. 

Metastases to the lung usually appear as rather dense shadows, often 
multiple, surrounded by areas of lesser density. After heavy therapeutic 
radiation, the involved lung area sometimes assumes a heavily striated 
appearance, suggesting fibrosis. Whether this is a reaction to the radia- 
tion or the disease is not yet known. 

Foreign Bodies in the Bronchi. — These may be localized with considerable 
accuracy in the stereoscopic roentgenogram. Even when not opaque to 
the X-rays and hence not to be directly visualized, Willis Manges working 
with the clinical material of Dr. Chevalier Jackson, has demonstrated that 
it is possible to diagnose foreign body upon the presence of an emphysema 
on the affected side. t 

Exudative Pleuritis. — (Pleuritis exudativa). — This presents a variable 
roentgen picture, according to the size and position of the exudate, its 
character, and many other factors. 

There may be marked displacement of the neighboring organs with relatively 
little exudate, or the reverse may be true. 

While easy to recognize in typical cases, one may meet with some difficulty 



Value of 
clinical data. 



More distinct 
and massive. 



Necessary 
precaution. 



Multiple bron- 
chiectases. 



Characteristic 
shadow. 



Metastases. 



Localization. 



Visceral 
displacement. 



322 



MEDICAL DIAGNOSIS 



Surmounting 

diagnostic 

obstacles. 

Small 
effusions. 



in those complicated by old fibrous thickening of the pleura the shadow of 
which may cover that of the fluid. Here the fluoroscopic screen is much 
superior to the roentgenogram, because one may observe the effect of respira- 
tion and of change of position upon the density of the shadow. Even a small 




Fig. 130. — Pleurisy with effusion. Xote density of fluid shadow and its horizontal 
upper border. Xote also cardiac displacement. (Dr. Frank S. Bissell.) 

exudate may usually be recognized early as it fills the complementary pleural 
sinuses, obliterates the phreno-costal angle, and interferes with the normal 
excursion of the diaphragm of the side affected. As the fluid increases in 
quantity, one notes its tendency to climb along the lateral wall toward the 
axilla. This is the so-called "curve of Damoiseau." This curve tends to 



ROENTGENOGRAPHS EXAMINATION OF LUNGS AND PLEURAE 323 



disappear as the upper level of the fluid descends to a point below the lung 
hilus. It also disappears when the patient is in the horizontal position. 

The heart and other mediastinal organs may become displaced toward the 
opposite side before the exudate has become large enough to exert direct pressure. 

This displacement is the result of an elastic pull of the normal lung, the 
compressed lung of the affected side having ceased to exert its normal 
counter-pull. When the exudate is sufficiently large, the displacement of 
the mediastinum including the heart and great vessels produces an elongated, 
triangular shadow with its base on the diaphragm and its apex at the sterno- 
clavicular articulation. This shadow furnishes information as to the amount 
of effusion and the expediency of puncture. 

The line of separation between exudate and lung is not a sharp one, there 
being a noticeable difference between the sharp straight upper border of the 
usual pneumothorax exudate and the more indistinct washed-out border of a 
pleuritic exudate. While a very large pneumothorax exudate, such as may 
follow spontaneous rupture of the lung, may be recognized as such with great 
difficulty, the air above the fluid having been fully reabsorbed, careful search 
will usually reveal a small pneumothorax bubble. 

Unless the roentgenologist is fortified with a suggestive anamnesia, 
however, he may mistake such an exudate for one of pleuritis. When air 
still remains above the fluid level, the latter' s sharp distinct line readily 
suggests the diagnosis. 

The recognition of the character of this exudate is highly important because 
its complete removal by paracentesis, as in pleurisy, is a grave technical error. 

Pleuritic Adhesions. — Pleuritic adhesions occur either as broad lamince 
or as fine bands. When the former occur in such a manner as to obliterate 
the costophrenic sinus, their differentiation from a small exudate is difficult 
but unimportant. A small exudate retained within the thickened pleura 
may entirely escape detection. If the thickened pleura lies near the plate 
or screen, its projected shadow is much more distinct than when it is on the 
opposite wall of the chest cavity. 

Fine pleuro -diaphragmatic adhesions are rarely if ever seen, but in some 
cases they may be recognized by the characteristic manner in which they cause 
the diaphragm to kink, tent-like, during deep inspiration. 

Fixation of the diaphragm is usually present with pleuritis even though 
no fluid or adhesions are present. This immobilization may be difficult to 
determine when there is an effusion on the right side since the diaphragm 
itself cannot be visualized. . On the left side, however, the presence of gas 
or air within the stomach renders the lower side of the diaphragm visible. 
The immobilization may persist for a long time after the fluid has become 
absorbed. 

Pneumothorax. — Uncomplicated by adhesions, exudate, etc., pneumothorax 
is recognized chiefly by the absence of normal lung markings, within the thoracic 
cavity. The unilateral area involved is much more translucent than its normal 
fellow, and the compressed lung may be observed, reduced in volume to a variable 
degree, and crowded sharply against the median shadow. 



Early visceral 
displacement. 



Pull and 
counterpull. 



Triangular 
shadow. 



Differentiation 
from pneumo- 
thorax. 



Distinct line of 
fluid level. 



A point of great 
importance. 



Adhesions. 



Fixation of 
diaphragm. 



Differentia- 
tion of types. 



324 



MEDICAL DIAGNOSIS 



Two important 
questions. 



Special 
technic. 



Early signs. 



Pneumonic 
triangle. 



Hilus pneumo- 
nia in influenza 
epidemic. 



Displacement of the mediastinal organs occurs as a result of the elastic 
pull of the normal lung and of the pressure from the accumulation of trapped 
air in the pneumothorax cavity. 

Artificial Pneumothorax. — Without roentgenograph^ examination, arti- 
ficial pneumothorax is not practicable. The roentgenologist is usually 
asked to determine the two most important questions: first, whether pneumo- 
thorax is possible, and second, whether it is indicated. 

While it is not possible to determine these points with certainty, it is 
possible to do so with a considerable degree of probability. Are there 
pleuro-pulmonary adhesions, and if so, what is their topography, extent and 
firmness? Diaphragmatic adhesions can at least be excluded when not 
present. When there is a partial or complete effacement of the costo- 
diaphragmatic sinus, immobilization of the diaphragm, or suppression 
of the respiratory movements, the base of the lung is probably adherent. 

The question as to the indication for pneumothorax is determined by the 
presence of cavitation and the absence of involvement in the other lung. 
Examinations made after an attempt at pneumothorax determine the degree 
of success and thus whether the procedure should be continued or abandoned. 
Serial examinations may demonstrate a gradual giving way of adhesions with 
final pulmonary collapse. 

Pneumonia. — In the study of pneumonia with the X-ray, technic is of the 
utmost importance. The lobe affected must be brought as close as possible to 
the roentgen plate, and tubes af slight penetration must be employed. 

Early in the disease, only a very faint diffuse density, due to decreased 
air content is noted. In a few hours this may have become a distinct 
shadow, sharply defined by the boundaries of the lobe involved. The 
subsequent course is very variable. The shadow of a pneumonic lung rarely 
reaches the density seen with tumor or effusion. The so-called pneumonic 
triangle, a dense shadow with its base toward the axilla, occurs most fre- 
quently in childhood and when present is very characteristic. 

Hilus pneumonia was a common type during the influenza epidemic of 
191 8 and could be recognized only by X-ray examination. This type was 
often hemorrhagic in character, and very accurate prognoses could be based 
upon a study of serial plates made during the first days of the disease. When 
the process became bilateral it was almost invariably fatal. 

Usually soon after the crisis a clearing-up process is perceptible, proceed- 
ing most frequently from the hilus toward the periphery. Certain veil-like 
shadows usually persist, however, and these may be observed many days or 
weeks after resolution. 

Broncho -pneumonia. — Here the process is not limited to a single lobe but 
presents disseminated shadows usually obscure and poorly-defined and 
involving different lobes of one or both lungs. This disease is characterized 
by the most bizarre roentgen manifestations, quite unlike those of any other 
acute infection. However, the chief value of X-ray studies here lies in the 
aid afforded to prognosis, which apparently varies directly with the number 
of lobes involved and the rapidity with which the process extends. 



ROENTGENOGRAPHS EXAMINATION OF LUNGS AND PLEURA 325 



The Heart in Pneumonia, Certain German observers (Holzknecht, 
Steyrer) have called attention to the condition of the heart during pneumonia. 
Holzknecht noted early in the disease a distinct enlargement of the right 
side oi the heart and a marked pulsation of the middle convexity of the 




Fig. 1.3 i. — Resolving pneumonia. Note marked prominence of the intermediate con- 
vexity of the heart border. This is frequently observed in acute pneumonic conditions; 
probably represents residual dilatation of the pulmonary artery. 

left border, representing left auricle and pulmonary artery. This indicates, 
in his opinion, a dilatation of the right heart and an over-distention of the 
pulmonary artery, conclusions which are wholly in accord with long-estab- 
lished bedside observations. Soon after the crisis these signs entirely 
disappeared. 



326 



MEDICAL DIAGNOSIS 



Lung Abscess. — A more or less localized area of increased density sit- 
uated entirely within the lung field is suggestive of lung abscess. The case 
history and clinical evidence are necessary to complete the diagnosis. Dr. 
William H. Stewart has reported successful diagnoses and localizations of 
abscess by means of bismuth paste injections through the bronchoscope. A 
pure roentgenological differentiation between abscess and infarct is probably 
not possible since both occur within the lung and have ill-defined borders 
by reason of the inflammatory process surrounding them. 

Gangrene. — Gangrene has no characteristic roentgen signs but the 
presence of an hydropneumothorax together with clinical evidence, may 
make the diagnosis. 

Empyema. — An empyema resembles a simple pleuritic effusion in the 
intensity and homogeneity of its shadow. Its borders assume various 
shapes dependent upon the adhesions which surround it. In the inter- 
lobar form, one depends upon the location of the shadow with relation to 
various lobes for its identification. Its most characteristic appearance is 
that of a transverse opaque band completely bisecting the lung field. 

Emphysema. — With an increase in the air of the lung there is a propor- 
tionate and usually striking increase in its penetrability to the ray, i.e., 
the brightness of the pulmonary fluoroscopic fields. While in the normal 
lung there is a marked difference between the density during inspiration and 
expiration, in the presense of a general emphysema this variation is not 
demonstrable. Other roentgenological signs of emphysema are, horizontal 
ribs, broad lung fields, and a flat diaphragm. 

COUGH AND SPUTUM 

COUGH. — Definition. — The term cough 'covers single or multiple, conse- 
cutive, explosive, expiratory acts immediately following glottic closure. 

Diverse Causes. — It may be voluntary, involuntary or truly paroxysmal 
and arise from any of a multitude of causes and from the irritation of widely 
separated and diverse regions, though commonly purposeful and intended to 
remove irritating material from the bronchi or throat. This irritant is 
ordinarily the secretion accompanying acute or chronic disease of the air 
passages, or, foreign bodies. 

The most sensitive regions are the inter arytenoid space, the tracheal bifurca- 
tion, pharynx, base of the tongue, naso- pharynx and certain areas in the nasal 
passages proper. 

Reflex Cough.; — Many forms of reflex cough are observed and these should 
always receive consideration in obscure cases. 

Arnold's branch of the pneumogastric nerve is accountable for a rare 
cough connected with irritation of the external auditory canal.* So also chill- 

* Such a case recently observed by the author was instantly and permanently relieved 
by the removal of impacted cerumen. The patient had been for several months under 
the treatment of a quack and, when bankrupt, was told, with engaging delicacy and frank- 
ness, that his lungs were "all rotted" and his case hopeless. 



COUGH AND SPUTUM 



327 



ing of the surface, pressure upon or diseases of the spleen or liver, when asso- 
ciated with involvement of the diaphragmatic pleura, may be the source of 
obstinate coughs. In women, chronic disease of the pelvic organs is an 
occasional cause and such a cough frequently disappears entirely after 
operation. 

Hysteric, Dyspeptic and Tobacco Cough. — Other coughs are purely 
neurotic in origin, such being the obtrusive, forced, hysterical cough and the 
barking cough of puberty. Dentition cough in infants is apparently purely 
reflex in character but the so-called "stomach cough" associated ordinarily 
with chronic gastritis and most frequently observed in drinkers, is no doubt 
due to the accompanying pharyngitis and the same statement applies to the 
"smoker's cough" and its associated laryngeal irritation and hyperesthesia. 

Many cases due to excessive irritability of sensitive turbinate areas are 
observed, particularly in young people and neurotic individuals, the condi- 
tions being very similar to those associated with certain asthmatic paroxysms 
or with hay fever. 

Direct Sources. — 77 should be remembered that irritation of the lung paren- 
chyma itself does not cause cough, but unquestionably irritation or inflammation 
of the bronchial mucous membranes or pleura does. 

Therefore, in pulmonary disease, acute or chronic, the cough is attributable 
either to bronchial or pleural irritation. The assumption that any cough is 
purely reflex or neurotic should be postponed until all other channels have been 
thoroughly investigated. 

11 Adenoids," enlarged tonsils, impacted cerumen, granular pharyngitis, 
hypertrophy of the lingual tonsil, enlarged turbinates, chronic disease of the 
accessory sinuses, goiter, chronic heart disease, diseases of the liver, enlarged 
bronchial glands, aneurysm, mediastinal growths, dorsal caries, occupation, 
habit, and imitation, are some of the many other potential or possible conditions 
to be considered aside from affections of the bronchi, lungs, and pleurae. 

Dry and Moist Cough. — In incipient phthisis and the early stages of 
bronchial or broncho-pulmonary inflammation the cough is wholly or rela- 
tively unproductive, i.e., dry. 

Such a cough may be extremely urgent, paroxysmal, or painful and acute 
bronchitis, pneumonia, whooping cough, asthma, and pleurisy • furnish the 
best examples. In their early stages, practically all of the nervous, reflex, 
or pressure coughs are dry. 

When pain is present an effort is made to suppress the cough, as is the case 
especially in. lobar pneumonia and pleurisy. 

Paroxysmal cough, best exemplified by whooping cough, may be en- 
countered in many other conditions. Whether due to direct irritation, as 
in the case of a laryngeal tumor, or to reflex causes, as in impacted cerumen 
or turgescence of the nasal passages, and particularly in pertussis, the cough 
paroxysm may be associated with vomiting and even with epistaxis and 
hemorrhages under the skin. 

A paroxysmal cough may also result from a gradual, silent, accumulation 
of secretion and be attended by a profuse and perhaps sudden discharge, as, 



Smoker's 
cough. 



Nasal cough. 



Bronchial 
cough. 

Pleural cough. 



Source of 
error. 



A host of 
possibilities. 



Dry cough. 



Suppressed 
cough. 



Many 
sources. 



Vomiting, 
nosebleed, and 
ecchymoses. 



Emptying of 
cavities. 



328 



MEDICAL DIAGNOSIS 



Hacking 
cough. 



Diminuendo 
cough. 



'Crowing. 



Toneless 
cough. 



Significant 
variations. 



Pulmonary' 
cavities and 
bronchi- 
ectases. 



for example, in bronchiectasis, certain pulmonary cavities, or the rupture of 
abscesses into the bronchi. 

Pressure cough due to mediastinal tumors, pericardial effusion and like 
causes, is not usually paroxysmal but may be most misleadingly so, even to 
the simulation of asthmatic seizures. 

The so-called hacking cough is especially common in incipient tuberculosis, 
but may occur also in acute or chronic irritation or inflammation of the upper 
air passages. 

VARIOUS TYPES.— "Barking," "Hollow" and "Brazen" Coughs.— 
Barking cough, if not neurotic, is usually associated with inflammation of the 
glottis; a hollow cough with advanced tuberculosis; and ringing, metallic 
or brazen cough with mediastinal pressure from whatever cause. The author 
has observed as good examples of the brazen cough in massive pericardial 
effusion as from its commoner causes, aneurysm and mediastinal growths. 

In emphysema the cough is peculiar in its prolongation of the individual 
expirations and the manifest forcing and prolonging of the series diminuendo. 

The "hoarse cough" of croup and the inspiratory crowing during the 
paroxysm are but too well known, and a noiseless cough may occur in certain 
forms of glottic paralysis or a toneless cough in terminal cases of pulmonary 
disease. 

The inspiratory whoop may follow various forms of paroxysmal cough, 
but is occasional and unusual, whereas in established w r hooping cough it is 
persistent and practically pathognomonic. 

An Ominous Sign. — Absence or cessation of cough, with persisting physical 
signs, may indicate profound toxemia, excessive weakness or approaching death 
and is seen especially in fatal pneumonias of infancy, childhood, and old age. 

Localized momentary protrusion normally occurs in the apices and 
upper intercostal spaces during cough. The condition is exaggerated in 
emphysema and diminished in infiltration of the lung apices. 

Postural Modifications. — In certain conditions posture markedly modifies 
the tendency to cough and in bronchiectasis, open pulmonary abscess and 
certain large phthisical or gangrenous cavities, a severe paroxysm of cough 
may be induced by a change of position which initiates and facilitates a flow 
of secretion from the cavity to the bronchi. Such patients may of their own 
volition assume a posture which, by lowering the head and thorax, drains the 
cavity by gravity assisted by the cough. 

THE SPUTUM 

Definition. — The sputum proper is that content of the air passages 
obtained by "clearing the throat" or coughing. The term embraces nasal, 
pharyngeal, laryngeal, bronchial, alveolar and, inevitably, a certain admixture 
of oral secretion. 

All sputum save that representing pure pus or blood is mucoid in con- 
sistence and the general term embraces all similar material derived from 
fistulous communication with adjacent structures, or destructive processes 



COIV.II AND SPUTUM 



3*9 



within the respiratory tract, i.e., perforating abscess, echinococcus cysts, 
cavities, etc. 

The Important Factors. — One must observe: (a) Reaction, (b) Color 
and transparency, (c) Air content, (d) Consistence, (e) Amount. (f) 
Odor, (g) Albumin content. (//) Microscopic findings. 

The reaction is alkaline save after certain decomposition processes outside 
the body. 

Color. — Aside from misleading tints derived from food or medicines, the 
color varies, according to its source and composition, from the colorless mucoid 
or serous sputum to that of pure blood. Slight purulent admixture (muco- 
purulent sputum) or predominance of pus {purulent) produces various degrees 
of yellow or greenish yellow. Dust and soot inhalation gives a dingy or 
grayish tint, and bile pigment or the development of certain germs, may pro- 
duce a faint or even vivid green. Blood may be pure or represented only by 
faint pink, light brown or salmon color, iron rust shading, faint yellow's and 
greens or the thin serous so-called "prune-juice" sputum. True icteric 
sputum appears only when actual jaundice or perforating hepatic abscess is 
present, though many blood-containing specimens of unusual tint react to 
the test for bile pigment. Greenish tints may occur in carcinoma, chloroma 
and various other conditions, and various occupational sputa are encountered, 
as in mirror polishers, aniline dye workers and others. 

Heart Disease Cells. — In disease of the mitral valve with brown sputum 
peculiar pigment-holding cells are present. In the perforating abscess of 
amebic dysentery the "anchovy sauce" sputum may be encountered, and in 
hysteria there is occasionally a viscid or jelly-like sputum exactly like crushed 
raspberries, which may create much unnecessary alarm.* 

A similar " raspberry-like " sputum is said to occur in certain cases of 
tumor of the lungs. 

Air Content. — Foaminess and low specific gravity measure the air content 
and all serous sputum is frothy. 

Cavity sputa dropped in water appear as globules, flattening to coin-like 
bodies (nummular sputum) as they sink to the bottom and, in general, the greater 
the pus content the less the amount of contained air, and the smaller the tubes 
of origin the greater is the air content. 

hi bronchiectasis and gangrene one finds three distinct layers because of the 
varying specific gravity of the constituent elements. 

Consistence. — Pus or serum content determines fluidity, and mucus and 
fibrin (croupous pneumonia) the viscidity and tenacity of sputum. 

Macroscopic Appearance. — A proper background for macroscopic ex- 
amination is readily obtained by laying a piece of glass or a Petri dish 

* A typical example was encountered by the author at the country place of some old 
friends whose sympathies and ministrations were in process of bestowal upon a most un- 
worthy object. An hysterical young female degenerate had entered the grounds and 
gracefully cast herself down under the bellies of a sedate team of horses. She then at- 
tempted to simulate coma and convulsions with considerable skill until the doctor arrived. 
Her "crushed raspberry" sputum had excited even more alarm than her other spurious 
symptoms. 



Soot. 



Blood. 



Bile. 



Bizarre 
forms. 



Nummular 
sputum. 



Fluidity vs. 
Viscidity. 



33° 



MEDICAL DIAGNOSIS 



Fibrinous 
casts. 



Collecting the 
sputum. 



Foul odors. 



Slight differ- 
ential value. 




Fig. 132. — Cursch- 
mann's spirals, t A, 
unmagnified. B, mag- 
nified. 



over black paper or cloth or employing a special glass plate with half its 
under-surface black. 

One may find (a) "Curschmann's spirals," which are not pathognomonic 
of asthma, but most frequent in that disease. They are refractile, visible 
to the naked eye and represent probably a bronchiolitic exudation. Though 
interesting they have no great diagnostic importance'. 

(b) "Dittrich's plugs" are yellowish- white, mustard-seed sized, foul- 
smelling aggregations of fatty acid crystals and bac- 
teria, closely resembling the tonsillar plugs of follicular 
tonsillitis and are found in decomposition processes 
(pulmonary gangrene, foul cavities, etc.). 

(c) Misleading food particles may be encountered 
w T hich are usually starchy and strike a -blue color 
with Lugol's solution. 

(d) Fibrin masses are white and extremely tena- 
cious and are rendered clearer and bulkier by the 
addition of acetic acid. They vary in size from the 
tiniest plugs to casts of the bronchial tubes 

(croupous pneumonia, fibrinous bronchitis), or the diphtheritic membrane. 

(e) The Fibrinous Casts. — These show best if shaken up in water. 

(f) Rarely and especially in old cases of tuberculosis, calcareous plugs 
or definite casts, often of considerable size are expectorated* or foreign bodies 
of recent or ancient introduction may appear. 

All sorts of substances may be introduced by fistulous communication 
with abscesses, echinococcus cysts, etc., etc. 

Amount. — Whenever possible the twenty-four hours' sputum should be 
obtained, and the transparent sputum cups are far better than the metallic 
and paper cups so generally used. Early stages of inflammation yield scant 
secretion. The morning is the most productive period in chronic processes 
though in pulmonary cavity and especially bronchiectasis large amounts 
may be raised at irregular times, often when assuming a special posture. 
Advanced pulmonary tuberculosis, bronchorrhea, bronchiectasis, perforating 
abscesses, pulmonary edema and resolving pneumonia furnish large amounts. 

Odor. — Ordinarily odorless when first raised, it may be extremely foul in 
any process attended with decomposition within the lung (bronchiectasis, 
certain tuberculous cavities, abscess of liver, communicating empyema) and 
characteristically so in gangrene. 

Albumin Content. — The albumin content of the sputum constitutes a 
rough measure of the severity of an inflammation and is said to be absent 
in simple bronchitis. Possibly some slight value may be attached to a 
decided percentage as differentiating simple bronchitis from pneumonic 
processes and from pulmonary tuberculosis. 

Zenoni's Differential Color Test. — This pretty and simple test for albu- 

* In a case observed some time ago a large lung stone was ejected after the sudden 
onset of a protracted and violent coughing seizure and no symptoms of the old disease had 
been manifest for over twenty years. 



COUGH AND SPUTUM 



331 



min and mucin consists in spreading the sputum on a slide, fixing it with 
alcohol (fifteen minutes) and staining with a half-saturated aqueous solution 
of safranin. The albumin is stained red and the mucin yellow. 

MICROSCOPIC FINDINGS.— Staining.— The sputum should first be 
examined as a flat preparation without staining and then by making a smear, 
drying in the air and staining for three minutes with Wright's stain, thor- 
oughly washing, and mounting. 

Cells. — One may find: 

(a) Flat pavement cells from the mouth and pharynx. 

(b) Columnar ciliated cells from the larynx, trachea and bronchi. 

(c) Mono- or polynuclear cells from the alveoli which may contain 

(d) Irregular highly retractile masses of myelin, showing concentric 
layers. 

(e) Blood-pigment-bearing (heart disease) cells. 
(/) Hematoidin crystals. 

(g) Fat. 

(h) Carbon. 

(i) Free myelin bodies. 

(j) Elastic fibers. If present these last structures may be obtained 
sometimes by merely pressing a cheesy, granular, or especially dense, portion 
of sputum between two glass slides and using a low-power lens, but a more 
elaborate procedure is usually required.* Such fibers indicate actual destruc- 
tion of lung tissue, most frequently advanced tuberculosis or pulmonary 
abscess, and usually show the alveolar arrangement. Staining is quite 
unnecessary, the only difficulty being the possible derivation of the fibers 
from retained food in specimens not properly safeguarded in the process of 
collection. Owing to the presence of a peculiar ferment, they often are absent 
in destructive pulmonary gangrene. 

(k) Leucocytes. Eosinophiles are abundant in asthmatic sputum and 
neutrophiles in all sputa. These may show phagocytic inclusions of fat, 
carbon or hematoidin. 

(I) Erythrocytes. Microscopic blood exists in most sputa associated 
with severe cough, but macroscopically it is present only in violent paroxysmal 
cough, accidental hemorrhage and true inflammatory or necrotic processes. 
Fibrin, if present, may be demonstrated by Weigert's method. 

(m) Crystals. The rhomboidal crystals of cholesterin indicate emphy- 
sema or lung abscess, seldom phthisis. The sharp slender fasciculated fatty 
acid crystals suggest gangrene or advanced tuberculosis, while the colorless, 
octahedral Char cot-Ley den crystals point to bronchial asthma. Yellow or 
brown amorphous masses or rhomboidal crystals of hematoidin point to 
blood retention and ulceration within the alveoli, and leucin and tyrosin 
may be present in emphysema. 

(n) Bacteria. Among those occurring in sputum are: tubercle bacilli 

* Boiling a mixture consisting of equal parts of sputum and 10 per cent. NaOH or KOH, 
setting aside for twenty-four hours and then examining selected portions of the precipitate 
is a useful device and search is seldom successful without it. 



Albumin and 
mucin. 



General stain. 



Significance. 



Spontaneous 
disappearance. 



Emphysema 01 
lung abscess. 



Asthma 
crystals. 



Simulators of 
tubercle bacilli. 



332 



MEDICAL DIAGNOSIS 



Animal 
inoculation. 



Rapid 

preliminary 

examination. 



Centrifugation. 



and its simulators, the smegma and timothy bacilli, and, those of pneumonia, 
anthrax, influenza, typhoid, glanders, plague and leprosy as well as the 
Friedlander bacillus, micrococcus tetragenous and others". 

THE TUBERCLE BACILLUS.— The tubercle bacillus is by Jar the most 
important, and for its determination most careful work and even animal inocu- 
lation may be necessary. In most instances it is easy to find the germ in the 
cheesy particles or thicker portions of the specimen, but at other times they 
must be obtained by centrifugation of the sputum. 

The bacilli are often readily found in sputum thinned by spontaneous 
decomposition. 

To Secure a Concentrated Sediment. — The Antiformin Method. — If 
the specimen yields none of the acid- and- alcohol-fast tubercle bacilli to the 
first rapid examination by the Gabbett or Ziehl-Neelsen method, one can 
procure a concentrated centrifugated sediment by the use of antiformin (a 
trade mixture of sodium hypochlorite and sodium hydrate solutions), which 
keeps fairly well and is readily obtainable. 

Loeffler's Modification of Uhlenhuth's Antiformin Procedure. — (a) 
Boil, for a period not exceeding fifteen minutes, equal parts of sputum and 50 
per cent, antiformin. 

(b) Make a mixture of 1 part chloroform to 9 parts alcohol. 

(c) Add 3 ex. of this mixture to 20 ex. of the original boiled mixture of 
sputum and antiformin. 

(d) Shake to form a fine emulsion. 

(e) Put required portions in corked sedimentation tubes and centrifuge for 
fifteen minutes. 

The original process destroys all save the acid-fast organisms. The 
chloroform in the centrifugated mixture holds the tubercle bacilli in a film 
at its upper margin. 

(J) The supernatant fluid is decanted and the film and its contained materials 
is then spread on slides, dried, treated with egg albumin in the usual manner, to 
insure subsequent secure fixation and is then ready for the usual stain, that most 
generally used being the Ziehl-Neelsen. 

The various steps of the staining process beginning with the removal of 
the centrifuged organisms in the film above the chloroform (stage "e") 
would be v as follows: 

Ziehl-Neelsen Method. — (a) Making a thin, even, smear after adding a 
little egg albumin or, better still, some of the original sputum, in order that 
subsequent firm fixation may be attained. 

(b) Drying by gentle heat or passing to and fro through the air. 

(c) Fixing. — The cover-glass smear is then fixed by passing it deliberately 
but steadily through an alcohol (or small Bunsen) flame four or five times, or 
ten or twelve times, if slides be used. 

(d) Staining. — It is then completely covered with the fuchsin* (acid) 

* To make this stain, a saturated alcoholic solution of fuchsin or gentian violet is 
added drop by drop to 5 per cent, solution of carbolic acid until a surface sheen 
appears. 



PLATE II. 



I 



















• ' </\?££ft V ■ 








•:• fs£ 



Kathi 



Tubercle bacilli in sputum (Ziehl-Xeelsen method). The plate is an unusually good 
presentation of the staining (red), form, and usual microscopic field relationships, of the 
tiny rods. {Webster.) 



COUGH AND SPUTUM 



333 



stain, and is gently heated over a flame for three or four minutes to such a 
degree as to cause sustained steaming but not boiling. A few more drops of 
stain may be added as evaporation takes place. 

(e) Washing and Decolorization. — It is then washed thoroughly and de- 
colorized with a 10 per cent, solution of sulphuric acid in 95 per cent, alcohol 
until only the faintest pink remnant of the fuchsin can be seen on well-spread 
sections of the smear. 

(J) Washing and Contrastaining. — It is then washed and stained one 
minute withLofflers methylene blue* as a contrast stain — washed, dried and 
mounted for examination. 

The tubercle bacilli appear as red rods in a light blue field. 

Advantages of the Antiform in Methods. — (a) Greatly increased power to 
detect small numbers of the acid-fast bacilli in sputum or other secretions and 
excretions. 

(b) Destruction of other organisms with preservation of the acid-fast bacilli. 
Inasmuch as a solution may be obtained in twenty-four hours without 
boiling and at room temperature, or in six hours if the incubator be used, it 
follows that — 

(c) It facilitates the making of pure cultures if this step be desirable. 

(d) It permits direct animal inoculation in urgent cases for in such prepara- 
tions all but the acid-fast bacilli are destroyed and these remain living and 
concentrated. 

Gabbett's Method. — This somewhat coarse but extremely rapid and con- 
venient method may be used, but negative results should count for nothing 
because of its liability to decolorize certain of the tubercle bacilli and the fact 
that it does not exclude the smegma or timothy bacillus for the decolorization 
of which the acid alcohol is essential. 

// does, however, give rapidly a very clear and definite picture with the 
limitations mentioned above. 

Procedure. — After spreading, drying and fixing one proceeds as follows: 

1. Stain. — Carbol-fuchsin as in Ziehl-Neelsen. 

2. Throw of stain and add Gabbett's solution (methylene blue 2.0; sul- 
phuric acid 25, and distilled water sufficient to make 100) without washing 
slide or cover-glass and allowing but one-half minute of contact. 

3. Wash in water. 

4. If thinner areas are still red repeat the Gabbett's stain and washing. 

5. When they are become blue, dry and mount in balsam.\ 

Caution. — The greatest patience is required in these examinations and diag- 
nosis should never be based upon a doubtful finding. 

Wherever there is one germ, more can and must be found and terrible mis- 
takes result from hasty conclusions though these are far less deadly than the too 
common failure to find the germ when present. 

* Loffler's alkaline methylene blue — sat. alcohol sol. methylene blue added to 100 c.c- 
of a 1-10,000 solution of potassium hydrate. 

t Prolonged single applications may decolorize the "acid-fast" bacilli. 



Convenient. 



Uncertain 
negation. 



334 



MEDICAL DIAGNOSIS 



RHINOLOGY, PHARYNGOLOGY AND LARYNGOLOGY 



A surgical 
specialty. 



Essentials. 



Technic. 



Vocal cords. 



Obstacles to 
examination. 



Position of 
head. 



Diagnosis at Sight. — The modern specialty which embraces these subjects 
has the advantage of permitting practically all its diagnoses to be made at sight 
through the use of highly specialized appliances. Furthermore, it is almost 
wholly surgical; hence the student must consult special text-books for any 
adequate description. 

Technic. — The essentials are (a) strong, steady light and a good reflector, 
(b) Properly heated laryngoscopy and rhinoscopic mirrors, (c) A steady hand 
and a thorough knowledge of the anatomy of the parts and of the regional 
pathology. 

The long-handled mirrors are held in the pen position and in the case 
of the larynx are introduced with the free edge downward and without touch- 
ing any structure until they press back the soft palate. The tongue is grasped 
in a dry napkin between the index-finger and thumb of the unoccupied hand 
and held firmly forward either by the operator or the educated patient himself. 
The index-finger of the examiner or the thumb, in the case of the patient, 
should rest against the lower teeth forming a support to steady the hand 
and prevent painful pressure upon the median raphe. 

Larynx. — If the mirror has been warmed to prevent misting and is held 
at, but not touching, the upper angle of the pharyngeal vault, an excellent 
view of the larynx is obtained. 

The upper portion of the image represents anterior, the lower, posterior 
structures. Deep breathing and voice production reveal the action of the vocal 
cords. 

Naso -pharynx. — In examining the naso-pharynx a smaller mirror is in- 
troduced with its free edge upward well back to, but not against, the posterior 
pharyngeal wall. If steady, deep breathing (through the nose, so far as 
possible) and passivity maintains a relaxed soft palate the parts may be seen 
without difficulty, but oftentimes some one of the special forms of the palate 
retractor must be used to pull that structure firmly forward and slightly 
upward. 

Hesitancy, fumbling and tremor on the part of the examiner invariably 
cause retching, and occasionally hyperesthesia may be so marked as to 
necessitate the preliminary administration of a bromide or the use of a dilute 
solution of cocain.* 

The small mirror should invariably be surgically clean, repeatedly warmed 
to prevent misting, and tested for excessive heat by laying its back against the 
skin of the operator's hand. 

The patient's head should be slightly tilted backward to best show the 
larynx and held perpendicular or inclined a trifle forward in examining the 
naso-pharynx. 

The anterior nasal chamber is examined by direct light, the patient's 
head being tilted backward and the alae widely separated by means of one 

* Decided anesthesia is a valuable sign of hysteria. 



DISEASES OF THE NOSE AND THROAT 



335 



of the various nasal dilators, bringing into view the vestibule, septum, inferior 
meatus, inferior turbinate, middle meatus and middle turbinate. Obstruct- 
ing secretion is sprayed or wiped away and any interfering congestion is 
readily reduced by a weak solution of cocain and suprarenalin. 

DISEASES OF THE NOSE 

ACUTE CORYZA (Acute Rhinitis). — A description of this universally 
known ailment is unnecessary. The susceptibility of an individual is 
markedly increased by the existence of a chronic catarrhal inflammation 
of the nasal passages, exhaustion, chronic diseases and lowered vitality from 
whatever cause. The mucous membrane in such cases shows primarily 
congestion, swelling and diminished secretion, secondarily, the characteristic 
profuse mucopurulent discharge. 

Chronic rhinitis (chronic catarrh) resulting from repeated acute attacks 
or due to general impairment of nutrition, presents much the same appear- 
ances as acute rhinitis. 

HYPERTROPHIC RHINITIS.— Through chronic catarrhal inflamma- 
tion the vascular turbinate tissues become permanently distended and the 
epithelial layer thickened and infiltrated. 

This condition is frequently associated with exostoses or ecchondroses of 
the nasal septum and is most marked at the anterior and posterior portions 
of the middle turbinate and the posterior portion of the inferior turbinate. 

Nasal obstruction and catarrh resulting from such conditions, lead to mouth 
breathing and frequent acute or subacute coryzal attacks, and there is a 
troublesome recurrent obstruction especially marked in recumbency, such 
patients awaking in the morning with dry lips, coated tongue and oftentimes 
a foul breath. The imperfect drainage of secretion may cause obstruction of 
the nasal duct; the senses of smell, taste and hearing are impaired, and the 
Eustachian tube may be the seat of a catarrhal process. Headaches are 
common either as the result of infundibular occlusion or actual disease of 
the accessory sinuses. \ 

EXOSTOSES AND ECCHONDROSES.— These formations are recog- 
nized at sight and their consistence determined by the use of the 
probe. 

SEPTAL DEVIATION.— This condition, rarely absent in slight degree, 
is pathologic only when it produces pressure or absolute obstruction. Marked 
deviations lacking a history of traumatism are usually associated with a high- 
arched palate and probably with previously existing adenoid growths of the 
naso-pharynx. Deviations may be partial or general, angular or curved, are 
readily recognized upon examination and usually associated with chronic 
catarrh. 

SEPTAL HEMATOMA is a blood-red tumor, usually the result of an 
injury. 

SEPTAL ABSCESS forms a fluctuating swelling and is a frequent 
source of septal perforation. 



Predisposing 
factors. 



Mouth 
breathing. 



Deafness 
common. 



Headache. 



When 
pathologic. 






MEDICAL DIAGX SIS 



ATROPHIC RHINITIS Dry Catarrh).— This condition usually follows a 
Foal breath. chronic hypertrophic rhinitis and is characterized by foul breath and a dry 
glazed mucous membrane earning scanty and foul secretions which dry 
into adherent scabs and scales. Not infrequently, there is ulceration of 
underlying tissues and, in long-standing cases, actual structural atrophy, 
the turbinate bones being shrunken and the septum thin* In delicate 
children the condition may co-exist with an excessively fetid, thin, watery 
5r::r:ion (ozena). 

NECROSING ETHMOIDITIS.— Inflammation of the middle turbinate 



may cause necrisis :: the interior turbinate and ethmoidal structures. 
Periostitis and necrosis are usually followed by the exfoliation of a limited 
amount of bone. The symptoms are those of a suppurative inflammation 
specially involving the middle turbinate. Pressure deviation of the septum 
is common and nasal polypi frequently result and may remain as evidence of 
past disease. The probe introduced at the site of the suppuration usually 
ie:ec:s rice necrc 

HAY FEVER Periodic Vasomotor Coryza). — However obscure the causal 
zictors, the disease offers few diagnostic difficulties. 

The symptoms are merely those of an unusually obstinate or persistently 
recurrent acute coryza. with a profuse watery, rather than mucopurulent, 
discharge, coming on periodically often at a stated day or week in each year 
?-:;- and not infrequently associated, alternating with, or substituted by, attacks 
of pure bronchial asthma. The ailment is most frequent in the later spring 
months (rose cold) and in August and September (hay fever) and in some in- 
stances oceans irregularly or as the result of such influences as are described 
under the exciting causes in asthma. In certain cases a violent harassing 
and markedly paroxysmal cough may be present, slight fever may occur at 
intervals and the usual duration is from four to six weeks. This disease 
boasts a wonderfully voluminous literature bearing upon its etiology and 
treatment. 

NASAL POLYPI. — These may be either mucous or fibrous, the former 
being soft and gelatinous, the latter hard. They are most common in the 
posterior chamber, may cause necrosis, invade the adjacent cavities, deform 
the nose and, in the case of fibrous growths, become sarcomatous. 

SARCOMA AND CARCINOMA.— The sarcomata are light red, usually 
sessile, bleed at the slightest touch, and are associated with ulceration and 
jfzensive discharge. 

C zrcinomota are usually epithelioma tous or encephaloid in type and are 
excessively rare as primary growths. 

NASAL SYPHILIS. — Primary lesions are almost unknown, secondary 
lesions coincide with the appearance of the exanthem upon other parts, but 
tertiary lesions may appear as nodular swellings on any part of the nose. 

Behaving here as elsewhere, they may undergo absorption if recognized 

and treated, or, a destructive necrosis, attended by profuse filthy secretion 

if eexosis and a foul breath due to a rapidly spreading involvement of the surrounding 

" T~r nasal :::a~ ;e:s '.: :k ex:ra:rf:zar:ly an i ±ara::eri=::; = lly r: :~y :z such eraser 



Friable and 
vascular. 



s * : ; ■- : i : _ 



DISEASES OF THE NOSE AND THROAT 



337 



and underlying tissues. Few more terrible pictures are presented than 
those of the malignant form of rapidly progressing syphilitic necrosis involv- 
ing the nasal structure. 

EPISTAXIS. — /;/ nine cases out of every ten, any spontaneous nasal 
hemorrhage occurs as the result of a small erosion affecting a tiny group of 
veins on the anterior portion of the septal walls. 

It is associated also with excessive physical and mental exertion, injuries, 
operations, ulcerations, tumors affecting the nasal mucous membrane, and 
venous trunk obstruction, as in the case of tumors of the throat and 
mediastinum. It occurs in cases of mitral and tricuspid disease and, with 
considerable frequency in cases showing high arterial pressure associated 
with interstitial nephritis, left ventricular hypertrophy and arteriosclerosis. 
In some of these instances no doubt, it acts as a safety valve and a substitute 
for phlebotomy. 

Nasal congestion alone or occurring as a part of a cerebral congestion gives 
rise to single or repeated hemorrhages. It occurs as a prodromal symptom 
of acute infectious diseases, especially typhoid, and is a complication of pro- 
found dyscrasias, such as leukemia, hemophilia, pernicious anemia, scurvy 
and purpura, in which it may be fatal. Rarely it represents vicarious men- 
struation or substitutes hemorrhoidal bleeding, and it should be remembered 
that repeated hemorrhages, often disregarded or overlooked in case-taking, 
may be the source of a profound secondary anemia. 

Foreign Bodies in the Nose. — In a child or insane person a mucoid dis- 
charge becoming purulent or perhaps fetid and bloody should suggest a foreign 
body in the nose, and demands a rhinoscopic examination. 

THE ACCESSORY SINUSES.— Until the past few years the great and 
far-reaching importance of these cavities has been little appreciated. 

They consist of the maxillary antrum (antrum of Highmore) and the 
frontal, ethmoidal and sphenoidal sinuses, any one of which may be the seat 
of inflammation and an acute or chronic sepsis which may lead to serious 
secondary septic absorption of either the acute of chronic type. 

We have learned recently that these cavities play a large part in severe 
chronic or recurrent headaches and that many cases of chronic and persistent 
ill health with nebulous findings and intractable relapsing secondary anemias 
have their origin in these sinuses. 

The Antrum of Highmore. — This, the largest of the accessory sinuses, 
opens into the middle meatus about i inch above its floor. 

The roots of the teeth of the upper jaw and especially those of the molars 
are separated from the antral cavity by only a thin plate of bone. 

If acute infection occurs through ordinary acute coryza, influenza, 
peridental abscess, necrosis, or what not, the antral outlet is readily blocked 
and retention or even abscess formation may follow. This condition is 
but too often overlooked and neglected whether in its acute or its chronic 
form. 

Transillumination. — Most valuable information is afforded by the use of 
a small electric bulb of special pattern held within the mouth with the 



Horrible 
cases. 



Most frequent 
source. 



Widely varying 
causes. 



Prodromal. 



Dyscrasic. 



Useful blood- 
letting. 



Great 
importance. 



Sepsis and 

septic 

absorption. 



Headache and 
anemia. 



Important 

anatomic 

relationships. 



Retained 
secretion. 



Abscess. 



33* 



MEDICAL DIAGNOSIS 



Eye reflex. 



Diagnostic 
shadow. 



Special 

diagnostic 

procedure. 



Special suc- 
tion device. 



Vasoconstric- 
tor sprays. . 



Mucocele and 
empyema. 



Inspection. 



Radical! 
procedure. 



Neglected 
cases. 



Important 
relationships. 



Serious 
possibilities. 



Catheteriza- 
tion of sinus. 



lips closed. In a dark room the sound cheek and corresponding pupil 
show a dull red glare and if the eyes are closed the lower lid on the sound 
side and lower margin of the orbit show the same illumination. 

The affected side will show usually a more or less decided shadow or de- 
ficient illumination if the cavity contains a large amount of secretion or is the 
seat of inflammatory thickening, acute or chronic. 

Inspection. — Inspection may show some drainage from the sinus, especially 
if the head be bent far forward, but in many instances retention is complete 
and direct exploration of the opening and the establishment of lavage or 
artificial drainage through the wall of the inferior meatus is necessary. 

In all sinus cases the use of suction apparatus applied to one nostril with 
the other nostril held closed while the patient repeats the word "tick/' 
will often draw pus from the affected sinus. 

In all sinus inflammations the use of vasoconstrictor sprays or douches 
may temporarily reestablish drainage and aid in diagnosis both by this 
result and by the prompt but transient relief or amelioration of pain so 
often experienced. 

THE FRONTAL SINUSES.— These like the maxillary antra open into 
the middle meatus and blocking of the outlet by mucus (mucocele) or 
mucopus (empyema) is an extremely common complication or sequence 
of various infections affecting the nasal passages or even of hypertrophy 
of the middle turbinate or the presence of polypi. 

Transillumination. — This maneuver is of service here as in the case of the 
maxillary antrum but the more direct method of inspection of the nose and, 
if necessary, the introduction of a probe or catheter into the sinus after a 
primary and thorough shrinking of the tissues by local applications, is more 
satisfactory. 

If necessary, a resection of the anterior extremity of the middle 
turbinate may be performed and the results of direct inspection or explora- 
tion together with the subjective symptoms and the external signs, 
will aid in making a positive diagnosis. 

The anterior wall of the sinus is relatively thin and neglected empyema 
with retention may cause actual necrosis and external pus accumulation. 
A decided redness, swelling or edema of the overlying tissues is sometimes 
present before necrosis is far advanced. 

THE ETHMOIDAL SINUSES.— These lie along the inner orbital walls 
in dangerously close relation to the meninges and the cavernous sinus. 

In neglected empyema the thin orbital boundary wall may yield and exoph- 
thalmos, strabismus, retrobulbar neuritis, ptosis, or even cavernous sinus 
thrombosis or basal meningitis result. The anterior cells, like the sphenoidal 
and nasal sinuses, open into the middle meatus, the posterior cells into the 
superior meatus. 

THE SPHENOIDAL SINUSES.— These He at the base of the skull 
posteriorly and open into the superior meatus by a passageway which may 
be traversed by a curved probe passed back over the middle turbinate at 
the junction of its anterior and posterior halves if the instrument is in 



DISEASES OF THE NOSE AND THROAT 



339 



specially skilled hands and proper preliminary cocainization and shrinkage 
of the tissues precedes the maneuver. 

The intimate deep relationships of the sphenoidal cells indicate clearly 
the dangers accompanying empyema of these structures. 

Symptoms. — In both ethmoidal and sphenoidal cases more or less severe 
deep-seated pain is felt in the orbit and back of the nose and often a deep 
boring pain in the occiput. 

It is usually possible to demonstrate a discharge of mucus or mucopus 
into the middle meatus if the anterior ethmoidal cells are involved and from 
the inferior meatus if the posterior ethmoidal cells or the sphenoidal cells 
are affected. Nevertheless, in many instances, sphenoidal and posterior 
ethmoidal retention cases may be very obscure. 

Pain in Disease of the Accessory Sinuses. — The pain of a sinusitis, 
mucocele or empyema with complete or intermittent retention may be very 
severe. 

It is usually worse in the morning and this is especially true of cases of 
frontal sinus retention. 

Its maximum localization and its character are fairly definite or strongly 
suggestive in both frontal -and maxillary sinus lesions but extremely indefinite 
in cases involving the sphenoidal regions. 

It is evident that in all cases the specific diagnosis must depend chiefly 
upon direct inspection of the districts into which the various sinuses normally 
drain their secretion and by means of preliminary shrinkage of tissue, the 
use of the probe, and even of a special suction apparatus, the skilled specialist 
can usually make a positive diagnosis. 

Every physician should consider these regions in relation to the etiology 
of asthma, obscure chronic headache, rheumatism, anemia, arthritis deformans 
and even endocarditis, myocardial insufficiency and the nephritides, for 
they, like the tonsils though in less degree, offer exceptional opportunities 
for the continued growth and reproduction of pathogenic organisms. 

DISEASES OF THE PHARYNX 

ACUTE PHARYNGITIS.— In this ailment the throat is sore, stiff and dry. 
There is dysphagia, hoarseness and, in severe cases, swelling of the cervical 
glands. The patient is harassed by the recurrent cough and persistent 
pharyngeal irritation. Any secretion present is usually viscid and tenacious 
and causes persistently repeated but vain efforts to "clear the throat." 

CHRONIC PHARYNGITIS.— This presents much the same symptoms 
during its period of exacerbation and frequently shows a special involve- 
ment of the follicles, giving the throat the granular appearance some- 
times separately described as u follicular pharyngitis." 

ATROPHIC PHARYNGITIS.— The atrophic form shows a thin, glistening 
mucous membrane. The throat is dry and stiff. It may be dotted with 
islands of dried secretion and an harassing cough is common. The naso- 
pharynx may be chiefly involved and cause a burning sensation. Most 
troublesome and irritating efforts to dislodge secretion result. 



Pain 
localization. 



Localization. 



'Sun pain." 



Specific 
diagnosis. 



Etiologic 
importance. 



"Hawking." 



34o 



MEDICAL DIAGNOSIS 



Invite disease. 



In acute conditions the secondary increase of secretion may be profuse. 
The atrophic form is especially disagreeable if it involves the naso- 
pharynx and a hypertrophic form may involve the lateral walls of the 
pharynx. 

POST-NASAL ADENOIDS.— " The Curse of Childhood."— These lymph- 
oid structures may greatly impair the health, physical and mental development, 
and future life, of childre-n. 

They represent hypertrophied lymphoid tissue and form vascular growths, 
broad-based, sessile or pedunculated and sometimes moderately firm and 
fibrous. They are astonishingly frequent and may affect whole families. 
Excessively cold or damp and changeable climates seem to increase their 
frequency and, though the condition may be congenital, it is seldom symp-. 
tomatically declared before the age of two years. 




/ 



Fig. 133. — Adenoid Facies. The condition may exist with little or no evidence of this kind 

The Symptoms, — These are varied and interesting. In the typical and 
pronounced cases the child is a mouth breather with the physiognomy shown 
in our illustration and in such cases the growth is usually large. 

Smaller bodies may nevertheless produce marked irritability, nocturnal rest- 
lessness and a complete change in the disposition and mental alertness of 
the child. 

In all cases there is an increased liability to acute coryza, otitis media, 
croup, tonsillitis, laryngitis, bronchitis and middle-ear disease, as well as added 
danger from attacks of measles, scarlet fever, whooping cough and diphtheria. 

If unremoved, they may undergo atrophy as adult life approaches, usually 
leavir ":^:'::A chronic naso-pharyngeal catarrh, a high-arched palate, a de- 
formed chest, and imperfectly expanded 



DISEASES OP THE NOSE AND THROAT 



341 



Mouth breathing, a muffled nasal tone, snoring, and the evident increase of 
respiratory obstruction in the dorsal recumbent position should call attention to 
these cases. 

Impaired hearing is extremely common and is due to involvement of the 
Eustachian tube. 

Adenoids may cause asthma, enuresis, night terrors, teeth grinding, 
gastrointestinal disturbances, croup and possibly pseudo-epilepsy and cho- 
reiform manifestations. 

Retardation in mental development is often attributable to "adenoids" 
and this statement is equally true in relation to certain vicious traits in unruly 
children. 

Direct Diagnosis. — A positive diagnosis is readily made by slipping the 
index finger behind the palate and exploring the post-nasal vault or, by the 
use of the mirror and retractor. 

SYPHILITIC PHARYNGITIS.— A secondary syphilitic erythema is dif- 
fuse or takes the form of a vertical red band on the anterior pillars which ends 
abruptly at the uvula. Mucous patches, if present, tend to be symmetrical, 
but tertiary lesions are frequently unilateral and there is usually an associ- 
ated laryngitis. 

RETRO -PHARYNGEAL ABSCESS.— Such abscesses are unilateral and 
most often in the oro-pharynx, but may be opposite either the nasal or 
laryngeal portion and are often to be seen only with the mirror. Injury 
and caries of the vertebrae are the usual causes, though they may complicate 
tonsillar abscess, syphilis and tuberculosis. According to their location, they 
cause obstructed nasal breathing, spasmodic dyspnea, deafness, or tinnitus 
aurium, combined with symptoms of severe pharyngitis and the local and 
general symptoms of abscess. 

PARALYSIS AND TUMORS.— Paralysis of the pharynx need not be 
separately considered and the tumors of this region may take any form. 
Paralysis of the soft palate may follow diphtheria and cause characteristic 
changes in the voice and difficulty in swallowing liquids. 

DISEASES OF THE TONSILS 

ACUTE TONSILLITIS.— This common disease of young people is rare 
in infants and in elderly persons. The relation of tonsillar infections, acute 
and chronic, to rheumatism, chorea, endocarditis and myocarditis is now 
definitely established and the remarkable instances in which chronic ill health, 
recurrent anemia and obscure albuminurias have been relieved by complete 
tonsillar enucleation are so frequent as to enormously increase the legitimate 
indications for that procedure. 

The recent studies of their bacterial flora show that tonsils which have 
been the seat of repeated attacks of tonsillitis are, as a rule, dangerous posses- 
sions and, unfortunately, one cannot always estimate their evil potency by 
the external appearance of the glands. Acute tonsillitis prevails chiefly in 
the spring in this country and affects both sexes equally. 



Reflex cause of 
disease. 



Mental effect. 



Usual site. 



Causes. 



Symptoms. 



Related 
ailments. 



Importance of 

complete 

enucleation. 



Dangerous 
possessions. 



342 



MEDICAL DIAGNOSIS 



Incubators 

and 

commissaries. 



A complication, 
sequel or 
neurosis. 



Symptoms. — A chill or chilliness and severe muscular and bone pains are 
followed by rapidly rising fever, sore throat and dysphagia. The temperature 
reaches 103 to io$°F., and the voice may be thick and nasal. The tonsils are 
swollen and dotted with a readily detachable exudate, which may become confluent, 
but tends to be confined to the limits of the tonsil. 

The disease lasts but a few days and is usually uncomplicated. In many 
instances the diphtheritic membrane is so closely simulated as to demand 
cultural tests and in certain cases of diphtheria the first appearance is that 
of follicular tonsillitis. 

Despite the fact that most cases terminate favorably, one must remember 
that this ailment almost invariably precedes any attack of acute rheumatism. 

Furthermore, it is often the first known manifestation of many other ailments, 
the true nature of which may be revealed only after several or many days. 

SUPPURATIVE TONSILLITIS {Quinsy).— This difersfrom the preceding 
form chiefly in the predominatingly unilateral primary involvement of the peri- 
tonsillar tissues, the more violent onset, higher fever and pulse rate, the greater 
prostration present and its tendency to abscess formation. 

The staphylococcus pyogenes is usually the dominant and predominant 
organism. 

The local symptoms are those of pain, dysphagia and marked swelling 
of both the tonsil and the peritonsillar tissues. The cervical glands are 
enlarged, salivary secretion is increased and within two or three days fluc- 
tuation is evident and through rupture or, preferably, by the use of the 
knife the disease passes. 

Both tonsils may be involved, the pus burrow with unexpected 
rapidity, and even an edema of the glottis may occur. 

Quinsy should not be allowed to go on to spontaneous rupture. 

CHRONIC TONSILLITIS.— Chronic hypertrophy, often associated 
with dense adhesions, is closely associated with so-called lymphatism, and the 
significance and effect of this lesion and of naso-pharyngeal adenoid growths 
is somewhat the same. 

Furthermore, as stated previously, such tonsils are usually veritable 
commissaries and incubating ovens for the various strains of streptococci 
responsible for acute and chronic arthritis, endocarditis and myocarditis. 

Hypertrophied tonsils should not be allowed to remain in the throat of 
children or adults unless a distinct contraindication to their removal exists. 

DISEASES OF THE LARYNX 

SIMPLE, ACUTE AND SUBACUTE LARYNGITIS is too well known 
to need extended description, its chief characteristics being varying degrees 
°f hoarseness, painful and distressing cough, general congestion of the mucous 
membrane and vocal cords and scant viscid secretion. 

Chronic laryngitis is a common complication of other diseases of the res- 
piratory tract and a very frequent form of fatigue neurosis, such as is experi- 
enced by singers, auctioneers, hucksters, army officers and others. In its 
milder forms it is associated with the excessive smoking of tobacco, overuse 



DISEASES OF THE NOSE AND THROAT 



343 



Cough. 
Atrophic form. 



Prompt relief 
demanded. 



of alcoholics, and the rheumatic or gouty diathesis. It is particularly 
frequent in all poorly nourished persons, especially mouth breathers, and 
such as live or work in dusty, steamy or vitiated atmospheres. 

Symptoms. — Chronic or recurrent hoarseness of varying degree, scanty 
tenacious secretion, local irritation, laryngeal congestion and more or less cough Cords 
are the chief symptoms. The vocal cords are sometimes unaffected and even 
whiter than normal, though occasionally their movement is restricted by 
swelling of adjacent structures. The cough may be paroxysmal or violent 
and projectile, the dried secretion acting like a foreign body. A form 
precisely similar to atrophic rhinitis and pharyngitis may occur. 

Singer's Nodes. — These are papillary excrescences or nodules such as may 
be encountered on the true vocal cords of any victim of inveterate chronic 
laryngitis. 

Edema of the Glottis. — Cases of sudden onset and rapidly fatal termination 
may occur, but usually it is preceded by progressive inspiratory dyspnea with 
hoarseness or aplwnia. The laryngoscope or even the finger at once reveals it 
and no condition more urgently demands prompt, often immediate and radical, 
treatment* It should be remembered that this condition may complicate 
actual traumatism, especially burns, or the inhalation of poisonous and irri- 
tating gases, the ingestion of corrosive poisons, diphtheria, erysipelas, quinsy, 
scarlet fever, typhus, Bright's disease, syphilis, tuberculosis and diabetes 
mellitus. It is very rare in association with primary acute laryngitis. 

CROUP. — This well-nigh universal ailment of children, while possibly, 
quite distinct from the spasmophilic form known as laryngismus stridulus, 
is distinctly of a spasmodic type and, in the author's opinion, cannot prop- 
erly be called merely an acute laryngitis. It occurs between the ages of 
six months and three years, rarely later. Deficiency of calcium in the diet, 
rickets, the irritation of teething, large tonsils and adenoids are important 
exciting or contributing factors. It is a distinctly spasmodic ailment 
associated with a mild and usually transient laryngeal catarrh and in many 
instances seems to indicate a close relationship to spasmophilia both as to 
exciting causes and basic etiology. 

Symptoms. — The symptoms are those of spasmodic inspiratory dyspnea 
and laryngeal congestion. It is preceded by marked hoarseness, and during 
the spasm the child is cyanotic and asphyxiation may seem imminent. 

The peculiar "crowing" sound attending the forced indraft of air through the "Crowing. 
glottic chink and the hoarse metallic cough are characteristic of the disease and 
all too familiar to both physician and layman. 

In many cases the attacks last only for a short time, usually coming on 
about midnight; in others, they may recur on several successive nights and 

* In more than one instance a timid, hesitant physician has watched the slow suffo- 
cation of these patients. Cocain and adrenalin, on a swab or as spray, and scarification of- 
the tissues may serve at least for temporary amelioration, but, as in the cases of sudden 
extreme laryngeal stenosis in the diphtheritic child, an emergency tracheotomy with a 
razor for scalpel and hair pins for retractors, if no better means offers, may be imperatively 
demanded. 



344 



MEDICAL DIAGNOSIS 



A spasmophilic 
form. 



Probably 

always 

diphtheria. 



Usually 
tertiary. 



Therapeutic 
test. 



Seldom 
primary. 



Hoarseness, 
cough and 
aphonia. 

Cords 
ashy gray 
and " moth- 
eaten." 



Pyriform swel- 
ing and epi- 
glottic turban. 



the child is hoarse and has a croupy cough during the day. Convulsions 
rarely occur and death during the attacks is almost unknown. 

LARYNGISMUS STRIDULUS is a term applied to an adductor laryn- 
geal spasm which may be either nocturnal or diurnal and lacks the hoarseness 
and cough of croup. It corresponds to "passion fits," "child crowing," 
"holding the breath," of the laity, and convulsions, carpopedal or general, 
may occur. 

It is a prominent member of the group of syndromes included under the 
term "spasmophilic diathesis." 

MEMBRANOUS CROUP {Laryngeal Diphtheria) .—In rare instances, 
especially in measles and pertussis, this terrible disease is said to occur un- 
associated with diphtheria, and is credited to streptococcus infection, but 
for practical purposes any persistent membranous laryngeal stenosis must 
be considered and treated as diphtheria and demands prompt intubation 
and large doses of diphtheria antitoxin. 

SYPHILITIC LARYNGITIS.— This is ordinarily a tertiary manifestation 
and may occur two or three decades after the primary infection. The sec- 
ondary stage may, however, give rise to hyperemia, symmetrical ulceration 
and condylomata which may resolve or ulcerate. The gumma may cause deep 
ulceration or necrosis with resulting stenosis from cicatricial contraction. The 
specific tests are often necessary. Congenital laryngeal syphilis usually 
appears in infancy, more rarely at the age of puberty {hereditaria tarda). 

TUBERCULOUS LARYNGITIS.— Primary tuberculosis in this region 
is extremely rare and usually, though not always, the lesion indicates and is 
found to be associated with an advanced pulmonary lesion.* 

Symptoms. — The symptoms are those of a persistent chronic laryngitis, 
hoarseness or aphonia being a marked and early symptom. Swallowing is 
painful if there is epiglottic or pharyngeal ulceration. The laryngeal mucous 
membrane is at first pale and later an ashy gray, the arytenoids showing a 
pyriform swelling and the epiglottis becoming turban- shaped. 

The ulcers themselves are shallow and broad with gray granular bases and 
irregular, sharply cut outlines, and the vocal cords usually appear "moth- 
eaten" from ulceration. The tubercle bacillus can usually be demonstrated 
easily in the sputum and makes the diagnosis positive. 

A lupoid form may be encountered, characterized by small gray nodules 
centered in a zone of redness and non-ulcerative. 

TUMORS OF THE LARYNX.— The general symptoms oj laryngeal tumors 
are dysphonia and aphonia, intermittent or persistent dyspnea, cough, and 
sometimes laryngeal spasm. 

Certain growths above the cords are subjectively symptomless and some 
sessile growths produce strikingly intermittent and irregular symptoms with 
violent paroxysmal cough and are often difficult to see with the laryngoscope. 
Any extended discussion belongs to surgery. 

* Nearly all of the supposedly primary cases prove to be secondary to advanced but 
latent or partially arrested pulmonary lesions. They will become still rarer as the X-ray 
is more generally used in diagnosis. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 



345 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 
BRONCHITIS 

Etiology. — The general etiologic factors are essentially the same in all 
forms of simple bronchitis. 

Exciting Causes. — In all forms of bronchitis bacteria play a prominent 
part: "Micrococcus catarrhalis," pneumococci, the streptococcus and staphy- 
lococcus, Friedlander's bacillus and many others are found, quite aside from 
specific infections in which a bronchitis is a secondary factor. 

Predisposing Causes. — The extremes of life, a changeable, damp climate, Age, 

, . r b . . . ,. . i climate and 

whether temperate or tropic, and general low vitality, primary, or secondary previous 

.. ...... health. 

to disease, alike invite it. 

Chronic malaria, gout, alcoholism, B right's disease, incompensated cardio- 
vascular lesions, especially those associated with pulmonary stasis, cause or Antecedent 

.,...,-, . • 11. i diseases. 

predispose to it and it invariably accompanies active tuberculosis, emphy- 
sema and asthma. 

In certain acute diseases, such as measles, typhoid, smallpox, influenza, and 
whooping cough, it is a common or invariable complication, but in so far as acute Acute 
bronchitis is concerned, the common "coryza" is ordinarily the primary factor. 

Males are chiefly affected by reason of their greater exposure both to cli- Sex. 
matic variations and the diseases of etiologic relationship. 

Steel grinders, stone cutters, bakers, millers, stokers, felt workers, em- 
ployees in flax and cotton mills and such as must be exposed to irritants of Occupation, 
any sort show a special tendency to this disease. 

The foolhardy process of "hardening" young infants by excessive and 
reckless exposure to harsh weather and the irrational use of insufficient out- 
door clothing helps greatly to swell the infant mortality though an increasing 
use of intelligently regulated open-air living for children and adults alike is 
one of the most hopeful advances in preventive medicine. 

Morbid Anatomy. — In acute bronchitis, the mucous membranes are at 
first inflameS, dry and irritable, later there is a reactive mucopurulent 
secretion, the membranes are swollen or edematous and, should the bronchioles 
become affected, a disseminated broncho-pneumonia {"capillary bronchitis") 
results. 

In chronic bronchitis the long-continued inflammatory changes, often 
associated with and increased by chronic venous congestion, lead to permanent 
thickening or atrophy of the mucous membrane, with granulation or even 
ulceration, and it is one of the causes of the fusiform or saccular dilatations 
known as bronchiectases. 

ACUTE TRACHEO-BRONCHITIS 

Symptoms. — These are: fever, usually moderate (99. 5 to 103 °F.); sub- Fever, 
sternal pain, soreness or oppression; hoarseness, general malaise and cough, at distress, and 
first urgent, dry, ringing, harsh and somewhat painful, later moist and hollow. 



"Hardening' 
infants. 



346 



MEDICAL DIAGNOSIS 



Sputum. 



Rales chiefly. 



Lumen of 

bronchi 

reduced. 



Dryness fol- 
lowed by over- 
exertion. 



Brief duration. 



Prolonged 
attacks. 



Fever, local 
discomfort. 



Dry and moist 
rales. 



The sputum, at first mucoid and scant, soon becomes mucopurulent and 
sometimes profuse, and if the cough is violent may show blood streaks in the early 
stage. 

Physical Signs. — The only important physical signs are the sibilant and 
sonorous rales of the first stage, followed by the mucous bubbling or even 
gurgling rales, of the stage of exudation. Slight dyspnea and cyanosis may 
be evident, and palpation may reveal rhonchal fremitus. Marked cyanosis 
suggests disseminated broncho-pneumonia, a preexistent emphysema, or a 
complicating cardiovascular lesion. In the bronchitis of influenza or typhoid 
fever, toxemia may be profound even in the absence of serious pulmonary 
lesions. Broncho-pneumonia is suggested by a prostration disproportionate 
to the physical signs. 

The Prognosis in Acute Bronchitis. — In this form it lasts from a few days 
to several weeks and one may anticipate a prompt and complete recovery 
and freedom from relapse save in those persons exhausted by antecedent 
disease, badly nourished or suffering from emphysema, cardiovascular or 
renal disease. 

Its conversion into a broncho-pneumonia is to be feared in patients 
representing the extremes of life. 

RATIONALE OF ACUTE BRONCHITIS 

Obviously, infection, irritants or foreign substances must induce varying 
degrees of congestion, together with edema of the bronchial mucosa in the 
. severer cases, resulting in various degrees of stenosis, especially affecting the 
! tubes of relatively small caliber, but not the terminal bronchioles. 

The surface of the inflamed mucous membrane is at first dry from the 
checking of normal secretion; later excessively moist from the usual reactive 
oversecretion characteristic of congested mucous (or serous) membranes. 
Desquamation of varying degree is present but pronounced round-celled 
infiltration of the deeper structures of the bronchial tissues is usually absent 
and prompt regeneration follows. Certain cases are primarily so severe or 
meet such conditions of impaired resistance as furthers the establishment of 
a chronic process. The lung tissue is practically unaffected. 

Results. — Fever results if there be an acute infection, either primary or 
secondary, together with distress over the region of the inflamed and hyper- 
sensitive trachea* and main bronchi, and racking and unproductive cough 
is followed by one productive and " softer," but no physical signs are present 
save dry whistling or snoring rales in the first stage and both dry and moist 
mucous rales in the second. 

The production and intensification of some of the smaller rales is favored 
by certain areas of dilatation of the lesser bronchi. The quality, pitch and 
intensity of the various rales will vary with the calibration of the tubes and 
the amount and character of exudate present at the site of their production. 

* Certain ganglia at the tracheal bifurcation are chiefly responsible for the substernal 
distress so commonly present. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 



347 



CHRONIC BRONCHITIS.— This is essentially a secondary disease. It 
may result from repeated acute attacks or long-continued exposure to 
irritating substances; is relatively common in connection with gout, the 
cardiovascular degenerations and circulatory inadequacies of advanced 
age; is an invariable accompaniment of asthma, incompensated mitral 
disease or emphysema, and in many instances is associated with chronic 
nephritis. 

The diagnoses of " chronic bronchitis" and "winter cough" have diminished, 
as more exact methods have proven many to be cases of pulmonary tuberculosis, 
chronic cardiac or cardio-renal insufficiency, or bronchiectasis. 

The bronchitis may be dry, moist, or actually bronchorrheic, in which 
event more than a liter of sputum may be raised daily. In all persisting 
severe cases an emphysema results and the physical signs of the disease are 
in direct accord with this fact. 

EOSINOPHILIC BRONCHITIS.— This condition differs in no respect 
from other forms of chronic bronchitis save in the obstinate severity of the 
cough, the special tendency to decided dyspnea and the almost exact like- 
ness of the sputum to that of "bronchial asthma." This secretion is tena- 
ciously mucilaginous, is streaked with yellow, is rich in eosinophile cells and 
often contains Curschmann's spirals and the Charcot-Leyden crystals. 
The eosinophiles of the blood may also be greatly increased. 

OBLITERATIVE BRONCHIOLITIS.— This rare and curious condition 
may result from the inhalation of irritant gases as in the horrible " chlorine 
gassing" of the European war, but also occurs without assignable cause as a 
sequel to an apparent simple bronchitis. Acute emphysema, dyspnea, 
cyanosis and a failing heart with moderate fever may progress to a fatal 
issue, pursue an extremely chronic course or even terminate in recovery. In 
the typical case the lungs are'filled with gray nodules which resemble miliary 
tubercles. These are found to respresent cross-sections of obliterated 
terminal bronchioles. 

PUTRID BRONCHITIS.— This form is chronic and characterized by 
foul-smelling sputum, but hardly deserves a separate place because of its 
almost invariable association with bronchiectasis, gangrene, ruptured abscess, 
or empyema. 

Physical Signs. — Unless, as is commonly the case, one finds superadded 
symptoms of emphysema or other primary conditions, the physical signs of 
this ailment are limited to sibilant, sonorous, mucous or bubbling rales with 
more or less profuse expectoration. 

FIBRINOUS BRONCHITIS.— In this ailment fibrinous casts are formed 
and expelled; these are often extensive and sometimes produce bronchial 
blocking and atelectasis of lung areas. Dyspnea and cough are much more 
urgent than in ordinary bronchitis and the attacks may be single, recurrent, 
acute or chronic. 77 is a clinical curiosity. 

SYPHILITIC BRONCHITIS.— It is necessary to remember that syphilis 
may and often does affect the bronchi and may produce any and every variety 
of bronchitis. In all cases of persistent intractible bronchial inrlamma- 



Seldom 
primary. 



Common 
associations. 



Diminished 

incidence. 



A dubious 
entity. 



Chiefly 
auscultatory 



Fibrinous 
casts. 



Urgent 
symptoms 



348 



MEDICAL DIAGNOSIS 



Probable 
agent. 



Peculiar 
adaptability. 



Respirators. 



Intense 
congestion 
and edema. 



Heart. 



Agonizing. 



tion especially, one should remember this fact and endeavor to ascertain 
by direct or indirect diagnostic methods whether or not lues is present. 

Hemoptysis occurring suddenly and without apparent cause or in asso- 
ciation with what appears to be a simple bronchitis, acute or chronic, should 
always suggest the possibility of a syphilitic origin. This is an important 
diagnostic point very frequently overlooked. Such hemorrhages may occur 
in syphilitics in whom bronchitis or any signs of pulmonary disease are 
wholly absent and may be profuse and recurrent. 

TRENCH GAS POISONING (CHLORINE "GASSING") 

A Horrible Agent of Warfare. — The most terrible of the agents of de- 
struction used in the European War, is concentrated chlorine gas, introduced 
by the Germans as a means of trench warfare. 

This substance is perfectly adapted to its horrible purpose in that even 
when wind borne it hugs the ground, being more than twice the weight of air; 
is readily compressed and safely transportable in metal cylinders; and even 
in high dilution (1-10,000) exerts a most violent irritative and asphyxial 
action. 

Means of Protection. — The use of proper respirators makes immune its 
users and indeed, to a large degree, those under attack; but the advantage 
lies always with the former who attack unexpectedly and only with a favor- 
ing wind and are fully and properly protected whereas the latter are always 
to a greater or less degree unprepared, even though supplied with the respi- 
rators, all too readily torn, mislaid or lost. 

Early Effectiveness. — During the first days of its use this barbarous agent 
inflicted the most insufferable agonies upon the unprotected foe. 

Morbid Changes Produced. — It produces an intense congestion of the 
mucous membrane of the trachea, larynx and larger and lesser bronchi, with 
a profuse flooding bronchorrheal discharge. In fatal cases the lungs are the 
seat of a congestion and edema so intense that they do not collapse when 
removed at autopsy "but appear like a solid cast of the thoracic cavity." 
On section the lesser bronchi are wholly unrecognizable and here and there 
local patches of emphysema bear testimony to the "agonized violence" of the 
respiratory efforts brought to bear upon the relatively few small parts of the 
lungs which escape the obliterative process and prevent the more merciful 
prompt strangulation. 

General venous congestion is present in such cases and right heart dilata- 
tion is a prominent figure. Marked irritation of the gastric mucosa is 
described by various writers. 

Symptoms. — The symptoms vary in intensity with the severity of the 
individual case but are essentially those of intense febrile suffocative bronchitis 
associated with a peculiarly intense and persistent cyanosis, bronchorrhea, 
pain ( epigastric, intrathoracic, and cephalic), stupor or mental confusion, 
conjunctivitis, salivation and vomiting. 

In severe cases the painful gasping respiration, asphyxial fades of the 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 



349 



orthopneic patient racked by recurrent paroxysms of painful cough make a 
picture of suffering such as no pen may describe. 

BRONCHIECTASIS 



Usually 
multiple. 



Definition. — Bronchiectatic dilatation, single, multiple or universal, saccular 
or fusiform, regular or irregular, unilateral or bilateral* is always secondary 
to other bronchial or pulmonary disease. 

- It ordinarily follows chronic inflammation of the bronchial wall attended 
by obstruction and accumulation of secretion and is oftentimes associated with 
pulmonary tuberculosis, chronic pleurisy with adhesions, chronic emphysema, 
aneurysmal pressure, or fibroid disease of the lung. 

Though rarely caused by acute disease, it has been reported in pertussis, 
influenzal and broncho-pneumonia, and in its cylindrical form is probably a not 
uncommon sequence. 

As usually encountered the sacculations are multiple, but cases of single 
cavity occur and in rare instances these are enormous. 

In tuberculosis the apices are chiefly affected but in other forms the bases 
are oftenest involved. 

Unilateral universal bronchiectasis is a rare condition, almost always 
congenital, which in the still rarer acquired form is a sequence of chronic 
interstitial pneumonia. 

Physical Signs. — With respect to the bronchiectases themselves they are often absent. 
often wholly absent. When present, they are merely those of lung cavity, usually 
but by no means always, lacking the distinguishing qualities of a vomica 
occupying infiltrated tissue. 

Hence the diagnosis of bronchiectasis usually rests upon the presence of 
causative factors, the peculiar paroxysm of cough, the characteristic fetid sputum 
and the X-ray findings, which are peculiarly satisfying in the saccidar type. 

The more or less regular filling and emptying of the bronchiectatic cavity 
causes an instability of physical signs which is of diagnostic importance in 
rare instances. 

In some cases daily fever occurs and the hectic physiognomy is present. Fever. 
Dyspnea is sometimes decided and cyanosis marked in the severe generalized 
forms. Clubbing of the terminal phalanges is not uncommon in such cases. 

Cough and Sputum. — Once or twice daily, usually in the morning on 
arising, and bending forward or while turning over in bed, a violent paroxysm Posture, 
of coughing occurs attended by extraordinarily profuse expectoration 
not infrequently attended by vomiting. J 

This is offensive in odor, gray or grayish brown and purulent, and upon 
being placed in a glass it will after a time separate into three layers. The Three layers. 

* 6o-j- per cent, are bilateral and in some cases the lungs are literally honeycombed. 

t Its occasional occurrence in the influenzal hemorrhagic pneumonitis of 1918 has been 
reported by several observers. 

+ Over a liter daily has been reported in the medical literature. The odor is sometimes 
less offensive than would be expected. 



A clinical 
curiosity. 



Signs of 
cavity. 



Typical 
sputum. 



35° 



MEDICAL DIAGNOSIS 



Posture 
and cough. 



Superficial vs. 
deep lesions. 



Cavity with or 
without infil- 
tration zone. 



Compression 
dulness. 



X-ray. 



Extremely 
chronic. 



Great variety. 



Right side 
chiefly. 



lowest is thick and granular; there is a thin mucoid intermediate layer, and 
the surface layer is brown and frothy (high air content). 

The tiny yellowish white, bread-crumb like, foul-smelling Dittrich's plugs 
may or may not be present. 

Changes of attitude may greatly influence the onset of cough, and to 
empty the bronchiectatic cavity some patients learn to assume an attitude 
that brings the head and upper thorax below the level of the rest of the body. 

RATIONALE. — It is evident that a secreting bronchiectatic cavity must 
of necessity be at one time more or less completely full and at another empty. 

Its stagnant contents must necessarily be continuously foul, full of micro- 
organisms, capable of causing toxic absorption and hectic fever, of keeping 
up a persistent irritation or even ulceration, and of tending to further enlarge 
the cavity. 

Varices may form and hemoptysis from this source occurs in about one- 
third of the cases. 

If it be superficial in location, occurs as a complication or one of the end 
results of tuberculosis or fibroid phthisis, or is associated with marked re- 
active inflammation in the limiting tissues, one may elicit the physical signs of 
cavity with surrounding infiltration. Usually however, such sacs lack the 
boundary zone percussion dulness and peculiar auscultation signs of tubercu- 
lous cavities, and diffuse more widely such auscultatory signs as may be present. 

As usually occurring, it will present masked cavity signs or none at all, 
unless near the surface, because of the absence of reenforcement of vi- 
brations no less than the common presence of an obscurant emphysema. 

If multiple large sacs exist, however, the lung tissue between them may 
be markedly infiltrated or compressed and highly conductive over a sharply 
limited field. 

It follows that diagnosis must be based chiefly upon the character of the 
cough and sputum reenforced by the presence of potential etiologic factors 
and more or less indefinite physical signs of cavity, often clearly demon- 
strated by the X-ray. (See under " Roentgenography.) 

Prognosis. — The condition once established is permanent and slowly 
progressive, though usually extremely chronic, and is rarely relieved save 
by operative measures in selected cases. 

Pleuritic adhesion, pleurisy with serous or purulent effusion, pulmonary 
gangrene or broncho-pneumonia may occur as complications and it is 
obvious that right heart decompensation may be induced. 

Patients live long, usually for decades, and die of exhaustion or inter- 
current disease. 

In exceptional cases of superficial single cavity, surgery is effective but 
the surgical mortality in general is high and the results on the whole un- 
satisfactory. 

FOREIGN BODIES IN THE BRONCHI.— Coins, whistles, nails, pins, 
tacks, buttons, jewelry, bullets, pebbles, false teeth, tooth crowns, bones, 
fruit stones, peas, beans and the like may be drawn into the glottis and 
usually fall promptly in the larger and more direct right bronchus. 



DISEASES OF THE LUNGS AND PLEURA 



351 



Violent cough and air hunger or true stenotic dyspnea and cyanosis usually 
follow and arc associated with widely varying degrees of pain. 

If the object is not expelled, death may result in a few minutes, but, more 
often, the attack subsides and secondary inflammation, often suppurative, 
ensues and results in localized septic broncho-pneumonia, abscess, or even 
gangrene. In some instances chronic pneumonia with or without 
bronchiectasis results and lasts for months or years, ending rarely in the 
extrusion of the foreign body. 

Diagnosis. — This depends upon the anamnesis, violent paroxysmal cough , 
the roentgen-ray findings and the physical signs of localized inflammation 
often associated with airless areas representing atelectasis. 

EMPHYSEMA 

VESICULAR EMPHYSEMA.— Definition— A condition which may be 
primary or secondary, general or local, temporary or permanent, acute or chronic, 
and is characterized by dilatation of the infundibular and alveolar walls of the 
lung with resulting atrophy of the latter in the chronic forms. 

The chronic type occurs chiefly in males over forty years of age, is frequently 
accompanied by a generalized arteriosclerosis and may be associated either 
with enlargement or shrinkage of the lungs, the former being the common form. 

A localized emphysema may be temporary or permanent and is usually 
vicarious and compensatory, representing the effect of overaction associated 
with temporary or permanent loss of function on the part of the other lung 
or in portions of the same lung (cicatrices, tuberculous areas). 

The best examples of the chronic compensatory form are afforded by 
the otherwise unaffected lung in cases of unilateral pulmonary tuberculosis 
or extensive pleural adhesion with its persisting unilateral . impairment 
of pulmonary expansion and capacity. 

The acute compensatory emphysema is beautifully shown in pneumonia, 
pneumothorax and unilateral pleural effusion and in either condition the 
vital respiratory balance is acquired with astonishing rapidity.* 

Acute Bilateral Emphysema. — This occurs abruptly in asthmatic seizures 
and in certain cases of angina pectoris and rapidly subsides as the attack passes. 

Interstitial Emphysema. — This condition is caused by the rupture of a 
superficial air vesicle which, during violent cough or straining, permits the 
escape of the air into the areolar tissues and produces (a) interlobular or (b) 
subcutaneous emphysema, or even (c) pneumothorax according to the site and 
degree of its extension. 

Subcutaneous emphysema is especially common in connection with 
traumatism or ulceration involving the lung structure and as a clinical 
rarity in interstitial emphysema. It is at once detected by the exquisite, crack- 
ling, palpable, crepitation produced by the pressure of the fingers upon the dis- 
tended skin. 

* In one of the rarest of clinical accidents, recently observed by the author, namely, a 
sudden and complete spontaneous pneumothorax in a healthy adult, a few days sufficed to 
render him able to get about in comfort. 



Immediate 
symptoms. 



Sequelae. 



Usually 
simple. 



Dilated alveoli 

and 

infundibula. 



Alveolar 
atrophy. 



Vicarious 
emphysema. 



Ruptured 
septa. 



Subcutaneous 
"crackling." 



352 



MEDICAL DIAGNOSIS 



The common 
form. 



Bronchitis, 
dyspnea and 
cyanosis. 



Slight emphy- 
sema the 
common type. 



Diminuendo 
cough. 



Barrel-chest. 



Wide epi- 
gastric angle. 



Chest move- 
ment. 



Expiratory 
lagging. 



Apex- beat 
obscured. 



Spinal curve. 



VESICULAR HYPERTROPHIC EMPHYSEMA 

Cause and Effects. — In this, the common form of emphysema, the air cells 
are over distended, their walls weakened, atrophied, and prone to rupture, with 
resulting coalescence of the dilated cells and obliteration of the lung capillaries. 
As a result, the lung is increased in size, its alveoli become fused in certain 
areas and its circulation ana expansile power are greatly and progressively 
diminished. The impeded circulation causts ultimate hypertrophy and 
terminal failure of the right heart and greatly increases the tendency to chronic 
bronchitis so generally observed as a persistent or frequently recurring ailment 
in this condition. 

SYMPTOMS. — In established cases of hypertrophic emphysema the symp- 
toms are primarily those of a chronic bronchitis plus slight or intense cyanosis, 
dyspnea, either persistent or developed only by exertion, and certain well-defined 
and easily recognized physical signs definitely expressing the pathologic changes. 

A considerable degree of emphysema may exist without evident dyspnea, 
marked cyanosis or persistent signs of bronchitis, and as a matter of fact, the 
great bulk of the cases observed are of this type, yet it occasionally exhibits the 
most profound cyanosis seen in adult walking patients* 

Cough. — This may be variable in degree as in persistence and may be dry, 
moderately productive, or accompanied by profuse expectoration. In severe 
cases it is somewhat characteristic, the recurring coughs of each individual 
paroxysm being greatly prolonged diminuendo. 

Heart. — Symptoms of failing right heart may be long postponed but the 
strain to which its chambers are subjected must ever 
be remembered. 

PHYSICAL SIGNS.— Inspection— The shape of the 
chest is that of forced held inspiration {barrel chest). 
The anteroposterior diameter is increased and the epigas- 
tric angle wide. True expansion is largely replaced by a 
vertical lifting movement, and constant overuse makes 
prominent the accessory muscles of respiration, particularly 
the sterno-mastoids. Inspiratory retraction of the lower 
interspaces with excessive supraclavicular bulging is com- 
mon in advanced cases. The ribs are rigid, the costal 
cartilages prematurely ossified, the interspaces broadened 
and the expiratory descent of the thorax is prolonged. 
The apex beat of the heart is ordinarly invisible, the neck 
appears short though often thin, and a compensatory curve of the spinal column 
may cause the chest to appear flattened and the patient round-shouldered. 

If such a patient lies upon the back on a table, the chest will at once 
assume its typical emphysematous outline. Epigastric pulsation is common 

* The author has carried throughout his professional life the vivid clinical picture pre- 
sented by two walking cases showing extreme cyanosis, which were shown simultaneously 
to students by the great London clinician in whose clinic he was working; one a toddling 
child with congenital heart disease, the other an aged man with emphysema. 




Fig. 134.' — Emphy- 
sema. Attitude fre- 
quently assumed in 
marked cases, conceal- 
ing barrel form of 
chest. 



DISEASES OF THE LUNGS AND PLEURA 



353 




Fig. 135. — Emphysema (barrel chest). Same 
chest, patient in dorsal recumbent posture. 



inspection and reveals an enfeebled vocal fremitus; a weak or wholly obscured 
apex beat, and some downward displacement of the liver. 

The author has seldom or never seen a well-marked case lacking some 
degree of arteriosclerosis. 

Percussion. — Percussion develops hyperresonance; low position of the lung 
border, impaired, movement of the lung bases and apices; downward displacement 
of the liver dulness and diminution or entire absence of the superficial cardiac 
area* 

Auscultation. — The breath sounds are enfeebled; the expiration prolonged 
though usually low-pitched, and bronchial rales are often present at the base. 
The heart sounds are muffled, especially in the mitral area, and the pulmonary 
second sound, though enfeebled and distant may or may not show relative accentua- 
tion when compared with the aortic tone which is often exaggerated because of 
co-existing arteriosclerosis. In old and severe cases tricuspid regurgitation 
may be present. 

Secondary Symptoms. — The effect of long-standing severe emphysema 
and chronic or recurrent bronchitis is to overburden the pulmonary circula- 
tion and right heart; hence if incompensation follows, one may expect to find 
the symptoms of a cardiac lesion. As a matter of fact, such severe terminal 
symptoms are rarely encountered, because of the extreme chronicity of the 
primary ailment, and the interposition of fatal intercurrent diseases, though 
minor degrees of secondary congestion affecting the organs tributary to the 
heart and great veins are extremely frequent. 

RATIONALE OF EMPHYSEMA 

In hypertrophic vesicular emphysema we deal with dilated air cells; an 
overvoluminous , inelastic, chronically overinfiated lung; atrophied vesicular 
walls, an impaired intrinsic circulation and a more or less rigid thorax. 

The elasticity of the lungs is one of the chief factors in normal expiration 
and lack of post-inspiratory pulmonary retraction means a diminution of the 
range of expansion and hence of the inspiratory filling. 

* In certain cases marked dulness may be present at an apex and in others the general 
percussion note is not clearly hyperresonant. 
23 



Fluoroscopic 
appearance. 



and Littcns sign shows an abnormally slight respiratory range of diaphrag- Litten'ssign 
matic excursion confirmed by the fl Horoscope and by careful comparative 
percussion, which procedures show also the abnormal lung rarefaction and 

persisting low position of the dia- 
phragm, characteristic of this ail- 
ment. 

In severe cases of long standing, 
as in all cases of chronic right heart 
over-strain and insufficiency, one is 
likely to encounter more or less club- 
bing of the finger tips and incurva- 
tion of the nails. 

Palpation. — Palpation confirms 



Drumstick 
fingers. 



Feeble vocal 
fremitus. 



Low lung 
borders. 



Enfeebled 
sounds. 



Cardiac strain. 



Diminished 
expansion. 



354 



MEDICAL DIAGNOSIS 



Lessened 
exchanges. 



Capillary 
obliteration. 



Dyspnea and 
cyanosis. 



Bronchitis. 
Right heart. 



Right heart 
decompensa- 
tion. 



Wide epigas- 
tric angle. 



77 is obvious, therefore, that the inelastic, voluminous lung and rigid non- 
expansile chest wall } so characteristic of emphysema, not only will embarrass the 
movements of respiration, but also diminish the air exchanges of the lung. 

Overdistention of this organ is persistent in established chronic emphy- 
sema and oxidation is further diminished by the wiping out of a variable 
but considerable proportion of the capillary network of the pulmonary 
alveoli in consequence of the overstretching and atrophy of their walls. 

This interference with the interchanges between air and blood in the lungs 
results in further diminished oxidation and a carbon dioxide retention which 
so overstimulates the respiratory center in the medulla as to impel deeper 
and perhaps more frequent respirations, a tendency increased by any co- 
existent bronchitis. 

It is thus quite evident that both cyanosis and dyspnea in varying degree 
must inevitably accompany any established hypertrophic emphysema. It 
is also evident that a constant obstruction to the "lesser circulation" exists 
which must of necessity invite bronchitis, greatly increase the work of the 
right ventricle and ultimately lead to hypertrophy and perhaps dilatation 
of that heart chamber. 

We would expect primarily, therefore, an accentuation of the pulmonary 
second sound because of the emphatic closure of the valve as a result of the 
increased primary thrust and the sharp recoil of the right ventricular blood 
column against the resistance in the pulmonary artery resulting from 
the obstructed flow in capillary areas of the emphysematous lungs. 
To this is added sometimes a considerable sclerosis of the pulmonary 
artery itself. 

If we do not hear such accentuation we, allowing, of course, for the obscura- 
tion of the sound by the overdistended lungs, assume (a) that the ventricle is 
greatly weakened or, (b) that the tricuspid valve has yielded to the strain 
and cast its own burden and that of the ventricle backward upon the great 
veins and systemic circulation. 

If, as is usually the case, corroborative evidences of such extreme cardiac 
decompensation are absent, we remember that the voluminous, air-stretched, 
rarefied lungs push forward and so bury the heart and valvular areas as to 
muffle and obscure all heart sounds or murmurs, wholly obliterate superficial 
cardiac dulness and even depress the diaphragm and the sheltered viscera 
to the extent of several inches. 

Any relative accentuation of the pulmonary second sound as compared 
with the aortic second is of decided importance, though as previously stated, 
arteriosclerosis may so intensify the latter as to cause misinterpretation 
unless this possibility is remembered. In such cases equality between the 
two sounds would mean decided accentuation of the pulmonary second. 
Epigastric pulsation is a common sign in this disease because of the right 
heart enlargement. 

The physical signs are equally obvious. The persistently overinflated 
bulky lung progressively demands more space and this can be met only by 
a widening of the circumference which results in a shortened vertical measure- 



DISEASES OF THE LUNGS AND PLEURA 



355 



ment, a consequent broadening of the intercostal spaces and an " opening up" 
of the epigastric angle. The chronically overinrlated lung must yield a 
hypcrrcsonant note because of its excessive air content. 

Expiration is prolonged as is indicated by the " lagging" descent of the 
thorax and the known elasticity of the pulmonary tissue. 

The breath sounds are feeble and muffled unless severe dyspnea or existing 
bronchitis intensifies or harshens them for the same reason and because of 
the reduced volume of air passing to and fro. 

Vocal fremitus is of course enfeebled by the poor conduction of bulky 
but rarefied lung and perhaps also damped to some degree by the excessive 
pressure sometimes exerted upon the chest wall. 

In no disease are the subjective symptoms and physical signs more abso- 
lutely the logical and inevitable result of the pathological conditions. 

Chronic hypertrophic emphysema is almost unbelievably slow in its advance 
and the cases of the extreme typical form are few in comparison to those showing 
an imperfect syndrome. 

ATROPHIC OR SENILE EMPHYSEMA.— The small contracted 
chest, wasted muscles, increased costal obliquity, depressed sternum and clav- 
icles, narrowed lower interspaces and bowed shoulders are striking features. 

The expansion of the rigid chest is trifling and inspiratory retraction, 
both supraclavicular and costal, may be evident. 

The lungs are small but present an extraordinary appearance post-mortem, 
being made up of large vesicles representing the result of degeneration and 
atrophy of the alveolar walls and their fusion into large air sacs. 

SPASMODIC ASTHMA 

Definition. — This is an ailment of ill-defined causation characterized by 
more or less severe transitory paroxysms of dyspnea, dominantly expiratory, 
and acute emphysema; tending to recurrence and chronicity, and associated 
with a tendency to establish chronic bronchitis and emphysema. 

Etiology. — Spasmodic asthma may be an isolated, apparently causeless 
clinical syndrome, but is often closely associated with, or one of the mani- 
festations of hay fever, a weakened right heart, polypi, adenoids, super- 
sensitive or hypertrophied turbinate bodies, intestinal auto-intoxication or 
irritation, malnutrition, hysteria, psychasthenia or epilepsy. 

The question of anaphylaxis has assumed great importance of late in 
this connection and sensitization to certain proteins has been demonstrated 
repeatedly and may be tested easily by the intradermic injection of minute 
quantities of protein. The author has observed several striking examples. 

The onset of an attack may be precipitated by any sensation of limitation 
of respiratory movement or even by the remembrance of previous seizures. 
Such sensations may not proceed directly from the respiratory tract. Flatu- 
lent distention, straining at stool, or even a tight belt or corset, may be 
sufficient. 

Eppinger and Hess have described as "vagotonia" a condition character- 
ized by heightened response of the vagus to pilocarpin injections. 



Hyper- 
resonance. 



Prolonged 
expiration. 

Muffled 
sounds. 



Enfeebled 
fremitus. 



Most cases 
mild. 



Associated or, 

related 

conditions. 



Anaphylaxis.] 



Vagotonia. 



356 



MEDICAL DIAGNOSIS 



Broncho- 
tetany. 

Sex and age. 



No one of them 
causative. 



All operative 
in some 
degree. ' 



In part mere 
consequences. 



Probable 
cause. 



Bizarre 
factors. 



Food 
sensitization. 



A similar condition in spasmophilic children is termed "broncho- 
tetany" by Lederer. 

There is no doubt that in asthmatic adults and children alike, phenomena 
of the sort described by Eppinger and Hess may occur, but it is by no 
means true of all, nor does it serve to clear up the fundamental factors in 
etiology. 

Males are chiefly affected, the ratio being as two to one, and 80 per 
cent, of all cases occur in persons under forty and one-third of these in 
children under the age of ten. 

Heredity. — In some instances it appears to be distinctly an hereditary 
alternative in the group of neuroses. 

Theories as to the Pathology of the Attack. — Five 0] those which have 
been advanced in the past may be mentioned: 

1. Bronchial spasm, i.e., spasmodic contraction of the muscles controlling 
bronchial caliber. 

2. Hyperemia and swelling of the mucosa. 

3. Spasm of the diaphragm. 

4. Spasmodic contraction of other inspiratory muscles. 

5. Exudative bronchiolitis. 

Combining certain of these we would have bronchial spasm (1), congestion 
and the attending exudation (2 and 5), as undoubtedly representing the most 
prominent events, while it is probable that all five are operative in varying 
degrees. 

At present no single etiologic factor can be held accountable for spasmodic 
asthma and it will be noticed that these so-called u causative factors" are after 
all, merely the phenomena attending an attack. 

It is more than probable that a more exact knowledge of allergic and ana- 
phylactic processes and cryptogenic infections will yield the solution. 

Exciting Factors. — Careful inquiry should be made concerning the exciting 
causes and the number and variety of the attacks. Such patients become 
close observers and often describe with exactness the clinical phenomena and 
apparent determining factors. Among these are odors of all sorts; those of 
drugs, perfumes, talcum powders, of certain flowers, of hay, of horses or 
dogs or cats, fish, game or coffee; irritants such as dust or fog and heat or 
cold, whether local or general. Old feather beds and pillows have in more 
than one instance proved causative factors and emotions such as pleasure, 
pain, joy and sorrow, sexual stimuli, grief and worry are alike potent in 
excitation. In certain instances heavy meals at night and certain articles of 
food or drink may cause a seizure and in some cases it is distinctly related 
to the menstrual epochs. Chronic poisoning, such as that from gout or 
lead, intestinal worms, and various occupations exposing their followers 
to dust, animal emanations, pollens and the like, or alternations of heat or 
cold may invite attacks. The sensation of hampered respiratory move- 
ment or mere remembrance of it as an exciting cause has already been 
mentioned. 

It must be remembered also that bacterial proteins absorbed from 



DISEASES of I'HK LUNGS AND PLEURA S57 



points of focal activity and certain sera, such as diphtheria antitoxin, may 
be potent factors in excitation. 

Inherited sensitiveness to certain food substances, pollens, and the like, 
is a factor of considerable importance. 

Food sensitization is especially common in cases which have originated 
during childhood. 

Method of Testing for Protein Sensitization (Walker). — "A number of 
small cuts, each about }£ of an inch long, are made on the flexor surfaces 
of the forearm by means of a sharp scalpel, not deep enough to draw blood, 
although they do penetrate the skin. On each cut is placed a protein and 
to it is added a drop of }{$ normal hydroxide solution to dissolve the pro- 
tein and to permit of its rapid absorption. At the end of a half hour, the 
proteins are washed off and the reactions are noted,, always comparing the 
inoculated cuts with normal controls, on which no protein was placed. A 
positive reaction consists of a raised white elevation or urticarial wheal 
surrounding the cut. The smallest reaction to be called positive must 
measure 0.5 cm. in diameter and any smaller reactions are called doubtful. 
Negative skin tests with protein rule out those proteins as a cause of asthma 
and all proteins which give a positive skin test should be suspected as a 
cause of asthma. In the case of bacteria, however, the skin test has to do 
only with the protein element, so that even though bacteria give a negative 
test, they may still be a cause of asthma through their infectious nature, and 
the patient need not be sensitized to bacterial protein. 

"Proteins Recommended for Routine Tests.- — For practical purposes, 
however, such an outlay of proteins is not necessary, since the majority of 
patients are not exposed to such an extensive list of proteins and conse- 
quently they are not sensitive to such an unlimited number. The following 
kinds of proteins should be used as a routine: horsehair or dandruff; cat hair; 
feathers; the pollens of timothy, redtop and ragweed; staphylococcus pyo- 
genes aureus and albus; streptococcus hemolysans and viridans; pneumo- 
coccus types I and IV and diphtheroid bacillus; the common foods such as 
egg, milk, cereals, meats, chicken, potato, and any other that the patient is 
accustomed to eat frequently. Occasionally the patient's history, occupa- 
tion, or surroundings may lead one to suspect some other common or even 
unusual type of protein. 

"An understanding of the seasons during which the different types of 
plants pollinate and the usual variety of plant pollen which causes asthma 
is most helpful. There are three definite pollen seasons in New England. 
The first occurs in April and May when the various trees pollinate; among 
the first to pollinate during this season are the willow, birch and maple, and 
the last one to pollinate is the pine, which occurs the last day or two in May. 
Although the pollen of any of these trees may cause asthma, we have had 
only one case caused by willow, one by birch, and one by pine pollen. Since 
the length of time which each tree requires to complete pollination is no 
longer than two weeks, and in the case of the pine tree only one day, it is quite 
unnecessary to treat these patients for such a short exposure to the pollen. 



358 



MEDICAL DIAGNOSIS 



"The second pollen season, and a more important one, occurs during 
June and July. The principal plants which pollinate at this time are the 
rose, June grass, orchard grass, redtop, and timothy; the latter two are also 
grasses and are familiarly known as hay. We have not had a case of asthma 
caused by the rose, although there are such on record; neither have we found 
orchard grass to be a cause; these two plants surely are not frequently a 
cause of asthma. June grass is so similar botanically to redtop that it may 
be disregarded in tests. The important plants in this group are redtop, and 
the timothy grasses, and of these two timothy is the chief cause of bronchial 
asthma at this season. Practically every patient who was sensitive to 
timothy was also somewhat sensitive to redtop, but usually less so, and red- 
top never gave a stronger reaction than timothy. 

"The third pollen season, and by far the most important, occurs during 
August and September, and the important pollens at this time are those 
of ragweed, goldenrod and daisy. The daisy really begins to pollinate in 
July and finishes in early September; goldenrod pollinates during August and 
September and ragweed usually begins to pollinate about the middle of 
August and ceases with the first heavy frost, which, in New England for 
example, usually occurs early in October. Ragweed is practically always 
the cause of pollen asthma at this season, and in only one case have we found 
the daisy the cause, and in one other was goldenrod the cause. These three 
plants belong to the same botanical family, although they are not intimately 
related to each other, and consequently every patient that reacts positively 
to one need not react to all. 

" Stated briefly, 18 per cent, of the pollen asthmas were due to timothy 
and redtop, 72 per cent, were due to ragweed, 9 per cent, were due to both 
and had continuous asthma from June to October, and the remaining 1 per 
cent, was due to miscellaneous pollens. Frequently, hay fever patients have 
a very slight attack of asthma at some time during their hay fever, often hay 
fever symptoms end with a day or two of asthma, and still others are more 
or less choked up at times during their hay fever. Asthma, caused by pollens, 
may continue after the termination of the pollen season. The continuation 
of asthma in these cases is due to secondary bacterial infection, causing 
bronchitis in a patient whose resistance, either local or general, has been 
lowered because of prolonged severe pollen asthma." 

Spurious Spasmodic Asthma. — A Word of Warning. — The utmost care 
should be observed to avoid the common and disastrous error of confounding 
"renal," "aneurysmal" and "cardiac" asthmas with those of the ordinary 
spasmodic type. 

Renal Asthma. — The paroxysms of "renal asthma" are absolutely like those 
of true asthma and the cause can be determined only by a careful examina- 
tion and quantitative analysis of the twenty-four hours' urine, and an appli- 
cation of the sphygmomanometer and the tests of renal permeability, for the 
attacks are usually coincident with low urea excretion and high arterial 
tension. 

Aneurysmal Asthma. — In the absence of roentgen-r ay findings, the pseudo- 



DISEASES OF THE LUNGS AND PLEURA 



359 



asthmatic paroxysms produced by aneurysm of the aortic arch may at times 
deceive the elect, but are fortunately rare save in connection with frank physical 
signs. 

Cardiac Asthma. — The ordinary cardiac dyspnea is either persistent or 
distinctly dependent upon exertion and is inspiratory in type or a mere air 
hunger. 

Nevertheless, typical asthmatic attacks occur in association with, and appar- 
ently as one of the results of, a weakened heart and especially in myocardial 
cases with unstable, delicately balanced compensation. They are associated 
often but not always with decided coronary sclerosis and may substitute or alter- 
nate with attacks of major angina pectoris in rare instances. 

In established asthma the heart strength is an extremely important factor 
both in treatment and prognosis. 

Time of Attack in Spasmodic Asthma. — Like croup, angina pectoris major 
and nocturnal epilepsy, attacks of true asthma occur usually at or after 
midnight and commonly, in the early morning hours. The same is true of 
the spasmodic cardiac asthma which seems so closely allied to angina 
pectoris of the severer type. 

Aurae. — like epilepsy, attacks of asthma may be preceded by premonitory 
symptoms recognized by the patient. Among these are mental depression 
or exaltation, flatulence, yawning, sneezing, itching, headache and polyuria. 
Ordinarily, however, the attacks occur without any such warning. 

SYMPTOMS. — The onset may be gradual, but is usually abrupt. There 
is a sense of constriction of the throat or chest and pronounced dyspnea with 
labored, stridulous and prolonged respiration affecting chiefly the expiratory 
phase though marked in both. The agonized patient brings every muscle to 
bear but in spite of frenzied effort the rate of respiration is usually below 
normal. 

A short, dry, feeble cough increases the patienfs discomfort, and an acute 
bilateral emphysema enlarges the girth of the lower chest so that the female 
patient, if attacked when dressed, is obliged to loosen the clothing. 

The eyes are blood-shot and staring, the voice gasping and weak, the face 
pallid, cyanotic, drawn and agonized. 

The mind is absolutely clear, the patient usually apprehensive and fearful. 
If in bed, orthopnea is extreme, the knees are drawn up, the shoulders ad- 
vanced, the back rounded, and the head is on the hands, or, sometimes, one 
will be found leaning over a rigidly held chair or bed-post, or, thrown back, 
with raised arms grasping some support above that will give added purchase 
to the accessory muscles of inspiration. In many cases patients rush to 
an open window, regardless of extremes of temperature. 

Cough. — This is ordinarily feeble and unproductive until the end of an 
attack, when there may be a thick, viscid sputum or, more rarely, free expec- 
toration. In cases of pure asthma uncomplicated by bronchitis one may find 
the pearly globules of the size of a hemp seed which contain Curschman's 
spirals and Charcot-Leyden crystals. 

Pulse. — The pulse may be markedly weak and accelerated. During any 



May fool 
the elect. 



Frequent asso- 
ciation with 
coronary 
sclerosis. 



Watch the 
heart. 



Usually 
absent. 



A pitiable 
picture. 



Acute 
emphysema. 



Facies. 



Mental state. 



Attitudes 
assumed. 



Spirals and 
crystals. 



Heart. 



360 



MEDICAL DIAGNOSIS 



Recurrence. 



Apparent 
sensitization. 



Nervous 
instability. 



Swollen 
mucosa. 



Bronchial 
spasm. 



Abrupt onset. 
Dyspnea. 



Inspiratory, 
dyspnea. 



Predominance 
of expiratory 
dyspnea. 



Cumulative 
factors. 



A pitiable 
condition. 



severe attack the right chambers of the heart are dilated, yet death during 
a paroxysm is most unusual in true spasmodic asthma. 

Duration of the Paroxysm. — Attacks usually end gradually, less often 
abruptly, after two or three hours, but may be shorter or much longer; usually 
recur with increasing severity on successive days, and are followed by a vari- 
able period of immunity. 

EXAMINATION OF THE CHEST.— Inspection shows prolonged expira- 
tion, an increased basal girth, urgent dyspnea, a defective excursion, an in- 
active low diaphragm, and rigid, abdominal muscles with which the patient 
is seeking to reinforce the thoracic and cervical groups of muscles. 

Palpation. — The rales are easily felt and vocal resonance and fremitus 
alike are enfeebled. 

Percussion and Auscultation. — The signs are those described under 
"Emphysema" with bronchitis and stridor superadded. 

RATIONALE OF SPASMODIC ASTHMA 

Dominant Factors. — One may reasonably assume: 

i. An extreme susceptibility on the part of the patient to certain substances 
often specific for the individual. 

2. A lability of the nervous system especially marked in the psychic sphere, 
and in many instances akin perhaps to that encountered in the spasmophilic 
diathesis of children . 

3. Transient hyperemia and swelling of the mucosa, with a variable amount 
of exudation, perhaps involving even the bronchioles. ' . 

4. A decided spasmodic tonic contraction of the muscles controlling bronchial 
caliber and also of the thoracic, and, to a less degree, the accessory thoracic, respira- 
tory muscles. 

5. That all these factors usually become operative very suddenly. 
Symptomatic Results. — Extreme dyspnea is inevitable and the breathing 

is both slow and noisy because of the mechanical difficulties at once estab- 
lished. The spasmodically stenosed bronchi obstruct inspiration, trap the 
air and yet more strikingly block expiration. The lungs progressively and 
quickly expand up to and beyond the normal forced inspiration boundaries 
thus still further diminishing the respiratory radius and air movement, 
and producing acute emphysema with excessive dyspnea predominatingly 
of the expiratory type. 

The extreme overdistention of the lung, impotent diaphragm, loss of use 
of the spasmodically contracted respiratory musculature of the thoracic wall, 
the imperfect aeration of the blood, consequent unsatisfied oxygen demand, 
CO2 overload and overstimulation of the respiratory center in the medulla, 
all combine to produce a condition of acute and pitiable suffering, and often- 
times a sensation of impending death.* 

Physical Signs. — A combination of emphysema and acute bronchitis. 
It is evident that the physical signs must be those of acute emphysema com- 

* When this last symptom is excessively marked one must always consider the possi- 
bility of cardiac or cardio-reual asthma or a dangerously dilated right heart. 



DISEASES OF THE LUNGS AND PLEURA 



36: 



bined with acute bronchitis in the dry stage, viz., a hyperresonant note, 
extreme prolongation of expiration, diminished fremitus, low-lying, widely 
expanded and almost immobile lung borders, loud sibilant rales, a widened 
thoracic circumference, highly deficient expansion and a broadened epigastric 
angle. 

Cyanosis must inevitably be marked and the right heart is under great 
strain. With the subsidence of the attack moist rales may appear and a 
thick viscid sputum or more rarely, free expectoration, be present. 

Effective coughing or loud talking is manifestly impossible at the height 
of the attack. - 

Prognosis. — The attacks are recurrent, the condition itself chronic and long 
endured, but on the average there is, nevertheless, marked shortening of life ex- 
pectancy as is proven by life insurance statistics. 

Asthma occurring in childhood usually depends upon a removable cause 
and is often curable. Those cases occurring between the ages of ten and 
twenty are sometimes cured, those of the intermediate period are rarely 
cured, and those in patients above sixty years of age, it has been said, are 
never cured. The author's experience would indicate that at no age is the 
last statement absolutely true if all contributive factors are sought and the 
full resources of medicine and surgery drawn upon. 

Rest and stimulation for the tired heart, proper attention to the accessory 
sinuses and naso-pharynx, removal of obscure septic foci, and improved 
nutrition for the individual, may accomplish much even in some apparently 
hopeless cases, but the complete cure of secondary conditions of long standing 
is never possible in the adult. 

PLEURISY {Pleuritis) 

Definition. — An inflammation of the pleura, acute or chronic, associated 
with an exudate which may be fibrinous, serous, bloody or purulent. 

Applied Anatomy. — Each pleura completely invests the lung, dips be- 
tween the lobes and is reflected upon the chest wall so as to form a closed 
potential cavity. Normally the parietal and visceral pleural layers are in 
close apposition and move freely over one another, lubricated by the normal 
lymph. 

The pleural cavity is actually a great lymph space structurally continuous 
with the diaphragm, pericardium, cervical fascia, chest wall and lung.* 

When inflamed, the pleura becomes dry, exfoliated and harsh and the attrition 
of apposed surfaces gives rise to pain, cough, and the characteristic physical sign 
of dry pleurisy, viz., an audible, often palpable, friction sound. 

The course of the inflammation is variable and may terminate as follows, 
viz.: 

(a) A slight attack of pleurisy with a small fibrinous exudate may terminate 
promptly, without permanent damage to the pleura. 

(b) The fibrinous exudate may become organized and form pleural adhesions 
of variable extent and density. 

* The pleural folds or sinuses and Traube's space are discussed elsewhere. 



Chronic but 
shortens life. 



Age important. 



Important 
relations. 



Genesis of 
friction sound 



Terminations 



Varieties. 



362 



MEDICAL DIAGNOSIS 



Exudates. 



Secondary or 
primary. 



Effect upon 
lung and heart. 



Empyema. 



Serous 
exudates. 



A complication 
of many 
diseases. 



(c) A serous exudate may result, relieve the pain by separating the pleural 
layers and in its turn be reabsorbed or remain and become converted into pus 
{empyema). 

The character of the exudate varies greatly with the cause of the pleurisy 
and the nature of the associated microorganisms. 

Hemothorax. — Bloody fluid in most instances indicates malignant growths 
of the lung and pleura, though the same appearance is presented in certain 
frankly tuberculous cases and in some rare instances of purpura, hemophilia 
and scurvy. 

Other causes of hemothorax are rupture of an aortic aneurysm, pul- 
monary abscess, and, of course, direct injury or penetrating wounds. 

Purulent exudate is usually the result of neglected effusion, but is often 
primary, particularly in cases associated with the lobar pneumonia of children 
and in streptococcus and staphylococcus infections.* 

Pressure. — Bearing in mind the important structures contained in the 
mediastinum, one readily understands the importance of the pressure symp- 
toms of large unilateral pleural effusions. The lung of the affected side is 
compressed from below upward and toward its root pari passu with the 
increase of exudate and in long-continued cases may remain permanently 
crippled and bound down by adhesions after resorption of the effusion. The 
heart is pushed toward the unaffected side unless the mediastinum is firmly 
anchored by adhesions. 

ETIOLOGY. — The pneumococcus, staphylococcus, or streptococcus, 
may be found alone or in combination in cases of purulent pleurisy, and 
apparently sterile purulent exudates (10 to 15 per cent, of the total) are for 
the most part tuberculous in origin. To these may be added, as rarer 
causative agents or associated organisms, the influenza, typhoid, and colon 
bacillus. 

Bacteria other than the tubercle bacillus are found in from 15 to 20 per 
cent, of the serous exudates, pneumococci and staphylococci predominating. 

Disease Associations. — Pleurisy may appear as a complication of various 
diseases. First in importance are tuberculosis, lobar pneumonia and peri- 
carditis, but peritonitis, influenza, acute rheumatism and chronic nephritis 
are frequent. It may occur in the exanthemata, in typhoid fever and the 
acute infectious diseases generally, as well as in scorbutus, gout, chronic dis- 
eases of the liver and gallbladder, and in cancer. Traumatism of the chest 
with or without perforation may cause it. 

Complicating Pneumonia. — Pleurisy is almost invariably present in lobar 
pneumonia, but in adults is seldom then associated with large or even demon- 

Notei — Transudate vs. Exudate. — Fluid in the pleural cavity may be non-inflamma- 
tory in origin. 

Rivalla's Test. — Add 2 drops of glacial acetic acid to 200 c.c. of distilled water. A drop 
of the suspected punctate is then dropped upon the surface of the acetic acid solution. 

If it is exudate a gray nimbus indicates the course of the drop as it falls to the bottom. 
If it be a transudate, only a laggard haziness appears. The nature of the protein 
precipitate is unknown. 

* Pneumococcus empyema is said to offer the best prognosis. 



DISEASES OF THE LUNGS AND PLEURA 



363 



strable, serous effusions. The greater number of so-called simple pleurisies 
doubtless represent a localized, but as regards the pleura, usually self-limited, 
tuberculous infection, and the statistics of foreign observers show a percentage 
of tuberculosis pleurisies ranging from 25 to 90 per cent.* in the different 
reports. Few autopsies are made which do not reveal evidence of past 
pleurisies whatever the actual cause of death. 

SYMPTOMS OF ACUTE FIBRINOUS PLEURISY.— (1) Fever, usually 
moderate in degree and lasting but a few days. 

(2) Pain, most commonly felt in the axillary or inframammary region, 
yet sometimes referred to the terminations of the intercostals over the ab- 
domen or even to the sound side. It may be fixed, stabbing or shooting in 
character, and is increased by deep breathing and cough. 

The fact that abdominal pain may be pleuritic in origin should never be for- 
gotten for many important surgical conditions may be accurately simulated 
even to an apparent defensive rigidity and localized superficial tenderness. 

3. Cough; this is harsh, unproductive, painful and suppressed. 

4. Friction: Auscultation yields a shuffling, creaking, squeaking, or even 
a crackling sound, simulating at times true crepitation or even rhonchi, but 
persisting after cough, superficial in character and usually occurring early in 
the inspiratory phase of a respiration. Friction is often palpable as well as 
audible. 

Physical Signs. — Inspection reveals shallow catchy breathing, and compara- 
tive immobility of the affected side due solely to pain which causes both voluntary 
and reflex inhibition of chest movement, and suppressed cough. 

The patient's decubitus is variable, oftentimes he lies upon the affected 
side as if to limit its movement during the stage of congestion and primary 
inflammation or give greater latitude to the expansion of the sound side if 
effusion follows. 

PLEURISY WITH EFFUSION 

The first effect of effusion is to separate progressively the inflamed surfaces, 
relieve pain and diminish the area of friction sounds. 

Sudden large effusions are unusual but may constitute a source of con- 
siderable danger owing to the resultant abrupt heart dislocation and lung 
compression. 

Borders and Mobility. — The fluid gravitates primarily to the most 
dependent portions in about one-fourth of all cases and in most instances 
fills ultimately the inferior thoracic cavity. If not encapsulated or limited 
by adhesions it may slightly or, more rarely, markedly, change its level in 
accord with the position of the patient and the amount of effusion. The 
small effusions are sometimes freely movable but large ones of inflammatory 
origin seldom show any gross change in the line of percussion dulness on 
change of posture. 

* These are based upon the injection of large amounts of exudate into susceptible 
animals. Of public service cases nearly one-half develop a definite pulmonary tuberculosis 
within five years. In private, well-to-do patients the percentage is much smaller. 



High percent- 
age of tubercu- 
lous pleurisies. 



Ferer, pain, 
cough and 
friction. 



Referred pain. 



Character- 
istics. 



"Catchy" 
breathing. 



Decubitus. 



Precipitate 
effusions. 



Variability of 

shifting 

dulness. 



Small vs. 

large 

effusions. 



SH 



MEDICAL DIAGNOSIS 



The Ellis 
curve. 



Owing to the conformation of the chest and the peculiarities of internal 
pressure, the upper line of pleural effusion often describes a parabolic curve 
when the patient is sitting or erect. This reaches its maximum height in 
the mid-axillary or posterior axillary line. If the fluid reaches the middle 
of the second rib, the curve disappears. The lateral posture usually assumed 
by the patient when attacked and while the effusion is forming doubtless is 




Fig. 136. — Encapsulated serous pleural effusion. Right pleura. 

a factor in determining the line of the upper level of flatness. When he is 
in dorsal recumbency the level is highest near the spine. 

In moderate effusions this line may resemble somewhat an attenuated 
letter "S" lying on its side ("Ellis' line") and, near the spine, in the trian- 
gular niche formed by the upward and outward ascent of the fluid level and 
the vertical line of the spinal column sufficient, resonance may be elicited 
by percussion after cough and deep inspiration, to contrast with the flatness 



DISEASES OF THE LUNGS AND IM.I.l R.\ 



365 



below the level of the line of dulness. Both the curved upper border and the 
angle of resonance ("Garland's angle"), when present, aid in differentiating 
pleural effusion from massive pneumonia. 

PHYSICAL SIGNS. — Inspection. — There is relative immobility and loss 
of expansion of the afected side, shallow or flush interspaces * increased dyspnea, 




Carland's 
an 'le. 



Fig. 137. — Encapsulated serous pleural effusion. Right pleura after removal of 
800 c.c of serum (see Fig. 135). 

with cyanosis or even in extreme cases lividity, and a displacement of the heart Displaced 
to the opposite side which may carry the visible cardiac impulse to the axilla 
on the left side or, on the right, nearly to the mid-clavicular line, the beat 
being due in the latter instance to the right ventricle. Occasionally in 
moderate left-sided effusion no cardiac impulse is visible. 

* The "bulging interspaces" are a clinical curiosity in simple acute exudative pleurisy. 



3 66 



MEDICAL DIAGNOSIS 



Lessened 
fremitus. 



Palpation. — Palpation confirms inspection and reveals absent or diminished 
vocal fremitus unless a fibrous adhesion band crossing through the fluid conducts 
sound from the compressed lung and bronchi, or a dislocated bronchus lies in 
contact with the sternum and conveys the vibration. 



Resistance and 
flatness. 



S'.codaic note. 




Fig. 138. — Pleurisy with effusion (same figure as shown under Roentgenography). 
Note displacement of heart to left. Right lung is undergoing gradual compression, pari 
passu with accummulation of the exudate. {Dr. Frank S. Bissell.) 

Percussion. — Palpatory percussion best reveals the absolute resistance over 
the exudate and simple percussion elicits a flat note, decidedly differing from 
that of consolidation and simulated only by pleural growths and dense pleural 
adhesions. Just above the level of the fluid anteriorly, the note is often hyper- 
resonant or tympanitic in quality (skodaic resonance). 



DISEASES OF THE LUNGS AND PLEURA 



367 




Lung 
compression. 



Traube's 
space. 



Characteristic 
change of note. 



Boundaries. 



Little difficulty is ordinarily encountered in delimiting the upper border 
of the effusion or in following any slow alterations of its level with changes 
of posture when these are present.* • 

Posteriorly, dulness due to a compressed lung may be encountered and, well 
above the fluid level in small or moderate established effusions, the unaffected 
tissue may yield the hyper resonance of vicarious emphysema. Movable dulness 
in Traube's semilunar space often reveals very small free exudates in the left 
pleural space if light percussion is used. 

The note is not typically flat in such cases, but passes sharply from slight 
dulness on light percussion to pure stomach tympany as the patient changes 
from the erect to the recumbent posture. 

Grocco's triangle is an area of dulness lying outside the spinous processes 
of the unaffected side. Its vertical median boundary represents the vertebral 

spines and slightly exceeds the 
height of the effusion; its horizontal 
inferior border may extend from 2 to 
7 cm. outward from the spine and 
thus the hypothenuse is formed by 
a line extending from the median 
line at the upper level of flatness to 
the outer extremity of the line lying 
at the lowest level of the same area. 
Its presence is readily explained 
by the pressure of the dislocated 
mediastinal contents upon the sound 
lung and the effect of the liquid 
exudate in damping vibrations of the 
adjoining vertebral column. The Rationale 
patient should be sitting or standing, 
moderate or strong percussion being 
required and the area best deter- 
mined by percussing rapidly from 
the sound lung toward the spine in 
oblique lines until decided dulness is 
encountered. 

In such cases Grocco's triangle 
usually shows a marked shrinkage when the patient lies upon the affected 
side and an increase if he lies on the unaffected side (Ewart's "crucial 
test"). An area similar to Grocco's triangle may be observed in massive 
ascites, though it presents a broader base and less height. 

Auscultation. — Over the compressed lung posteriorly and near the 
spine the breathing is tubular, but below the level of the fluid the voice 
and breath sounds are markedly and abruptly obscured, though seldom 
entirely lost. 

* Marked shifting of the level of dulness is far more constant in transudates than in 
inflammatory exudates. 



Fig. 139. — The Grocco-Koranyi Para- 
vertebral triangle. Pleural effusion on right 
side. Stippled area represents dulness — 
arrows indicate the lines of percussion. 
(After Da Costa.) 



Area in 
ascites. 



Compressed 
lung. 



3 68 



MEDICAL DIAGNOSIS 



Over the elastic chests of children, and even adults, conducted breath 
sounds may prove misleading though these are usually of a suggestively dis- 
tant quality * 

The greatly diminished fremitus as determined by palpation is a valuable 
and striking symptom in most of such instances. 

Pleuritic friction is sometimes heard above the level of the fluid, particu- 
larly if this is receding, and may persist for long periods either as friction or 
crepitation. 

Mensuration. — In large effusions the measurement of the affected side is 
increased. 

Fluoroscopy. — The diaphragm of the affected side is lowered and shows a 
greatly lessened respiratory excursion and the fluid is clearly indicated by 
the corresponding shadow. 

Rhythmic Lateral Displacement of the Heart. — In 1902, the author re- 
ported! observations based upon a number of cases of unilateral pleuritic 
effusion. He found that in the presence of a considerable unilateral effusion, 
the heart, in addition to its primary displacement, showed a distinct lateral 
movement of respiratory rhythm varying w'ith the depth of respiration and 
the amount of effusion. In some cases, the superficial heart impulse could be 
seen with the naked eye to move outward and inward; in nearly all, auscul- 
tatory percussion during full inspiration and full expiration verified the ob- 
servation, and in every case the fluoroscopic findings were positive. 

The phenomenon seems to depend chiefly upon the piston-like action of 
the diaphragm initiated by the thrust of the abdominal muscles. In full inspi- 
ration, pressure is relieved by the descent of the diaphragm and the expansion 
of the chest, and the readily movable heart tends to approach the median 
fine. In forced expiration, the rising fluid columnf and the narrowing 
chest force the organ away from the median line, sometimes to the extent 
of 3 inches. 

The only importance of the observation lies in the fact that it does not seem 
to occur under conditions such as subdiaphragmatic abscess or in other conditions 
likely to be confounded with pleurisy, either serous or purulent. 

The maximum range of movement occurs in medium-sized effusions. In 
very small effusions there is practically no movement. In massive effusion both 
the chest and diaphragm are almost passive. In no such case so far observed 
has the author found an entire absence of upward thrust and lateral cardiac 
displacement. Hence, he has not been able to confirm the statement made 
by certain writers to the effect that in massive pleurisies the diaphragm is 
completely immobile and may even bulge into the abdominal cavity. In 
every case so far observed the diaphragm on the affected side has shown move- 
ment of some degree and must if the abdominal muscles act strongly. Forced 

* Recently the author removed over 1,500 c.c. of serous fluid from an elderly patient in 
whom pure tubular breathing was marked throughout the area of flatness. 

f New York Medical Journal, 1902. Transactions of the Association of American 
Physicians, 1905. 

I In every case so far examined the upper border of the effusion was seen to rise in 
expiration. 



DISEASES OF THE LUNGS AND PLEURA 



369 



Pleurae nor- 
mally silent. 



respiration is necessary and might demand the exhibition of morphia if pain 
were severe despite the effusion. In no instance so far observed has this been 
necessary. 

RATIONALE OF PLEURISY 

The Normal. — In health the smooth, glistening, lubricated, closely approxi- 
mated serous surfaces of the pulmonary and costal pleura constituting 
the internal and external walls of the great potential lymph space move 
smoothly upon each other without exciting sound or sensation. 

Checking of Secretion. — Given an active congestion or inflammation 
of these surfaces, whatever the exciting cause, they primarily suffer endo- Congestion 
thelial exfoliation and become dry and harsh: hence pain, limitation of move- ; friction, 
ment and friction sounds, audible and sometimes palpable, appear, to which ! 
frank manifestations of toxemia in the form of fever and malaise may or may 
not be added. 

Reactionary Changes. — As in the case of all serous or mucous surfaces 



primary checking of secretion is followed by reactive oversecretion 



to a 



degree dependent upon the intensity and nature of the inflammatory exci- 
tation and the constitutional peculiarities of the individual attacked. 




Fig. 140. — Pneumothorax (left), encapsulated pleurisy (right). Lung compression may 
reach a much higher degree in pneumothorax. Inevitable displacement of heart to right, 
not shown in diagram. (Repetition of plate.) 

Friction Variants. — Manifestly, the friction sounds must be super- 
ficially produced and convey to the trained ear the sensation of proximity. 
Unlike liquid rales due to exudate which are more or less modified by cough 
or deep breathing, the friction sounds tend to be fixed in location and per- 
sistent during any given seance. On the other hand, they may be modified 
even by a reactive fibrinous exudate and the movement of the glutinous 
surfaces may produce softer friction sounds or even a resemblance to liquid 
or crepitant rales, which, however, as to persistence and proximity, follow 
the general rules outlined above. 
24 



Toxemia. 



Tendency to 

reactive 

oversecretion. 



Qualities of 

friction 

sounds. 



Misleading 
modifications 



37° 



MEDICAL DIAGNOSIS 



Lung tissue 
silent. 



Complete. 



Incomplete. 



Separation of 

pleural 

surfaces. 



Loss of friction. 



Filling inferior 

pleural 

sinuses. 



Displacement 
of adjoining 
viscera. 



Compression 
of lung. 



Deceptive 
hilus region. 



Lung Substance Uninvolved. — Aside from the softer breath sounds 
due to pain limitation of movement there are, of course, at this juncture, no 
pulmonary signs except such as may represent the antecedent lung lesions 
in the case of secondary pleurisies. 

Recovery. — If the inflammatory process now subsides the signs disappear 
and the lung function may be restored despite any small permanent areas 
of adhesion between the parietal and pulmonary pleural surfaces, costal or 
diaphragmatic. On the other hand, most extensive adhesions may remain 
and seriously impair lung function, chest movement and thoracic symmetry. 

Serous Effusion.- — If serous effusion appears the pleural surfaces are 
separated primarily to a degree and over an area dependent upon the amount 
and location of the exudate and the location and firmness of previously 
formed adhesions. 

As a result friction sounds are lost over the area underlain by the effusion. 

The liquid naturally gravitates to the lowest free spaces, rilling the pleural 
sinuses if these be not already firmly adherent, slowly but steadily encroach- 
ing upon the cardiac area and pushing aside the mediastinal space and its 
contents. 

Thus it dislocates the readily movable heart, depresses the liver, spleen, 
and stomach and obstructs the movements of the diaphragm. 




Fig. 141. — Pleurisy with effusion (bilateral). Note pulmonary compression on left. 
Such exudates as shown upon the right may exist in pneumonia and obscure symptoms. 
They accompany also malignant growths involving primarily or secondarily the pleura 
or may occur in any type of pleuritic inflammation. 

Lung compression is shown on left side. On the right the upward compression chiefly 
would be operative at this stage. Displacement of heart not shown in diagram. (Repeti- 
tion of plate.) 

As an exudate increases its field of action through gradual accumula- 
tion, the lung, so to speak, floats upon it, and its involved portion is 
gradually and gently compressed toward its hilus and rendered increas- 
ingly airless and bloodless. This process does not demand that the exudate 
shall be under great pressure nor is such the case in most instances. 

In extreme cases the compression is carried to such an extent as to produce 
consolidation signs anteriorly, and, even more intensely, posteriorly, over 
and near the hilus region, provided that the large bronchi remain patent. 



DISEASES OF THE LUNGS AND PLEURA 



371 



These signs contrast sharply with the muffled or absent breath sounds 
below the level of the exudate itself. 

The effect upon air exchanges and the pulmonary circulation is manifestly 
great and explains the cyanosis and dyspnea, no less than the real danger 
involved in the rarer cases of abrupt onset of profuse, massive exudates. 

In that portion of the lung just above the fluid level the normal tonus 
is markedly relaxed, from which may result the almost constant hyperresonant skodaic 

, , , , ill • ii« • it resonance and 

percussion note and the less dependable, curious bleating voice sound, known egopnony. 
as egophony. 

Even below the level of effusion the voice sounds and whispered voice Paradoxical 
sometimes may be clearly heard or even carry the timbre, pitch and intensity 
of consolidation. 

Such may be the case if an area of compressed lung connected with a 
large bronchus be dislocated against the chest wall, or, if tense conducting vagaries of 
bands or cords traverse the fluid and are attached at such points as to per- 
mit them to carry vibrations from the bronchi. 

The chest, itself, may be so resilient as to convey vibrations from the hilus. 
Vocal fremitus is, however, rarely increased, save in the elastic chests of chil^ 1 
dren, and still less often is it undiminished even though still palpable. 

Decisive Character of Percussion Note. — In these exceptional cases the 
differential value of the characteristically flat percussion note elicited by light 
percussion* and the sense of absolute resistance, is extremely great. 

As stated previously, decided dulness on light percussion may be present 
over Traube's space even in very small free exudates if the patient lean 
forward while erect or in the sitting posture, and such dulness may disappear 
and be replaced by normal gastric tympany in recumbency. In like manner 
the area of hepatic relative dulness may be replaced by a flat note with 
change of posture, very early in the onset of right-sided effusions. 

In each case it is the low-lying and roomy complemental pleural space, 
lying below the lung level and extending almost to the costal border, which 
receives the flooding exudate. 

It is evident that, save for their diagnostic significance as to etiologic 
factors, the hemorrhagic and purulent exudates, as affecting physical signs, 
differ in no essential respect from those of serous effusions. 

Auscultation signs over the back, in the region of the hilus or in 
front over and about the compressed lung are manifestly unreliable in large 
effusions. 

It should never be forgotten that encapsulation of effusion may occur 
through limiting adhesion bands and that this is especially common in Encysted 

, .... . effusions. 

empyema, when one or more separate or communicating cavities may exist, 
each containing pus. 

Marked Postural Changes Unusual. — The author ventures to repeat 
that even serous effusions, if inflammatory, unless associated with pneu- 
mothorax, are not necessarily freely movable with changes of posture; 

* In the child, especially, heavy percussion may produce a fictitious resonance which 
obscures the true character of the note. 



37 2 



MEDICAL DIAGNOSIS 



probably because of the constant resisting pressure offered by the lung and 
mediastinum and also the tendency to marginal agglutination or adhesions 
too strong to be overcome by mere gravity, though unable to resist tidal 
fluid accumulation. 




Fig. 142. — Adhesion following double lobar pneumonia. Point of adhesion indi- 



cated by arrow. Displaceme nt cf heart 

comparison. j 



to left clearh- shown. (See Fig. 142 for 



Many effusions are overlooked because this postural displacement of 
the upper line of flatness is deemed an essential factor in the diagnosis. 

Course and Termination of Pleurisy. — Simple plastic pleurisy runs its 
course in a few days, leaving behind, ordinarily, a few adhesions often dis- 
coverable only post-mortem. In cases with serous effusion aspiration 



DISEASES OF THE LUNGS AND PLEURA 



373 



is usually required, but spontaneous reabsorption is not uncommon espe- 
cially in cases with a rheumatic etiology. 

Long persisting, slow receding exudates leave behind extensive adhesions 
and, all too often, a lung incapable of more than partial expansion. Em- 
pyema almost invariably demands surgical interference and leaves behind a 




A\=?xw 



n m .ym 



i*\v\Y 



Fig. 143. — (E 87')- Note disappearance of adhesion . shown in Fig. 141. and 
return of heart to approximately normal position. These exposures were made three 
weeks apart. 

variable area of thickened adherent pleura, and an imperfectly expanded, 
more or less crippled lung. 

DIAPHRAGMATIC PLEURISY.— Such a primary pleurisy may be 
acute or chronic, dry or wet, serous or purulent, and may not extend beyond 
the diaphragmatic surface, though usually other portions are involved. 



374 



MEDICAL DIAGNOSIS 



Marginal 
thoracic pain. 



Tenderness. 



Wet pleurisy 
phis sepsis. 



"Empyema 
necessitas." 



Blood findings. 



Aet 

promptly. 



Signs and Symptoms of Diaphragmatic Pleurisy. — The physical signs 
may be absent or be those of simple acute pleurisy, with fever, rigid abdominal 
muscles, costal breathing, an extraordinary degree of marginal thoracic pain 
on breathing, swallowing, talking or laughing, and oftentimes tenderness over 
the region of the tenth rib. Referred abdominal pain is especially common and 
pain in the neck or shoulder is not an unusual finding. 

EMPYEMA 

Symptoms. — This form of pleurisy is usually distinctly a secondary process, 
and to the symptoms of serous effusion are added: intermittent {septic) tempera- 
ture, with or without chills and sweating, sometimes a localized edema, and in 
rare instances, actual bulging of the interspaces or the ultimate absorption or 
escape of pus from the pleural cavity into and through the lung to the bronchi. 

In such neglected cases it may "point" at an intercostal space, where it 
forms a tumor beneath the skin and may cause an intractable fistula through 
spontaneous rupture. Such wall perforations usually occur in the anterolateral 
portion of the chest. 

The urine may show albumose, and a marked leucocytosis is the rule; the 
average count being about 18,000, few falling below 12,000,* and the blood may 
show iodophilia. One would naturally expect the highest counts in pneumococcus 
cases. 

Pyogenic Organisms. — The pneumococcus and the streptococcus pyo- 
genes occur with about equal frequency (40+ per cent.) save in children, 
in whom the former is the dominant or sole organism in two-thirds of the 
cases. 

While no absolute rule can be formulated, it is usually true of complicat- 
ing empyemas that streptococcus cases are encountered usually in broncho- 
pneumonia cases and are likely to develop early in contrast to those due to 
the pneumococcus which are more sluggish in their development, tending to 
become manifest after crisis and during the convalescent period. 

Of these the pneumococcus, while usually producing the more decided 
symptoms, offers the best prognosis if promptly and efficiently dealt with. 

Staphylococcus cases are unusual (3 to 4 per cent.), the balance being 
tuberculous with rare exceptions. 

In the epidemics of influenza, measles, and streptococcus pneumonias 
experienced during the Great War, the streptococcus empyemas greatly 
predominated. During certain epidemics the virulence of this complication 
varied widely and in the fulminant streptococcus type drainage seemed 
futile, if not harmful. 

Neglected Cases. — Obviously cases of rupture and internal or external 
discharge are almost invariably the result of neglect or carelessness on the 
part of the physician and one of the readiest methods of avoiding such disaster 
and of resolving doubt in difficult cases, is the early and fearless use of the ex- 

* In simple serous pleurisy a few cases may show moderate leucocytosis during the 
febrile period, but in fifty-two cases examined by R. C. Cabot, the average count was 
8,820, and in only nine did it exceed 12,000. 



DISEASES OF THE LUNGS AND PLEURA 



375 



flaring needle in all cases of pleurisy with efusion and its repeated use if 
any suggestive symptoms arise, 

In elderly and debilitated individuals especially, but by no means ex- 
clusively, empyema may develop most insidiously. In children with lobar 
pneumonia it is a frequent and too often, unsuspected complication. Most 
of the cases of suppositious "delayed resolution" prove to be empyemas. 

Undue persistence of leucocytosis and fever in lobar pneumonia always 
suggests strongly the presence of empyema or abscess of the lung. 

The Use of the Exploring Needle. — Aspiration may sometimes be per- 
formed with an ordinary hypodermic syringe, but inasmuch as a negative 
result is without significance, owing to the fact that thick pus cannot enter 
the tiny needle, and further, that the needle itself is much too short even to 
penetrate the greatly thickened pleura of most empyemas, one usually needs 
one of the larger syringes of the same type with a long needle of at least 
threefold caliber. 

The resistance felt and the fixation or holding of the exploratory needle 
in cases of dense adhesion is decided and constitutes one of the oldest of the 
grosser symptoms of this condition. It may be encountered also in long- 
standing cases of empyema or the persisting serous effusions of polyserositis. 

Such an examination, performed under proper antiseptic precautions, is 
almost absolutely free from danger. The physician's fingers laid upon the ribs 
should mark the limits of the interspace and the needle should be thrust 
quickly and deeply between them without touching the rib and keeping well 
to the lower part of the interspace to avoid the intercostal artery. If fluid 
be present and the point entered has been rendered anesthetic by the ethyl 
chloride spray, or other means, the procedure is painless. 

The site of the puncture is ordinarily the fifth interspace in the axillary line, 
but it is often necessary to enter the chest at other points representing maximal 
dulness, and if care be taken to avoid the heart, spleen, liver, great vessels and 
diaphragm the operator has a wide latitude. 

The X-ray. — It is unnecessary perhaps to emphasize the great value of 
X-ray examinations in these cases where the proper facilities exist for its use. 

PLEURITIC ADHESIONS.— ,4 clinical diagnosis of slight adhesions is 
often impossible, even fluoroscopically, but in general, the symptoms are as 
follows: 

Inspection shows impaired movement of the affected side or retraction 
and mediastinal displacement if extensive adhesions are present, and Lit- 
ten's sign may show marked impairment of the diaphragmatic excursion on 
the affected side. 

Palpation shows diminished vocal fremitus and lessened expansion. 

Percussion shows a change of note varying from slight dulness to absolute 
flatness according to the extent and density of the adhesion. 

Auscultation shows diminished breath sounds and voice conduction, and 
oftentimes, in certain areas, pleuritic rales. 

Fluoroscopy. — A distinct shadow may indicate extensive adhesions and 
the diaphragmatic movement is markedly impaired. 



Obscure cases. 



Common error. 



Choice of 
needle. 



Adhesions. 



Danger almost 
nil. 



Use needle 
boldly. 



Painless 
usually. 



Site. 



Lagging and 
retraction. 



376 



MEDICAL DIAGNOSIS 



An obscure 
disease. 



Usually 
tuberculous. 



Streptococcic 

vs. 

Pneumococcic. 



Treacherous 
guide. 



Relatively 

common 

finding. 



Necessary 
precaution. 



Usually 
tuberculous. 



Multitude of 

possible 

causos. 



INTERLOBAR EMPYEMA.— This ordinarily takes the form and pre- 
sents the symptoms of an interlobar abscess situated between the upper and 
middle lobes near the root of the lung. It presents great difficulties to the 
diagnostician unless the roentgen-ray is available, and is ordinarily mis- 
taken for true pulmonary abscess on account of its peculiar location. The 
purulent accumulation may vary from an ounce or two to a pint or more. It 
ordinarily follows a general pleurisy. (See "Roentgenography.") 

Chronic Pleurisies. — These maybe dry or wet, serous or purulent, and for 
the most part present the same physical signs as are found in acute disease. 
Chronic pleurisies are usually tuberculous and the same may be said of chronic 
empyema, but they often represent neglected non-specific cases. Malignant 
disease pf the pleura, and active tuberculosis, are the commonest conditions 
attended by hemorrhagic effusion and chronic inflammation. 

Chylous Exudate. — -In rare instances rupture or blocking of the thoracic 
duct may result from trauma, carcinoma or other tumors, and find an out- 
let in the pleural cavity. The nature and differentiation of such exudates is 
described elsewhere. 

Character of the Purulent Exudate. — The macroscopic appearance 
of the exudate is an uncertain guide to the identity of the dominant 
organisms. 

In general terms one may say that the streptococcic type is that repre- 
sented by the relatively thin purulent exudate, separating into a double 
layer, thin above, thick below and containing little fibrin. 

Pneumococcic purulent accumulation, on the contrary, is usually creamy, 
fibrinous, viscid and homogeneous. Nevertheless, the author has encoun- 
tered most virulent and deadly exudates, showing pneumococci in pure 
culture yet outwardly resembling the streptococcic exudate. 

Encapsulated Empyema. — The tendency of purulent exudates, especially, 
to become encapsulated must never be forgotten. Quite frequently the main 
cavity is emptied by operation and larger or smaller, single or multiple pockets 
left behind to continue the drain upon the vitality of the patient. 

In this connection the X-ray is most helpful, though usually unnecessary 
if a thorough physical examination is made before the patient leaves the 
operating table. 

PNEUMOTHORAX 

Definition.— A n effusion of air or accumulation of gas within the pleural 
cavity. A liquid exudate is almost invariably present and the true descriptive 
terms are pyopneumothorax, hydro pneumothorax, and nemo pneumothorax, the 
first being the commonest form as the tendency in almost all cases is toward 
ultimate purulent transformation. 

Etiology. — By far the greater number (90 per cent.) are associated with 
advanced tuberculosis of the lung and the formation of a fistulous communi- 
cation, though in neglected empyema a fistulous opening may originate in 
the pleura. Among other causes may be mentioned penetrating wounds of 
the chest wall, traumatic rupture of the lung, rupture of emphysematous 



DISEASES OF THE LUNGS AND PLEURA 



377 



vesicles, pulmonary abscess, gangrene, infarct, cancer, growth of the B. 
acrogcncs capsulatus in a liquid exudate, and even hydatids. 




Fig. 144. — Pyopneumothorax. Note knob indicating collapsed lung. Also dense 
shadows produced by bismuth paste, introduced through fistula under false diagnosis. 
{Dr. Frank S. Bissell.) 

Nearly all of the cases occur in males and the disease is invariably uni- ^ected. hief 
lateral. Sudden and complete bilateral pneumothorax should cause almost 
instant death.* 

*A case of left hydropneumothorax recently observed by the author occurred suddenly, 
without warning, when the patient, a healthy young adult, was engaged in office work and 
entirely free from any cough or other symptoms. After the primary collapse induced by 
the abrupt onset, which occurred in the absence of any muscular effort, sneezing or coughing, 



378 



MEDICAL DIAGNOSIS 



Lung 
compression. 



Usually 
pyopneumo- 
thorax. 



Shock. 



Dyspnea and 

cyanosis- 



Striking 
symptoms. 



Important 
peculiarities. 



Massini and Schonberg report a case, verified by the roentgen ray and 
by the autopsy, which lay alive in the Basel clinic for eight days after the 
seizure, though both lungs were compressed to an incredibly small volume. 

SYMPTOMS AND RATIONALE OF PNEUMOTHORAX 

In pneumothorax as ordinarily encountered, the first inrush of air is fol- 
lowed by a period during which it is rhythmically pumped into the pleural 
space, through a single valve-like opening, by the respiratory movement and 
recurrently "trapped," thus creating an intrapleural pressure such as is 
almost unknown in the case of large liquid exudates, as may readily be demon- 
strated by the X-ray plate. The lung is abruptly and excessively compressed 
in the direction of its root, the mediastinal tissues, if not anchored by old 
adhesions, being displaced maximally toward the unaffected side, and dia- 
phragmatic movement unilaterally almost wholly abolished. 

The pleura becomes inflamed and in most cases a small amount of puru- 
lent, rarely a serous, effusion is present. In open pneumothorax the mean 
intrapleural pressure is, of course, that of the atmosphere. With the closure 
of a pneumothorax of any type, gradual absorption of the gaseous content and 
relief of that pressure may be anticipated. 

The onset is almost invariably sudden and usually follows directly upon 
injury, physical strain, vomiting, or, more frequently, a paroxysm of cough. 

Symptoms Urgent. — Symptoms of severe shock result from the sudden com- 
pression of the lung and the mediastinal displacement, 'there is urgent dyspnea, 
cyanosis and lividity, as the result of the strain thrown upon the right heart and 
the sudden reduction of aeration areas, and the patient ordinarily feels that there 
has been some " internal ruptured 

Silent Onset Rare. — A genuinely insidious and subjectively symptomless 
onset is exceedingly rare and the author has observed but three such cases. 
In these the opening is tiny and so obstructed that only the smallest quanti- 
ties of air intermittently enter the pleural cavity. 

PHYSICAL SIGNS. — Inspection must necessarily show immobility and 
bulging of the affected side and shallow or flush interspaces, as the result of 
the substitution of high positive for the normal negative pressure, together 
with evidence of a displaced heart, unilaterally impaired diaphragmatic 
movement, the physiognomy of shock, cyanosis, and marked dyspnea. The 
patient usually lies upon the affected side in order to facilitate the move- 
ments of the sound side. 

Palpation. — This confirms inspection and as there is usually no underlying 
lung save that anchored by adhesions or compressed at the hilus, vocal frem- 
itus must obviously be greatly diminished or entirely lost over the air-filled 

and was so severe as to be most alarming, the case progressed slowly but steadily and 
uneventfully to complete recovery. Personal and family history were alike wholly nega- 
tive, the X-ray then, and after rapid, complete recovery, revealed absolutely nothing of 
etiologic importance, and the patient is now in perfect health. Such cases are among the 
curiosities of medicine. 



DISEASES OF THE LUNGS AND PLEURA 



379 



area, exactly as in the case of liquid pleural effusion and with the same rare 
exceptions, but extending over a wider area and without the upper limitation 
or definite demarcation of a liquid effusion. 

Percussion. — The percussion note is ordinarily distinctly tympanitic, 
though temporarily, and under conditions of extreme pressure, quite a marked 
degree of dulness may be encountered. 

The entire pleural cavity is air filled, if limiting adhesions,, are lacking. 

A somewhat neglected sign is the resulting extreme initial extension of 
hyper resonance, which in the absence of adhesions, follows the boundaries of the 
pleura rather than that of a lung and, therefore, involves the entire half of the thorax, 
sometimes extending across the median line to the opposite sternal border. 

Fluid is, of course, almost invariably present but is at first, and usually 
indeed throughout, not only small in amount but freely movable and hence 
easily displaceable by postural shifts made for purposes of examination. 

Moreover it always presents a horizontal upper boundary. 

Displacement of Sheltered Viscera. — It is evident that in such cases 
hepatic, cardiac, splenic and renal, thoracic areas of dulness appertaining 
to the affected side are markedly diminished or entirely lacking and that the 
contrast between the boundaries of thoracic resonance of the two sides is 
extremely marked. 

Auscultation. — Breath and voice sounds are necessarily feeble and dis- 
tant or entirely absent except directly over the region of the hilus near the 
spinal column or sternum. 

Hippocratic Succussion. — If the patient be raised cautiously to a sitting 
posture and gently rocked to and fro, Hippocratic succussion is obtained. 
This is merely a splashing sound caused by the waves of the free fluid in the 
great air space, readily detected if the ear is applied to the chest during 
the maneuver, and often heard at some little distance. 

Free mobility of the fluid may be readily demonstrable by fluoroscopy. 

An exquisite u metallic tinkling" is present in many cases, as is the u coin 
sound," obtained by placing the ear upon the chest wall anteriorly and having 
an assistant place a good-sized silver or gold coin on the back and tap it with 
another, the conducted sound having a musical, bell-like or clear metallic 
ring. 

The u water whistle sound" resembling that produced in drawing air 
through water by suction, as in smoking the narghili of the Turk, 
may be present when an open lung fistula lies below the surface of the 
exudate. 

Cardinal Signs. — The four cardinal signs are (i) metallic tinkling (due 
probably to the dropping of fluid from the lung above into the exudate below 
in the smooth, tense-walled, air-filled space); (2) Hippocratic succussion; 
(3) the coin sound which is due to selective reenforcement of vibrations and 
overtones; (4) the X-ray findings, usually clear and absolute.* 

* In certain cases the fluoroscope reveals the paradoxic diaphragmatic response to 
inspiration; that of the affected side ascending, by reason of the relief of intraabdominal 
pressure coincidently with the descent of its fellow on the sound side. 



Dulness 
possible 
but rare. 



Entire space 
air-filled. 



Free fluid. 



A "swashing" 
sound. 



Metallic 
tinkles. 



The bell 
sound. 



380 IffFDICAL DIAGNOSIS 



.4// of these signs together with the widely diffused hyperresonanee and cardiac 
dislocation, are ordinarily strikingly clear. An error in diagnosis can seldom 
occur save in the cases in which an encapsulated pneumothorax exists or in 
the extremely rare instances of huge pulmonary cavitation. Such may simu- 
late pneumothorax but rarely or never yield its pressure signs* In cases where 




Fig. 145. — Pneumothorax. Case quoted in text as showing sudden onset in patient 
enjoying then and now perfect health. Note knob representing compressed left lung. 
This picture was taken one week after onset. It will be noted that the heart (modified 
*'drop" type, showing congenital tendencies largely overcome is apparently normal in size 
(13 cmJ and position, though markedly displaced originally. Patient slender and small 
boned, but otherwise of exceptionally good physique. (.Compare with Fig. 145.) 

a large communicating opening exists, the signs may be merely those of an 
enormous open pulmonary cavity with firm nails. 

* In the most extreme cases of this kind ever encountered by the author, the 
entire right lung, save for a few shreds, had been destroyed and very imperfect 
physical signs of pneumothorax were present. The opposite lung, also the seat 
of multiple tuberculous foci, had so hypertrophied as to encroach upon its empty 
air-filled fellow, and thrust the heart so far into that cavity as to give the appearance of a 
sill's inversus. 



DISEASES OF THE LUNGS AND PLEURA 



38l 



Metallic gurgling and bubbling may result, if a patent fistulous opening 
enters below the level of the fluid. (See above.) 

/;/ diaphragmatic hernia the history, the X-ray, borborygmi (rumbling, 



Diaphragmatic 
hernia. 




Fig ; 146. — Apparently causeless pneumothorax. Case quoted in text occurring ab- 
ruptly in man of perfect health, robust physique, and extraordinarily clean family and 
personal history. Absolutely well up to this time (ten years). This picture was taken 
two weeks after onset. Note expanding left lung. Heart showed a decided reduction in 
size a few weeks later (total transverse measurement n cm.). Modified "drop." Such 
hearts are apparently almost invariably associated with a symptomless gastroptosis, an 
associated asthenic stigma less readily remedied structurally than the cardiac stigma. 
Initial small exudate promptly absorbed in this instance. (See Fig. 144.) 

cooing,) and the change of note on taking large quantities of water into the 
stomach or colon may assist in differentiation. 

Such hernias are almost invariably left sided, which fact goes far to rule 
them out when the right half of the thorax is found air-filled. Roentgeno- 



382 



MEDICAL DIAGNOSIS 



graphy after the ingestion of a bismuth meal is clarifying. The symptoms 
are predominatingly though not wholly abdominal, the stomach and a* part 
of the colon forming the hernial mass in most instances. Furthermore, the 
lung structure may be visible on the X-ray plate despite the presence of a 
gas-filled stomach or colon. " Idiopathic unilateral ascent of the diaphragm u 
is so rare as hardlv to need consideration in this volume. 




Fig. ^47. — Diaphragmatic hernia. Note gas and colonic markings high in right thoracic 
cavity. An unusual location, most cases being left-sided. {Dr. Frank S. Bissell.) 



Course and Termination. — The course of pneumothorax depends chiefly 
upon its cause and as those associated with chronic tuberculosis (90 per cent.) 
are almost invariably fatal, the mortality is enormous. 

HYDROTHORAX. — This is a serous pleuritic transudate without pleuritis, 
and is a secondary complicating ailment, associated with cardiac and renal 
disease or terminal anemias and cachexias. Unlike the effusions of pleurisy, 



DISEASES OF THE LUNGS AND PLEURA 383 



it is bilateral though unilateral predominance of transudation is not uncom- 
mon and the difference may be postural in causation. 

It is usually one of the later events in an anasarca and the physical signs 
are those attributable to liquid pleural effusions from whatever cause, to 
which may be added striking postural change in level. 

Such transudates may occur insidiously at any time, in Bright's disease 
especially, and the condition is often overlooked. 

LOBAR PNEUMONIA 

(Pneumonitis, Croupous Pneumonia, Lung Fever.) 

Definition. — An acute infection characterized in its typical and usual form 
by primary fibrinous inflammation of the lobar type, polymorphonuclear leuco- 
cytosis, profound toxemia, the frequent presence of pathogenic pneumococci in 
the circulating blood in the more virulent infections and an abrupt onset and 
termination. 

Agents of Infection. — Though found in normal buccal secretion and 
diseases other than pneumonia, FrankeVs diplococcus pneumonice or micro- 
coccus lanceolatus is the most constant causal factor. 
It is present constantly in the saliva of some persons 
(25 to 30 per cent.), and is found also in the sec- 
ondary processes of the disease. It is elliptical, the 
lanceolates- occurring in pairs, and, in sputum, is 
ordinarily encapsulated.* 

Other organisms such as the Pfeiffer bacillus, the 
streptococcus or staphylococcus are found not infre- 
quently in association with pneumococci in cases of 

lobar pneumonia, but the last is well established as (Frank el-Wei ch- 

. . . , , . . . , baumj and the pneumo- 

tne causative factor in an overwhelming majority ot bacillus of Friedlander. 

the cases. Upper segment shows 

rr-i i 1 i- i i r i • i t re former, lower segment 

I he recently established tact that wide diner- shows latter. 

ences with respect to virulence and the conferring 

of immunity exist in members of the pneumococcus group has served to 
explain much that was obscure and apparently contradictory in bacteriologic. 
clinical and statistical studies of this disease. 

We now recognize the existence of various strains possessing certain 
cultural characteristics in common yet varying sufficiently in their reactions 
to the sera of immunized animals to permit accurate classification and 
differentiation. 

Limitations of space forbid any extended discussion of this great advance 
in our knowledge of lobar pneumonia which makes possible more accurate 

* It is readily stained as follows: (a) Make thin smear, dry in air and fix by heat. (b) 
Cover surface with the His stain (gentian violet, saturated alcoholic solution 5 c.c. plus 
95 c.c. distilled water, (c) Heat till steam rises, (d) Wash with copper sulphate solution 
(20 per cent.), (e) Dry and mount. The germ is Gram-positive. 




3^4 



MEDICAL DIAGNOSIS 



Three stages. 



diagnosis, a better understanding of transmissibility, epidemiology, virulence, 
immunity, treatment and mortality. 

The table appended shows the classification at present in use at the Rocke- 
feller Institute. Adequate laboratory service is essential. 

Determination- of Pneumococcus Types by Agglutination 



Pneumococcus suspension 0.5 c.c. 



Serum I 
(1:20) 
0.5 c.c. 



Serum II 

undiluted 

0.5 c.c. 



Serum II 
(1:20) 
0.5 c.c. 



+ + 



+ + 



Serum III 

. (1:5) 
0.5 c.c. 



+ + 



Type I... + + 

Type II '. - 

Subgroups II 

a, b, x. - 

Type III 

Type IV - 

Incubation for 1 hour at 37°C. 



The incidence and mortality in ioo cases at the same institution are 
shown in the following table : 

Incidence of Various Types of Pneumococci and Resulting Mortality 



Type of pneumococcus 


Incidence, per cent. 


Mortality, par cent. 


I 


33 


25 


II 


3i 


32 


III 


12 


45 


IV 


24 


16 



MORBID ANATOMY. — Three stages of the disease are recognized for 
purposes of clinical convenience, but are often blended at autopsy. 

1 . Congestion. — The lung is enlarged, dark red, less elastic and less crepi- 
tant than normal and exudes frothy red liquid on section, but portions will 
float in water. The microscope shows marked capillary turgescence and 
erythrocytes, leucocytes and desquamated epithelium. 

2. Red Hepatization (Consolidation). — The lung does not crepitate, is 
friable, and sections sink in water. The cut surface is finely granular, the 
exuded serum is bloody (not frothy) and minute fibrinous plugs may be 
scraped from the surface. 

The microscope shows a coagulated fibrinous exudate and fibrinous threads 
holding in mesh great numbers of erythrocytes, leucocytes, and desquamated 
alveolar cells. There is marked round-cell infiltration of the interalveolar 
septa. 

3. Gray Hepatization (Resolution). — In this stage the gray color displaces 
the dark red of congestion and consolidation, the lung rapidly softens, 
becomes more crepitant, but is still friable, and a purulent exudate follows 



DISEASES OF THE LUNGS AND PLEURA 



38S 



the knife. As a result of the subsidence of inflammation and hyperemia, 
liquefaction of the corpuscles and fibrin takes place through a digestive fer- 
ment possessed by the leucocytes, the cellular elements undergo fatty and 
granular degeneration, and, within from two to four weeks, absorption 
taking place through the lymphatics, together with free expectoration, 
remove the inflammatory products. 

The duration of the stages of pneumonia is extremely variable. Consolida- 
tion may be complete in a few hours, but usually takes from twelve to twenty- 
four. The hepatization period varies from three days to two weeks or more, 
from three to nine days being the usual period. The process of resolution 
is wonderfully rapid, and with its coming the whole complexion of the case 
changes in a few hours. 

Points of Importance. — The morbid anatomy makes clear the physical 
signs of the disease, but one should remember that areas contiguous to consolidation 
are hyperergic and edematous and that bronchitis and pleurisy of some degree 
are invariable accompaniments of fully developed lobar pneumonia. Pleuritic 
e fusion is comparatively slight and usually undis cover able by physical examina- 
tion, yet pneumonia constitutes one of the chief causes of empyema, especially 
in children. 

Predisposing Factors. — 60 or 70 per cent, of all cases occur in males and 
in the United States the colored people suffer more than the whites. Children 
between the ages of two and six are especially susceptible, and after an interval 
of relative immunity its incidence and mortality steadily increase from pub- 
erty to old age. Hence, in incidence and mortality it is a disease of the ex- 
tremes of life. It is most prevalent in the late winter and early spring 
(75 per cent.), is present in all civilized countries whatever their latitude 
or climatic conditions, and is peculiarly fatal in some high altitude regions, 
as in Butte, Mont., where the elevation and smelter fumes, in the past 
made it exceptionally deadly. Alcoholism, acute or chronic, is a marked 
predisposing factor unfavorably affecting prognosis and many acute "drunks" 
are brought to the police station suffering from an unrecognized pneumonia. 

Fatigue and exposure to cold and wet if coincident are predisposing factors. 
Individual predisposition is marked; one attack invites others and an astonish- 
ing number of recurrences have been reported in the same individual. 

77 must be noted, however, that recurrent attacks in most instances represent 
the activity of a type of pneumococcus other than that producing the original 
attack. 

The contagiousness of pneumonia is a proven fact and a reasonable 
degree of isolation should be established in all cases. On the other hand 
individual immunity is common and the degree of contagiousness varies 
with the type of organism present in the given case. 

Cold in itself must be regarded merely as a means of depressing vitality 
and lowering resistance and is more potent when combined with dampness. 

City dwellers are much more subject to the disease than are those living 
in the open country. 

Antecedent Disease. — Coryza and bronchitis often precede an attack, 
25 



Rapid changes. 



Associated 
conditions. 



Males chiefly. 
Age. 



Season and 
altitude. 



Habits. 



Fatigue and 
exposure. 



Cold merely 
contributory. 



Coryza and 
bronchitis. 



3 86 



MEDICAL DIAGNOSIS 



Chronic 
ailments. 



Complicating. 



Hypertoxic 
cases. 



and no doubt furnish a favorable soil for the further development, increased 
virulence and wider dissemination of pneumococci. 

Terminal Pneumonias. — Chronic disease may play a prominent part, 
and pneumonia is a frequent terminal event in acute or arrested pulmonary 
tuberculosis, chronic nephritis, diabetes, carcinoma, arteriosclerosis, prostatic 
hypertrophy and chronic heart disease. 




Fig. 149. — Lobar pneumonia in child five years old. Upper right lobe involved. No 
clear physical signs. Patient roentgenized to determine cause of high temperature. Reso- 
lution by crisis on ninth day. Apparent cardiac displacement represents distortion of out- 
line due to faulty position of child at the moment of exposure. Probably a "massive" 
pneumonia, i. e., one with blocked bronchi. (Dr. Frank S. Bissell.) 

VARIETIES OF PNEUMONIA. — Pneumonia may complicate any acute 
infectious disease and is especially frequent in influenza. The term u typhoid 
pneumonia" should be confined to pneumonia with an overwhelming toxemia 
which produces a typhoid state, not to pneumonia complicating typhoid fever. 



DISEASES OF THE LUNGS AND PLEURA 



387 



Traumatic, Migratory, and Massive Forms. — Traumatic pneumonia is 
rare and migratory pneumonias are both unusual and interesting. 

Massive pneumonias are sometimes encountered in which the large bron- 
chi are plugged and the physical signs greatly obscured by suppression of 
auscultatory phenomena. 

They most strongly resemble pleurisy with effusion but lack marked 
visceral displacement signs and the low level of flatness of that condition. 
Furthermore, in the full-developed case one finds the dulness more or less 
definitely related to lobar divisions and the true flatness of liquid effusion 
is usually absent though dulness may be so extreme as to require the use of 
the exploring needle for differentiation. 




Fig. 150. — Lobar pneumonia (left); central pneumonia (right). The homogeneity and 
density of tissue resulting from the complete consolidation of tissue shown on the left 
makes clear the reason for the exquisite transmission of the peculiarly modified breath 
and voice sounds, no less than the dull percussion note. Compare this diagram with that 
illustrating pleural effusion. If the large bronchi were blocked the signs of pleurisy might 
be exactly simulated. (Repetition of figure.) 

Afebrile and Senile Pneumonia. — Afebrile pneumonia occurs especially 
in the aged, and it should be remembered that senile pneumonias may lack 
chill, high fever, cough, crisis, expectoration and typical physical signs. 

Central pneumonias are very misleading, and it may be days before the 
process reaches the surface and yields physical signs of a positive nature. 

One should carefully note any distant breathing of a tubular quality, however 
faint, especially if associated with increased transmission of the voice {fremitus) , 
whether to the finger or to the ear. No less significance should be attached to the 
circumscribed areas of hyperresonance which frequently precede the consolidation 
and are often sharply and suggestively limited by the interlobar division lines. 
The sputum is, moreover, often typical and diagnostic. 

Note. — In all varieties of lobar pneumonias save the senile group, the abrupt 
onset and decided symptoms of febrile toxemia suggest the disease which is 
further attested by the relatively high leucocytosis so generally present. It 
should be remembered that pleural effusion may accompany it. 

Delayed Resolution — In the author's experience long-delayed resolution 
is an extremely rare event, usually proving to be an empyema; but slow 



Puzzling cases 
lack displace- 
ment signs. 



Often obscure 

lobar 

boundaries. 



Often 
overlooked. 



Distant tubular 
breathing. 

Significant 
areas. 



Rare. 



3 88 



MEDICAL DIAGNOSIS 



Pseudo-crisis. 



Rusty sputum. 



resolution is relatively common. The oft-asserted frequency of delayed 
resolution in the lobar pneumonias of children is open to doubt, in the opinion 
of the author. 

In an astonishing number of instances in his consulting and public prac- 
tice a supposedly delayed resolution in the child has proven to be a pleuritic 
exudate and this, but too often, purulent in character. 

Doubtless pleural exudations complicate the lobar pneumonias of children 
with especial frequency and in the child, even the empyemas of the pneumo- 
coccus group may and occasionally do undergo spontaneous cure. These 
facts would lead to exaggeration with respect to the occurrence of "delayed 
resolution." 

Selective Points. — The right lung is affected in about 60 per cent, of 
the lobar pneumonias, the left in 30 per cent., and both in from 10 to 15 
per cent, of all cases. As regards the lobes affected, apex pneumonia occurs 
in about one-fifth of the cases, especially in influenzal infections, and the 
whole lung is affected about as often as is the lower lobe alone, in which 
the inflammation usually commences. 

General Comment. — In these United States from 70,000 to 80,000 of 
our people die each year of lobar pneumonia, and the disease is apparently 
increasing. As Osier says, it is the real "Captain of the Men of Death," 
and the true "friend of the aged." Its apparent increase may be due to 
more careful methods of diagnosis, but it is probable that other factors are 
operative. 

SYMPTOMS. — The ordinary symptoms of lobar pneumonia are: (a) 
Chilliness or repeated rigors, for which convulsions may be substituted in 
children. 

(b) Fever. — Rising abruptly from normal to 103 to io5°F. and tending to 
assume a continuous form. It lasts throughout the period of congestion and 
hepatization (ordinarily from three to fourteen days) and terminates by crisis. 

(c) Crisis. — A critical drop in temperature and the dramatic contrast 
between intense suffering and relative comfort is an astonishing phenomenon. 
The fall usually reaches subnormal and is attended by sweating or perhaps 
diarrhea. Immediately before it there may be a marked rise in temperature 
(pre-critical) ; following it there may be secondary elevation rapidly subsiding 
to normal (post-critical). A pseudo-crisis may occur and raise false hopes, 
and finally, an ante-mortem rise or fall may occur. The latter is most mis- 
leading, but is ordinarily associated with other signs of impending death 
that should prevent misconstruction. 

(d) Pain is almost invariably present and is distinctly pleuritic in- type. 

(e) Cough and Expectoration. — In the early stages the cough is dry, 
painful and unproductive, the sputum is at first scant and mucoid, then muco- 
purulent and blood-streaked, later, during hepatization, it becomes rusty 
and during resolution creamy, in appearance. The aptly named "prune 
juice" sputum is of serious portent and the sputum of the first two stages is 
so extraordinarily tenacious as to cling to the lips and to the bottom of the 
inverted sputum cup. 



DISEASES OF THE LUNGS AND PLEURA 



389 



(/) Respiration. — Dyspnea is always present, the respiration varying from 
30 to 70 per minute, according to the extent of involvement and still more 
to the severity of the toxemia, and pleuritic pain may cause a grunting 
respiration and shallow breathing. 

(g) Heart and Pulse. — The pulse is full and bounding, but, as in typhoid, 
relatively slow, and the pulse-temperature ratio and condition of the heart 
sounds are important factors in prognosis. 

If the heart is acting properly, the pulmonary second sound is strongly 
accentuated, and its marked diminution or absence, in the presence of per- 
sistent or advancing consolidation, points to right-sided cardiac dilatation 
and impending failure. 

The Blood. — In lobar pneumonia, pneumococci may be recovered from 
the blood in considerable proportion of cases (30-50 per cent.) and leucocytosis 
roughly measures the reciprocal action of toxemia and resistance. Its 
absence is ominous or may be suggestive of coincident infections other than 
that due to the pneumococcus, e.g., influenza or typhoid fever. The average 
number of leucocytes is about 25,000 per cu. mm., and counts between 
30,000 and 50,000 are not uncommon. The significance of a failure of 
leucocytosis is somewhat diminished in complicating pneumonias such as 
those associated with typhoid or smallpox, diseases in which the vitality of 
the patient may be greatly lowered.* 

The leucocyte count ordinarily reaches normal within two or three days after 
crisis and its undue persistence suggests septic complications. 

The Urine.— Alb uminuria is common but is usually of the febrile type, sub- 
siding promptly with the termination of the active process. The urinary chlorides 
are diminished or absent during the active stage of the disease and the urine is 
scant, dark, and of high specific gravity. 

Gastrointestinal Tract. — The tongue is ordinarily furred, vomiting or 
diarrhea may be present, and meteorism may greatly embarrass circulation 
and respiration. 

Headache and Delirium. — Severe headache may be present at the onset 
or more rarely throughout the patient's illness. Delirium is unusual, the 
patient being ordinarily rational and acutely sensible of his situation. 
Either low or active delirium is ominous. Maniacal delirium occasionally 
occurs, and delirium tremens frequently develops in alcoholic cases, f 

Physiognomy of Pneumonia. — If the patient be conscious, the expression 
is anxious, eye bright, the attitude active, and the decubitus usually lateral, 
the affected side being most often undermost during the early stages. Herpes 
appears on the lips in a majority of cases { and dyspnea is evident both in the 
chest movement and the working nostrils. Both cheeks may be flushed, or 



Grunting. 



Prognostic 
signs. 



Acute 
dilatation. 



Leucocytosis 
the rule. 



Persistent 
leucocytosis. 



Albumin and 
chlorides. 



Meteorism. 



Herpes. 
Flush. 



* From clinical experience the author would advise special care in the lobar pneumonia 
of arrested or apparently cured tuberculous cases. Many of these experience sudden 
collapse after a few days' illness and often at the time of apparent crisis. 

t Too frequently the pneumonia is overlooked in such cases. 

% Herpes occurs frequently not only in pneumonia, but in all other infections in 
which the pneumococcus plays a chief part. 



39° 



MEDICAL DIAGNOSIS 



Cyanosis. 



Lagging. 



Increased 
fremitus. 



Central 
pneumonia. 



Hyperres- 
onance of 
advancing 
consolidation 



Value of 
crepitation. 



Voice sounds 
best guide. 



that of the affected side alone and more or less cyanosis is always present. 
Deepening cyanosis should be carefully watched for and met by appropriate 
treatment directed to the circulation. If the nails become deeply cyanotic the end 
is usually near. 

PHYSICAL SIGNS OF FRANK LOBAR PNEUMONIA.— Inspec- 
tion. — Aside from the physiognomy and decubitus one notes lagging or 
immobility of the affected side as a whole or chiefly over the lower zone if 
the base only be involved, together with an increased rate of respiration and 
overaction of the accessory muscles of respiration. 

Palpation. — Confirms inspection and in established consolidation if frem- 
itus is tested after cough (to remove obstructive secretion) it will be increased 
unless the larger bronchi are filled with fibrinous exudate (massive pneu- 
monia). 

If only the engorgement of the early stage is present, fremitus may be 
normal or actually decreased. Pleural friction may be felt in some cases and 
palpatory percussion reveals marked resistance over the affected area. 

Percussion. — Dulness with well-marked resistance is the sign of consolida- 
tion; hyperresonance or tympany, that of primary engorgement, and in early or 
doubtful cases percussion may be made while the patient is lying prone, 
or, if deemed safe, sitting up and leaning forward to avoid confusing 
differences due to the unequal thoracic pressure involved in the lateral 
position.* 

Percussion may be wholly negative in central pneumonia for several days, 
but the note is so frankly dull, ordinarily (when hepatization is fully 
established), as to require no decided shifts of posture and leave no doubt 
in the mind of the examiner. Equally frank is the hyperresonance above 
the dull area (advancing infiltration — vicarious emphysema — impaired tonus) 
which may even simulate the cavity percussion note in quality, and variations, 
especially in cases of apex pneumonia. In a case of lobar pneumonia in its 
early stages, i.e., within twelve to twenty-four hours after the initial symp- 
toms, the affected area itself sometimes shows a most misleading hyperresonance. 

Furthermore, it may show resonance anteriorly long after dulness is demon- 
strable posteriorly. 

Auscultation. — In the first stage, or in massive pneumonia, the breath sounds 
may be diminished or even suppressed and, in the former, one should seek to 
hear the true crepitant rale at the end of inspiration. 

As the consolidation advances and nears the surface the intensity and bron- 
chial character of the sounds increase pari passu until exquisite, dry, tubular 
breathing is audible over the area of consolidation however varied may be the 
rales over adjacent areas or in the opposite lung. 

The voice sounds may be normal or diminished early in the case, but, as a 
rule, together with fremitus, give better and prompter news of an advancing 
process than do the breath sounds and ultimately yield the pure bronchophony of 

*It is seldom necessary to subject a highly toxic heart muscle to the strain 
involved in the forced assumption of the sitting posture. As stated previously, the 
patient who is too ill to sit up is too ill to be set up. 



DISEASES OF THE LUNGS AND PLEURA 



391 



superficial consolidation. As in palpation, if the signs are obscure, the patient 
should cough to clear the bronchi before auscultation is completed. 

In the stage of resolution there is a rapid recession of the pure tubular 
breathing and voice conduction, associated with the reappearance of fine 
crepitation (often missed by the physician), shortly succeeded by coarser 
moist rales, together with diminishing percussion dulness and fremitus. 

Diagnosis. — The diagnosis of lobar pneumonia, usually simple, depends 
upon the frank, febrile onset and high fever,* pulse- temperature ratio, rusty 
sputum and physical signs, and the sputum is often characteristic when 
physical signs are lacking (central cases). Blood cultures may be positive. 

The chief confusing conditions are: {a) afebrile senile pneumonias in 
which the physical signs and toxemic symptoms must govern. 

(b) Cases of pleural effusion with transmitted tubular breathing, which 
are differentiated by the flatter percussion note, displacement of the heart, 
more distant quality of the tubular breathing, relatively slight fremitus, and, 
positively, by the results of exploratory puncture. 

(c) Cases of acute pneumonic tuberculosis, in which an existing or pre- 
existent lesion or a tainted family history may be suggestive, but which can 
often be differentiated only by the subsequent course, evidences of a destruct- 
ive process and the recovery of the tubercle bacillus from the sputum. 

(d) Hypostatic pneumonia occurring in a febrile disease, in which case 
the primary condition itself usually suggests the probability of hypostasis 
which is often incomplete, usually bilateral, markedly and persistently dorsal, 
and is in correspondence with and dependent upon the decubitus of the 
patient and the heart strength. 

Lobar Pneumonias Associated with Mixed Infections. — It is well known 
that lobar pneumonia may be associated with a variety of pathogenic organ- 
isms but the student should remember that mixed forms almost always lack 
both the typical general symptoms and the frank physical signs of the pure 
or dominant pneumococcus form. They tend, on the other hand, to a sug- 
gestive irregularity of course and development. 

Broncho-pneumonia is wholly different as to course, sputa, and physical 
signs, save in the exceptional cases of extensive fusion of broncho-pneumonic 
areas, and in these the course, and the associated and antecedent pulmonary 
signs are usually sufficiently distinctive. 

Infarct. — When, as rarely happens, an infarct is of sufficient size to simulate 
lobar pneumonia and is accommodatingly typical, it is usually suggested by the 
nature of the primary disease with which it is associated, by its instantaneous 
onset, its sharply limited area of involvement and a bright bloody sputum or 
actual hemoptysis. 

Central Pneumonia. — This may not be positively diagnosed until rusty 
sputum appears or the signs become evident from superficial consolidation, but 
as a matter of fact, is to be recognized usually, even in its larval forms, before 
these evidences appear. Its onset, the more or less decided leucocytosis, and 

* The continuous type of the fever is usually emphasized but many cases occur in which 
it is markedly remittent. 



Value of 
sputum. 



Misleading 
conditions. 



Exploratory 
puncture. 



Usually unlike. 



Usually 
detected. 



392 



MEDICAL DIAGNOSIS 



Important 
diagnostic 
data. 



Fever and 
leucocytosis. 



Color, viscidity 
and tenacity. 



Disturbed 
tonus. 



Increased 
conduction. 



Ideal condi- 
tions present. 



Massive 
pneumonia. 



the suggestive though not clean-cut localized departures from norma! physical 
signs are usually sufficiently suggestive. 

As previously stated one must lay much stress upon localized areas of 
hyper resonance in such cases, especially if these stop abruptly at an interlobar 
division and, furthermore, increased fremitus and voice sounds together with 
faint distant tubular breathing are frequently to be made out. 

RATIONALE OF LOBAR PNEUMONIA 

Signs and Symptoms. — The physical signs and the symptoms of frank lobar 
pneumonia are in precise accord with the fundamental factors underlying their 
production in any disease of the lung. 

High-grade Toxemia. — From the known nature of the infectious agent 
(pneumococcus) one anticipates a profound toxemia, a high and relatively 
stable fever and, in persons of average resisting power, a well-defined re- 
active and defensive leucocytosis. 

Sputum. — The* extreme congestion and inflammation, and the fibrinous 
character of the exudate, readily explain the color and peculiar viscidity and 
tenacity of the sputum. 

Stage of Congestion. — The obscuration of physical signs in the early 
stage of congestion and edema is manifestly due to the diminution of normal 
pulmonary tonus combined with some disturbance of tissue homogeneity; 
obviously this would apply to any point of inflammatory, central pulmonary 
consolidation or the line advance of an extending superficial consolidation. 

Bronchial and Tubular Breathing.- — The bronchial and tubular breathing, 
increased fremitus, and bronchophonic phenomena, of the stage of complete 
or decided consolidation, reflect the extraordinary conducting quality of 
dense, airless lung in direct communication with patent bronchi and through 
these with the trachea. 

The Crepitant Rale. — The crepitant rales must, of course, result from the 
presence of the very conditions which we know to be ideally adapted to their 
production, viz. — a viscid glutinous secretion present in the alveoli and infun- 
dibula at the period of marked congestion and beginning consolidation, and 
to a less degree, at the period of recession represented by the commence- 
ment of resolution (crepitus redux). 

At a certain stage in each of these periods the forcible indraught of air 
can separate the agglutinated walls at the height of pressure, i.e.. the end of 
inspiration. 

Blocked Bronchi. — If the bronchi of any area are completely blocked 
by exudate, as rarely happens, the conduction is abolished or greatly dimin- 
ished; hence areas of massive pneumonia are silent, though yielding the 
percussion signs and constitutional symptoms of the disease and lacking, 
of course, the displacement symptoms and usually the absolutely flat 
note of liquid exudate. 

Toxemia the Dominant Factor — The dominant importance of the 
associated toxemia in prognosis and treatment rather than the degree of lung 



DISEASES OF THE LUNGS AND PLEURA 



393 



involvement, and the effect of the toxin and of the impeded pulmonary 
circulation upon the right heart must ever be in mind. 

Furthermore, the value, in prognosis and treatment, of accurate observa- 
tion of the changes in force and accentuation of the pulmonary second sound, 
a careful delineation of the accessible heart borders, and a critical study of 
the other heart tones cannot be overestimated. 

Cyanosis and Dyspnea. — The phenomena of cyanosis and dyspnea are 
self-evidently the results of a process which suddenly wipes out a consider- 
able capillary area in the lesser circulation, diminishes the air exchange 
poisons the heart muscle, and overstimulates the respiratory center. 

Crisis. — The changes wrought in the sputum and physical signs by crisis 
and resolution are so directly in line with the pathology as to need no extended 
comment. 

Complication. — Acute arteritis is an extremely rare complication.* 

PROGNOSIS. — Pneumonia is, as stated previously, an extremely fatal 
disease and kills from 10 to 70 or even 80 per cent, of the cases affected, ac- 
cording to the virulence of the type and the age and vitality of the individual. 

In a high-class private practice at least 10 per cent, of all cases die. In 
general hospital practice the mortality will vary from 20 to 40 per cent, according 
to the type and age of the patients. It is said that in patients above sixty years 
of age two-thirds will die.\ 

The outlook is bad at the extremes of life, in the obese, in those of bad habits 
and in such as are debilitated by overwork, unfortunate sanitary environment 
or chronic disease. 

The tuberculous experience a high mortality, and recurrent cases are 
somewhat more dangerous than primary attacks. 

Influenzal pneumonia of the lobar type is especially fatal, though some- 
times peculiarly transient and most atypical in its localization and duration. 

Excessive rapidity and arrhythmia, both as affecting pulse and respiration, 
are ominous signs, as also are extreme cyanosis, absent or markedly diminished 
pulmonary second sound, extending heart borders, profound albuminuria, 
low leucocyte counts, and marked delirium. 

The essential element in prognosis and treatment consists in the appreciation 
of the fact that one is dealing with a toxemia, to which all local manifestations 
are secondary, and that hope lies in assisting the patient to resist its virulence, 
and in guarding the poisoned, overburdened, myocardium. 

SEPTIC PNEUMONIA.— This extremely fatal type is characterized by 
the intensity and septic type of its manifestations, by a purulent sputum, 
often most profuse, and a tendency to destruction of the lung through the 
production of multiple abscesses or gangrene. Each form may be either 
broncho- pneumonic, the commoner type, or. more or less atypically lobar. 

* George Douglas Head; Amer. Jour. Med. Sci., August, 192 1, vol. clxii, p. 157. 

f So many variations enter into both private and public practice that arbitrary figures 
become ridiculous and our judgment must depend upon a knowledge of the favorable or 
unfavorable factors in the individual case. In general, public patients enter the hospital 
late and in bad condition. 



Public vs. 

private 

patients. 



Important 
factors. 



Ominous 

signs. 



Vital element. 



Intensely 
septic in 
course. 



394 



XIEDICAL DIAGNOSIS 



Three forms. 



Mixed 
infection. 



Bronchiolitis. 



Exudate. 



Bilateral. 



Fusion of 
areas. 



Miliary form. 



Three types are encountered which differ little save in causation: 

(i) Aspiration pneumonia; (2) sepsis by extension; (3) metastatic or embolic. 

Aspiration pneumonia is that caused by the entrance of foreign bodies 
or food particles. 

The septic form due to extension is encountered in certain cases of hepatic 
and subphrenic abscess or empyema. 

The metastatic or embolic form may, as its name implies, arise from 
almost any septic infection, is distinctly hematogenic and usually begins 
abruptly with more or less well-defined symptoms of infarction. It is quite 
unlike lobular pneumonia and lacks primarily the rusty sputum and 
immediate temperature rise of the true lobar form. 

BRONCHO -PNEUMONIA 

(Catarrhal pneumonia, lobular pneumonia, capillary bronchitis.) 

Definition. — An acute infection associated with profound toxemia and an 
inflammation of the terminal bronchioles and lobular tissue of the lung. 

Etiology. — Xo special germ has been identified, but the diplococcus 
pneumoniae is most often found, usually in connection with other germs, 
such as the pyogenic streptococci, Friedlanders bacillus, and, more rarely, 
Klebs-Loffler and influenza bacilli.* 

Mixed infections are the rule though pure cultures of the pneumococcus 
may be found in the primary and pseudo-lobar forms. 

The general predisposing factors are essentially the same as in lobar 
pneumonia. Seventy-five per cent, of all the pneumonias in children 
are of this type and of these about two- thirds follow bronchitis. It is very 
common in whooping cough, influenza, diphtheria, in the aged and, as a 
complication, in various acute and chronic diseases. 

Inhalation Pneumonias. — Any irritant, as irritating fumes or dust or the 
vapor of anesthetics may excite it, in the presence of pathogenic germs. 

Morbid Anatomy of Lobular Pneumonia. — The first stage is one of intense 
congestion and the capillary bronchiolitis and alveolar congestion is followed 
by a serofibrinous or hemorrrhagic exudation associated with pronounced 
desquamation of epithelium. Ordinarily an antecedent bronchitis extends 
to these structures, the bronchioles become plugged, the alveoli gradually 
lose their contained air and collapse. The exudate, ordinarily termed catarr- 
hal, is sometimes distinctly fibrinous, but its cellular constituents show a 
predominance of epithelium over leucocytes. The process is bilateral, affect- 
ing chiefly the lower lobes posteriorly; the lung appears mottled with bluish- 
brown airless depressions indicating collapsed areas, interspersed with bright 
red emphysematous and crepitant fields. Fusion of areas may bring about 
extensive consolidation or the affected portions may remain isolated and are 
sometimes so minute as to constitute an acute miliary broncho-pneumonia. 

the lungs are larger than 



Collapsed areas may be distended by the blowpipe, 



* The peculiar type of pneumonia proving so fatal a complication of influenza during 
the epidemic of 191 8 was associated with the presence of the influenza bacillus in most 
instances. 



DISEASES OF THE LUNGS AND PLEURA 



395 



normal, have a nodular feel, and drip on section and the process of resolution 
is much the same as in lobar pneumonia, but, save in the acute cases, is un- 
fortunately more irregular in its points of development so that the disease 
ordinarily terminates in protracted lysis. 

Two .Chief Divisions of Broncho-pneumonia. — The disease may be 
divided into primary and secondary cases. The former come on acutely, 
attacking primarily the terminal bronchioles and terminate, as a rule, 
quite abruptly. 

The latter are invariably subsequent to a bronchitis or complicate some 
existing disease. 

Primary Broncho-pneumonia. — The primary type is infrequent in patients 
over four years of age, but constitutes about one-third of the cases in children and 
is almost always a distinct pneumococcus infection, as might be inferred from the 
abrupt character of its onset and termination. The primary congestive form 
may kill in from twelve to twenty-four hours or may terminate favorably in a few 
days. 

Secondary Broncho-pneumonia. — Most broncho-pneumonias are of the 
long-persisting secondary type and it is a common sequel of the bronchitis 
of children and certain of the acute exanthemata, especially measles, scarlet 
fever and diphtheria,* and as a terminal event in cachexias and senile con- 
ditions. In the latter, its course may be insidious and lacking in the franker 
clinical manifestations. In measles and scarlet fever it is severe and pro- 
tracted, in diphtheria extremely fatal. In influenza one meets with two" 
types, one extremely brief, the other protracted and severe. The latter form 
is peculiarly liable to leave behind it a persistent spasmodic cough. 

Next to gastro -enteric diseases, broncho-pneumonia is the most common 
and certainly the most fatal of the more serious and common diseases of 
infancy. 

SUBDIVISIONS. — Aside from the general division into primary and sec- 
ondary cases, we recognize three forms of the disease itself: 

i . An acute congestive broncho-pneumonia. 

2. Disseminated broncho-pneumonia, often described as capillary bron- 
chitis, and 

3. The common formf of the disease. 

Ninety per cent, of the acute "congestive" and "common" types are 
bilateral, and the disseminated form invariably so. 

4. Acute hemorrhagic pneumonitis. (See under Influenza.) 
Selective Points. — In the acute congestive and the common form, the signs 

are always most marked posteriorly and nearly always in the interscapular space. 
Pulmonary at Onset. — Save in the acute congestive pneumonias, the 
symptoms and physical signs are strikingly pulmonary from the outset, 
though sometimes obscure, atypical, and silent as regards actual physical 
signs, save for significant multiple areas of hyperresonance, confusing and 

* Councilman states that broncho-pneumonia is seldom absent in the severer types of 
this disease. 

t Following Holt's classification. 



Primary vs. 
secondary. 



Affects espe- 
cially children 
under four. 

Primary con- 
gestive form. 



A serious com- 
plication. 



Persistent 
cough. 



Interscapular 
space. 



Sometimes 
silent. 



39^ 



MEDICAL DIAGNOSIS 



Explained by 
pathology. 



Often 
malignant. 



Toxemia 
profound. 



Miscalled 

capillary 

bronchitis. 



Abrupt. 



Low fever. 



Basic]signs, 



Abrupt onset 
usual. 

Remittent 
fever. 



Early rapid 
respiration. 



Dyspnea. 



wholly out of accord with the wide involvement shown by autopsy in fatal 
cases. 

The nature of the pathologic process explains this fact by showing that even 
where consolidation exists the condition of the surrounding tissues may be such 
as to produce a hyper resonance which masks the percussion signs of consolidation. 

ACUTE CONGESTIVE BRONCHO -PNEUMONIA.— Symptoms.— This 
may be rapidly fatal, killing in twenty-four to forty-eight hours, and the physical 
signs may be limited to harsh breath sounds and possibly a slightly dulled per- 
cussion note. 

The signs are usually bilateral, but not necessarily of equal intensity over the 
two sides. 

The onset is sudden, often with vomiting and occasionally with convulsions 
in children or chill in the adult. 

The fever runs high and may steadily increase to a fatal termination 
(103 to 107 ). 

Cough may be entirely absent or violent and harassing. 

Pulse and respiration are extremely rapid, cyanosis marked, mental dulness 
and apathy early and extreme and the attack may merge into the common form 
of the disease or terminate sharply by crisis. 

ACUTE DISSEMINATED BRONCHO -PNEUMONIA.— This form 
which some of the foreign clinicians still term "capillary bronchitis" is 
primarily an inflammation of the capillary bronchi; but, post-mortem, is 
invariably associated with areas of true broncho-pneumonia. 

Symptoms. — Like the other forms , it comes on acutely, pulse and respiration 
are rapid, prostration is marked but not immediate and both dyspnea and cyanosis 
are prominent. The cough is severe and harassing though not sharply painful, 
but the temperature usually runs low. 

The physical signs consist chiefly of the subcrepitant and coarser rales, 
generally distributed, always bilateral, and best marked in the interscapular 
space. The percussion note is hyperresonant or even tympanitic. 

Recovery is the rule and the disease ordinarily runs a short course of a 
few days or a week or ten days, terminates by lysis, or merges into the com- 
mon form of the disease. 

THE COMMON FORM OF BRONCHO-PNEUMONIA.— Onset.— 
Although often preceded by a bronchitis, the actual onset is often abrupt; the 
fever high at its maxima but, with rare exceptions, strikingly remittent (often 
showing a variation of three or four degrees). 

Vomiting sometimes marks the onset and very often complicates the estab- 
lished disease. Convulsions are infrequent as an initial event. 

Cough is early, intractable and persistent, harassing, but usually painless. 

Dyspnea. — The respiration is rapid (60 to 80 or even 120 in severe cases) 
and may be noted as a premonitory symptom even before the frank onset. 

The signs of actual dyspnea are pronounced; the alae nasi active and in- 
spiratory recession of the lower interspaces marked. 

Prostration is marked and soon becomes extreme and expectoration may be 
wholly absent in young children. 



DISEASES OF THE LUNGS AND PLEURA 



307 



Cyanosis becomes marked in all severe cases and convulsions may occur 
as one of the terminal events. 

In rare instances infants or badly nourished children may show a sub- 
normal temperature. 

The pulse may reach 200 and is always rapid and sometimes irregular. 

Gastrointestinal disturbances greatly complicate the treatment in 
many instances, flatulence and exhausting diarrhea or persistent vomiting 
aggravated by cough being the most troublesome factors. 

The urine is of the febrile type, scant, high colored, and containing an 
excess of urates and a trace of albumin. 

The ordinary course is from two to three weeks and even in favorable 
cases it usually terminates in a. tedious lysis. Cases may, however, be pro- 
longed for two or three months or a chronic broncho-pneumonia may suc- 
ceed the acute form and often proves to be a tuberculous process. 

PHYSICAL SIGNS OF THE CHIEF TYPES OF BRONCHO-PNEU- 
MONIA. — These are primarily the signs of an acute bronchiolitis, the most char- 
acteristic sign being the subcrepitant rales heard chiefly and predominantly over 
the lower lobes in the interscapular spaces. 

Unlike lobar pneumonia, the left lung is usually chiefly affected, though 
both are involved. 

Bronchial rales, dry and moist, of a larger and coarser character, may mask 
the finer crackles, and after a variable period evidences of consolidation may 
appear over scattered areas or, more rarely, produce extensive consolidation. 

Inspection. — Inspection reveals the fades of profound illness, and its 
pulmonary nature is indicated by the evident dyspnea, harassing cough, slight 
or marked cyanosis and inspiratory recession of the lower interspaces. 

Palpation. — Fremitus is negative or impaired in the congestive type and 
diminished in the disseminated form, but may be increased over certain areas 
in the u common form ,} if consolidation be sufficiently extensive and superficial. 

Percussion. — Percussion is negative in the congestive form or shows only 
slight dulness and there is hyper resonance or tympany in the disseminated 
variety. In the common form scattered areas of impaired resonance or decided 
dulness may alternate with hyper resonance and, furthermore, certain areas of 
dulness may disappear and reappear from day to day or hour to hour. 

Light percussion should invariably be practised and it should be remem- 
bered that consolidation areas are first and chiefly evident in the interscapu- 
lar spaces save in those instances, usually influenzal or tubercular, in which 
the localization is anterior and apical. 

Auscultation. — Auscultation is by far the most valuable procedure. The 
characteristic subcrepitant rales are usually overshadowed by their coarser 
congeners both dry and moist, and in their turn tend to obscure the crepitant 
rdles often intermingled with them. 

Areas of increased voice conduction and broncho-vesicular or even tubular 
breathing may make any existing consolidation manifest to the ear even though 
it is not revealed by the percussing finger. 

Friction sounds are rare and it should never be forgotten that all signs may 



Rapid pulse. 



Termination. 



Subcrepitant 
rales. 



Left lobe 
chiefly. 



Facies. 



Fremitus. 



Vague signs. 



Shifting signs. 



Light 
percussion. 



Most valuable 
procedure. 



Importance of 
roice sounds. 



Friction rare. 



398 



MEDICAL DIAGNOSIS 



Crying assists. 



Character of 
exudate. 



Dominant rale. 



Atelectasis. 



Fusion of 
areas. 



Hyper- 
resonance. 



Shifting signs. 

"Patchy" 
distribution. 



Diagnosis 
seldom 
difficult. . 



Trivial or 
"massive. 



Physiologic 
type. 



be lacking save in forced deep inspiration, in children often obtainable only 
during the act of crying. 

Remember that in all cases of broncho-pneumonia the patient is mani- 
festly too sick for the simple bronchitis which the disease may simulate in its 
early stage or directly follow. (See also discussion of the peculiar complicat- 
ing pneumonia of Influenza, p. 386.) 

Complications.- — Ileo-colitis is dangerous and troublesome when it occurs. 
Meningitis and nephritis are rare, tuberculosis is not uncommon and is un- 
doubtedly often primary, especially in the complicating broncho-pneumonias 
of measles and pertussis. Endocarditis is fortunately a clinical curiosity. 
Suppuration and abscess formation are rarely seen save in aspiration and 
deglutition cases. 

RATIONALE OF BRONCHO -PNEUMONIA.— The chief distinctions 
between lobar and broncho-pneumonia lie manifestly in the character of the 
exudate, which is catarrhal rather than fibrinous, and in the fact that the 
bronchioles and peribronchial tissue bear the brunt of the attack. 

These facts greatly assist one in understanding the peculiarities of its 
physical signs. 

Under such conditions of catarrhal bronchiolitis the subcrepitant rale 
must be the dominant one in auscultation, and with blocking of the lumen of 
the bronchioles comes atelectasis of certain lobular areas through absorption 
of the trapped air content and consequent collapse of the vesicles. 

With localized peribronchial and perivesicular inflammation, relaxation 
and edema in the intermediate areas must occur and affect those fields 
in which vicarious overdistention or emphysema exists. 

Furthermore, the blocking of any lobular inlet by the relatively thin 
catarrhal exudate may at any time be relieved and the tributary territory 
again become aerated or, per contra, by aggregation of involved areas, nearly 
or quite all of the lobe itself may become airless and a true lobar pneumonia 
be simulated. 

Hence the indeterminate, shifting medley of physical signs — hyperreson- 
ance over relaxed or emphysematous areas; adjoining areas of dulness of 
varying degree, situation, and persistence; hyperresonance masking and 
perhaps modified by underlying dulness, and the somewhat characteristic 
limitation of signs to patches of territory. 

Despite the seeming confusion and vagrancy of signs the diagnosis of the 
common form is not often really difficult. 

ATELECTASIS AND THE PULMONARY CONGESTIONS 

Definition. — A condition due to blocking of air passages, deficient 
respiratory action or lung compression and characterized by localized or 
extensive loss of the pulmonary air content and complete collapse of the 
vesicles in the area affected, whether temporary or persistent. 

Etiology. — Usually Secondary. — Aside from the atelectasis so frequently 
present at the lung bases in shallow breathers, the weak, and the bedridden, 



DISEASES OF THE LUNGS AND PLEURA 



399 



which is ordinarily abolished by a few long breaths, or that encountered 
sometimes in the insufficiently inflated lungs of the new-born child, it results 
from extreme respiratory weakness or actual obstruction of the bronchi, 
large or small. 

As examples one may cite broncho-pneumonia, compression of the 
lung by tumors, foreign bodies, or the pressure of growths or exudates, e.g., 
mediastinal or pleural growths, pleural effusion, pneumothorax, greatly en- 
larged heart and pericardial effusion. 

Slight grades result from mere deficient expansion in delicate women or 
children and higher grades from chronic obstruction in the upper respiratory 
tract, as from adenoids or enlarged tonsils. "Pigeon breast" and "Harrison's 
groove" represent chest deformities due in part to such a condition. In 
extreme cases the lung is carnified, and persistent and extensive atelectasis 
leads to atrophy or fibrosis. 

Examples of this last change occur frequently in cases of prolonged pleural 
exudation especially of the purulent type, in which the lung may fail to 
reinflate. 

Massive collapse of the lung following chest injuries with or without 
perforation of chest wall is rare in civil practice but occurred quite frequently 
during the Great War. 

It may affect the side opposite to that receiving the direct injury and 
produces symptoms easily mistaken for pleurisy or pneumonia if the follow- 
ing points are not borne in mind. 

(a) The chest is retracted over the collapsed lung. 

(b) The heart is displaced toward the affected lung. 

Radiography or fluoroscopy would show high position of the diaphragm 
on the affected side. 

Diagnosis. — The presence of an adequate cause, inspiratory recession of 
interspaces or actual retraction, absent or distant tubular, breath sounds and cor- 
responding fremitus variations may be present. 

These are for the most part silent or hushed areas, though in cases of broncho- 
pneumonia deep inspiration or cough may clear the bronchi and convert them 
into noisy ones. 

In atelectasis of this silent type the condition is very different from that 
which results from continuous obliterative or stenosing pressure upon a bron- 
chus, as in aneurysm or malignant growths, or from such extreme and long- 
enduring compression as may occur in pneumothorax or pleural effusions. 
In the latter instances the whole lung may be airless and carnified, yet directly 
in connection with the primary bronchus, and may transmit sound and yield 
dulness like any other consolidated lung. 

Fine crepitations heard over the lung bases at the end of inspiration and 
persisting after one full inspiration are of significance as indicating the onset, 
increase or persistence of myocardial insufficiency. 

CONGESTION OF THE LUNGS.— Active congestion and the three 
forms of passive congestion, in which is included so-called pulmonary edema, 
will be discussed under this head. 



Fundamental 
causes. 



Obstruction 

and 

compression. 



Adenoids, and 
the like. 



Carnification. 
and fibrosis. 



Atelectatic 
inspiratory 
retraction. 



Hushed areas. 



Variable areas. 



Important 
form. 



Deceptive 
cases. 



4oo 



MEDICAL DIAGNOSIS 



Irritation. 



Doubtful 
distinctions. 



Venous stasis. 
Toxemia. 



No dividing 
line. 



Decubitus a 

localizing 

factor. 



Slight 
symptoms. 



Hypostasis 

often 

overlooked. 



ACTIVE CONGESTION.— The inhalation of irritating substances, chiefly 
vapors and gases, and the primary stage of the pneumonias, are the chief 
factors in the production of an extensive, active congestion and it is almost 
invariably but a stage in some dominant disease process. 

PASSIVE CONGESTIONS, HYPOSTASIS AND EDEMA Dubious 
Distinctions. — Sharply drawn lines between obstructive and hypostatic 
congestion and between these and pulmonary edema are unfortunately 
largely confined to the autopsy room. 

Identical Fundamental Etiology. — Between the former two there is little need 
of distinction, for both arise from an obstructed venous circulation whether from 
valvular disease, a weakened myocardium, toxemia, the pressure of tumors, 
a pleuritic or pericardial exudate, abdominal distention, or cerebral lesions. 

Clinically, the hypostatic form as distinguished from the simple obstructive 
cardiovascular congestion is encountered in conditions of profound exhaustion^ 
especially such as are characterized by the typhoid state. It represents oftentimes 
a secondary circulatory weakness and extreme asthenia often associated with a 
more or less profound toxemia. Both forms are markedly affected by the decubitus 
of the patient. 

Pulmonary Edema. — Edema accompanying acute pulmonary congestion or 
inflammation is termed "infectious" or "inflammatory" as opposed to the 
ordinary edema of the lungs associated with passive congestion. 

This latter in its fulminant form is a terminal event, or paroxysmally re- 
current, in many diseases and may both come and kill suddenly and without 
warning or supervene upon prolonged congestion. In certain cases it seems 
to be purely toxemic but fundamentally its etiology is that of the associated 
congestion. 

Morbid Anatomy of Passive Congestion. — Long-continued passive con- 
gestion may produce brown induration, the organ being dense, bulky and 
russet brown; its capillaries are distended, the bronchioles and alveoli filled 
with epithelium, blood cells and pigment, and there is connective tissue in- 
crease. This represents especially the obstructive congestion typified in 
incompensated mitral lesions. 

In the hypostatic form the engorgement is intense and portions of the lung 
sometimes airless. If these areas are extensive the term splenization is 
applicable. 

In pulmonary edema the bulky lung is sodden and the foamy yellow or 
reddish serum infiltrates the interstitial tissue and fills the air passages. 

Any of the forms of passive congestion may exhibit unilateral predomi- 
nance of involvement, usually postural, but they are usually bilateral. 

Symptoms. — The milder types of all varieties of pulmonary congestion 
may produce but slight subjective and objective symptoms. 

The condition invariably demands cardiac stimulation. 
In cardiac disease, for example, the condition may not attract notice until 
here is marked dyspnea and a blood-streaked sputum containing the peculiar 
pigment-bearing cells. 



DISEASES OF THE LUNGS AND PLEURA 



401 



edemas. 



Variable 
physical signs. 



Marked sub- 
jective and 1 
objective signs. 



Liquid rales. 



A careless practitioner often entirely overlooks chronic hypostasis until 
it has reached a pneumonic stage (splenization). Less frequently mild forms Fugitive 
of edema occur which may be fugitive and transitory. 

In the severer forms of passive congestion, dyspnea and cyanosis are pres- 
ent and in marked edema are excessive. 

In all there is restriction of chest movement pari passu with the area involved. 

Fremitus may be diminished or increased, according to the degree of relaxation 
on the one hand or actual consolidation on the other. • 

The percussion note may be hy p err esonant from mere congestive relaxation 
or dull from consolidation. 

Auscultation may reveal harsh, diminished, absent or tubular breathing 
according to the stage of congestion, the presence of atelectasis or the establishment 
of true consolidation. 

Rales, both dry and moist are present, their pitch and quality varying 
with the pathologic conditions. 

In established, severe edema the objective and subjective symptoms are pro- 
nounced, the sputa being profuse, frothy, serous or blood-stained and in in- 
flammatory edema presenting the "prune-juice" appearance. In established 
edema, moreover, the rales are peculiarly and frankly liquid, the breath 
sounds and voice conduction being usually suppressed or feeble. 

Important Comment. — Slight persisting crepitation at a base in a nephritic 
subject, or in any patient suffering from the diseases associated with passive 
congestion, demands serious attention though it may persist over long periods 
without critical symptoms. 

Astonishingly sharp congestions may accompany obscure cerebral apo- 
plexies unassociated with persisting paralysis or loss of consciousness. 

In a case of this type recently observed two cerebral hemorrhages of the 
silent type occurred without loss of consciousness or persistent loss of power, 
the only symptoms being sudden pallor, mental confusion, transient motor 
weakness, acute cardiac dilatation, and, in the second attack, transient motor 
aphasia. In each there was marked pulmonary congestion lasting for about 
twelve hours. A third hemorrhage ten days later produced almost instant 
death. 

Many similar cases have been observed, one just at the time these words 
are written. The recovery of the pre-existing heart outline is usually prompt, 
even though direct cardiac stimulation is not employed. This is true, how- 
ever, only in the event that absolute rest is enforced. 

Cardiac stimulation, or, in hypostasis, mere attention to the necessary 
shifting of a patient's position may rapidly and markedly diminish the in- 
volved areas, the latter condition being often due to a weakened circulation 
plus a fixed posture, in senile, obese, cachectic or profoundly toxemic patients. 

TUBERCULOSIS OF THE LUNGS 

{Pulmonary Phthisis, Consumption) 
Definition. — An infectious disease caused by the tubercle bacillus of Koch, 
usually chronic, rarely acute, characterized by the formation of tubercles or diffuse 
26 



Congestions of 
apoplexy. 



402 



MEDICAL DIAGNOSIS 



" Koch's 
fulfilled. 



Law 



Slow vs. 
rapid. 



infiltration of tuberculous tissue and tending to acute general dissemination, 
ulceration, fibrosis or calcification. 

Distribution and Cost. — It is a universal disease visiting practically all 
races and every latitude. In the United States alone it kills at least 
110,000 persons each year, and the annual loss in potential wealth has 
been estimated at $500,000,000. It costs the life insurance companies of 
America at least $6,000,000 annually, and as the deaths occur chiefly at 
early ages when few premiums have been paid, it constitutes the source 
of their greatest early loss. 

It ranks second only to heart disease and pneumonia as a cause of death 
and has dropped from the first place only during the past decade. 

Susceptibility. — Domestic animals and pets, such as cattle, pigs, 
guinea-pigs, rabbits and monkeys are extremely susceptible. Horses, 
dogs, goats and cats are much less vulnerable. 

Climate. — Cold, damp, densely populated districts suffer most, and 
dry and high altitude regions least. 

MORBID ANATOMY.— If a pure culture of tubercle bacilli be injected 
into the tissues of a susceptible animal it produces tuberculosis. From the 
tuberculous tissues the germ can be recovered, grown in pure culture, again 
used for inoculation and so on indefinitely. This absolute proof of its infec- 
tious nature was established promptly and made the position of those fighting 
the " great white plague" unassailable. 

Changes Subsequent to Inoculation. — (a) Grouping of germs in tissue by 
multiplication, and their distribution by the lymph, or more rarely, blood-current. 

(b) The formation of epithelioid cells, about five days after inoculation, 
by multiplication and by metamorphosis of the cells of the capillary endo- 
thelium and connective tissues. 

(c) Outwandering of leucocytes to focus of infection and multiplication of 
mononuclear forms. 

(d) The formation of a marginal reticulum of connective tissue. 

(e) The production of large epithelioid cells containing from four to twenty 
nuclei grouped at the poles or periphery. 

These giant cells are most common in lupus and in glandular and bone 
tuberculosis and the more chronic and slowly developed the process, the 
greater is their number. In acute lesions they are scant and absent, nor are 
they peculiar to tuberculosis, being found in other of the granulomata such 
as syphilis. 

Caseation and Sclerosis. — The changes described tend inevitably to de- 
vitalize the affected tissue and produce areas of central coagulation necrosis 
converting all structures into a cheesy homogeneous substance. This may 
be extruded, leaving cavities of greater or lesser size, or, more rarely, calcifica- 
tion may accompany encapsulation. Many cases terminate spontaneously 
without reaching caseation and often without yielding any recognizable 
symptoms. 

The Spread of Infection. — It will be readily understood that lymph dis- 
tribution of the usual type means a slow process; infection through the blood 



DISEASES OF THE LUNGS AND PLEURA 



403 



stream or the thoracic duct, a rapidly developing and widely disseminated 
process. 

ETIOLOGY. — Race. — The Hebrews are to a certain extent immune, but 
in this country the Irish and the Scandinavian, the Indian and the negro 
show a heavy mortality. 

Sex. — Its incidence is about equal in the two sexes. 

Age. — Children are peculiarly prone to affections of the glands and bones, 
but after the age of childhood the lungs are chiefly affected and susceptibility 
diminishes considerably at the age of 30, although the mortality remains 
heavy even in the advanced age periods. 

During the period between the fifth and fifteenth years relatively few 
deaths occur. From the age of six months to twenty-four months the 
heaviest death rate occurs. 

Occupation. — Occupations involving exposure to extremes in temperature, 
dust and dampness are distinctly unfavorable. Workers grinding glass or 
steel or handling furs show a high mortality. 

Sanitary Conditions. — Lack of sunshine, fresh air, overcrowding, filth 
and physical exhaustion are all predisposing factors. Among the tenement 
classes all conditions are favorable to its development and transmission. 

Preexisting Diseases. — Tuberculosis frequently follows chronic disease 
of the tonsils, adenoids, neglected colds, broncho-pneumonia, lobar pneu- 
monia, pleurisy, influenza, measles, whooping cough and enterocolitis, and 
may complicate diabetes, aneurysm, locomotor ataxia, sclerosis of the liver 
or chronic Bright's disease, any condition in short reducing vitality and 
resistance or tending to prevent free lung expansion. 

Injuries. — Tuberculosis of the bones and joints and especially of the 
vertebra and hip-joints in children is frequently ascribed to injury, though 
due no doubt to a preexisting latent infection. 

Heredity. — Direct transmission in utero (placental tuberculosis) is prob- 
ably extremely rare, and heredity is but another name for post-partum im- 
plantation of the germ upon a fallow soil which is usually that constitutional 
defectiveness of structure and tendency to unstable and inadequate function 
known as "congenital asthenia". The tuberculous mother readily transmits 
germs to her offspring and a neglect of sanitary precautions in any infected 
house is peculiarly dangerous to the children. The germs may remain latent 
in the glandular system for an indefinite period, a fact undoubtedly explain- 
ing the increased adult mortality from tuberculosis in families showing the 
taint. 

Individual Predisposition. — The " habitus phthisicus" has long been recog- 
nized, certain individuals being from birth less resistant to the germ than 
are others. Small bones, a delicate complexion, and a contracted chest, 
long sweeping lashes, large lustrous eyes and silky hair are found in one type; 
a muddy complexion with marked tendency to glandular swelling, acne 
and weak eyes mark the other type. Extraordinary beauty, unusual intelli- 
gence and a quick wit were recognized even by the ancients as qualities often 
associated with tuberculous predisposition. The children of either type fre- 



Common 
factors. 



Predisposing 
factors. 



Diminished 
resistance. 



Post-partum 
infection. 



Often latent. 



Well-known 
type. 



404 



MEDICAL DIAGNOSIS 



May escape 
disease. 



''Habitus 
phthisicus. 



Delicacy of 
■tructure. 



Dependence 
opon hyper- 
nutrition. 



A temptation 
to the unwary. 



Visceroptoses. 



The nervous 
dyspeptic and 
hypochondriac 



Haunters of 
the "spas." 



Previous 
history. 



quently represent undoubtedly cases of latent infection and need unusual 
care along hygienic lines. Having this they may grow up to manhood strong 
and well and die of old age. 

Chronic Congenital Asthenia. — This condition is closely allied to if not 
identical with the so-called " habitus phthisicus" and embraces that great 
host of ailments associated with congenital delicacy of structure, ligamentous 
relaxation and unstable function. 

Physical Characteristics of Congenital Asthenia. — Slender bones, a weak 
illy-developed thorax, nephroptosis, gastro ptosis, constipation, the "drop" heart 
with its peculiar attenuation and weak and easily overstrained musculature are 
some of the conditions which characterize the asthenic state. 

Nutritional Instability in Asthenics. — According to the observation of the 
author, diminished resistance to acute disease, relatively slow or imperfect recovery 
from acute ailments, a tendency to chronic subnutrition and rapid weight reduc- 
tion are no less striking than the coming and going of symptoms of the most 
diverse sort in close accord with weight loss and gain. 

Gastric neuroses, psychasthenia and temporary, recurrent, or persistent, 
minor cardiac inadequacy are the chief manifestations aside from tuberculosis, 
to which they are peculiarly susceptible and by which many are actively infected. 
They represent in a considerable measure that great group of individuals 
who carry active or latent or larval, rather than wholly obsolete foci. 

The great army of invalids, actual or potential, recruited from the asthenic 
multitude with their manifold symptomatic possibilities still offer an 
apparently tempting, but actually most barren field, for the overzealous and 
unwise surgeon. 

Such readily present their nephroptoses, gastroptoses, uterine displace- 
ments, aberrant intestinal loopings and the like to the surgical enthusiast 
but those who survive operation for the most part relapse and become a 
plague to their would-be benefactor. 

The extreme type is represented by the dreaded patients who carry the 
notebook containing daily memoranda of symptoms and queries. Such are 
always seeking new theories and fresh advisers when, as a rule, their need is 
met and their cure effected by the simplest of measures, viz., helpful sugges- 
tion, rest and hypernutrition.* In times of peace these peripatetic and 
gregarious possessors of rebellious stomachs and "tittery" nerves nil the 
"spas" and the more bizarre of the sanatoria of Europe. 

Preferential Site of Tuberculous Lesions. — Almost any portion of the 
body may be involved, the lungs most frequently in adults, the bones, lymph 
glands and intestines in children, while the peritoneum, kidneys or brain 
may be involved at any age. Secondary involvement of the intestines is very 
common in advanced pulmonary tuberculosis. 

Modes of Onset. — It should never be forgotten that nearly every case of 
tuberculosis, whatever its form or apparent suddenness of onset, gives a history 
of previous impairment of health. 

* Unfortunately, however, an expensive matter, as it often involves prolonged hospital 
treatment. 



DISEASES OF THE LUNGS AND PLEURA 



405 



As regards actual onset, it may be acute miliary and widespread, or 
astonishingly insidious, slow and chronic, wholly glandular or osteal, or triable, 
peritoneal, pleuritic or pneumonic. 




Fig. 151. — Acute miliary tuberculosis in a child. Note diffuse studding of lung fields 
with miliary tubercles. {Dr. Frank S. Bissell.) 



ACUTE MILIARY TUBERCULOSIS 

{Acute Tuberculosis. General Diffuse Tuberculosis. Acute Disseminated 

Tuberculosis) 

Usual Cause. — The introduction of an adequate "dose" of virulent 
tubercle bacilli, from a latent or active glandular, osseous, or pulmonary 
focus, into the blood stream. 



406 



MEDICAL DIAGNOSIS 



Wide dissem- 
ination of 
lesions. 



A deceptive 
type. 



Important 
signs. 



Bacilli may be 
absent. 



Usually scant. 



Hyper- 
resonance. 



Usually 
broncho - 
pneumonic. 



Morbid Anatomy. — The viscera show general changes of an acute febrile 
infection and a general distribution of miliary tubercles; the lesions in the 
lung, pleura or brain predominating and the peritoneum or more often its 
diaphragmatic surface, being frequently much affected. 

Symptoms. — Typhoidal Form. — The onset may be gradual and exactly 
simulate typhoid. The fever rises gradually or more rarely, sharply, and 
to a variable degree, 103 to io5°F. being common and afebrile cases rare. 
The symptoms may be those of the "typhoid state," but the following are 
prominent and should be carefully noted: 

(a) Markedly accelerated breathing, (b) Subjective and objective dyspnea, 
(c) A rapid weak pulse, (d) Cyanosis, (e) Sweats. (/) A variable, often 
intermittent or inverse temperature. A continuous temperature may be present 
for some days prior to the development of inter mittency . Usually but not 
invariably one observes (g) cough, unproductive or attended by purulent or 
mucopurulent sputum, (h) Tubercle bacilli, which may be present early, more 
often late, or, in rare instances, be absent throughout, (i) Herpes labialis, 
(j) Rapid emaciation is constant. 

Physical Signs. — At first they are absent or only bronchitic in character 
and for days or weeks may be scant or misleading. A careful examination 
may demonstrate the presence of antecedent tuberculous lesions. The author 
believes that diffuse and almost universally uniform hyperresonance is the most 
constant and significant early sign. In rare instances patches of consolidation 
are clearly defined. 

The enlargement of the spleen occurs much later than in typhoid, and the 
same may be said of EhrlicWs diazo-reaction. WidaVs agglutination reaction 
is absent, the stools quite unlike typhoid and blood cultures are negative. 
Furthermore, the pulmonary symptoms are strikingly predominant even in 
that acute general form which presents abdominal symptoms.* 

Course. — Six to twelve weeks. 

Prognosis. — Almost invariably fatal, though rarely the acute symptoms 
subside leaving a progressive but limited lesion. 

Comment. — The general symptomatology of the disease is that of an acute 
intoxication with disseminated miliary foci and these facts explain the absence 
of marked physical signs. Cases may be wholly pulmonary or predominantly 
abdominal, but a division into pulmonary, typhoidal and peritoneal is 
useless. 

ACUTE PNEUMONIC TUBERCULOSIS {Phthisis fiorida, Galloping 
Consumption, Acute Tuber culo-pneumonic Phthisis). — This is a relatively 
rare disease representing not over 2 per cent, of the cases of pulmonary 
tuberculosis. It is usually bronchopneumonic in form; rarely lobar. 

The Lobar Form. — This may exactly simulate an ordinary pneumonia, but 
one often finds a history of previous illness or signs of old lesions.- 

In these cases the destructive process is often rapid and extreme and 

* As a matter of fact the confusion of typhoid fever and miliary tuberculosis need but 
rarely occur even if the diagnosis lacks the assistance of the Widal test and blood 
culture. 



DISEASES OF THE LUNGS AND PLEURA 



407 



the author recalls one in which at autopsy the right lung was found to 
be entirely destroyed, leaving a single huge cavity, the left lung being 
infiltrated and hypertrophied to such an extent as to force the heart to the 
right and produce a concentric dexiocardia. 

Instead of a true crisis, or following a deceptive pseudo-crisis, septic 
temperature develops with sweats and a purulent sputum containing tubercle 
bacilli, but in some instances the process subsides, be- 
comes chronic and may even become arrested. 

Early positive diagnosis is usually impossible. 

The Broncho -pneumonic Form. — The broncho-pneu- 
monic form is characterized pathologically by broncho- 
pneumonic tuberculous lesions and shows a tendency to 
fusion, caseation and cavity formation. 

It presents the symptoms of an acute broncho-pneumonia 
of the common type followed by the signs of septic absorp- 
tion, pulmonary infiltration and cavity formation. 

Tubercle bacilli may be and usually are present early, 
but their appearance may be delayed. Hemoptysis may occur and is some- 
times the first event. 

Comment. — In both the lobar and broncho-pneumonic forms of acute 
tuberculosis a delayed diagnosis is almost always necessary. The most careful 
questioning as to previous health and family history may yield no informa- 
tion, and the appearance of tubercle bacilli and the signs of destructive in- 
filtration associated with hectic fever mav be the onlv means of diagnosis. 



Pseudo-crisis 
or none. 




Fig. 



-Tuber- 



cle bacilli. (Exag- 
gerated. See plate 
under "Sputum" for 
better exposition.) 



Early diagnosis 
difficult. 



Is evident 
later. 



Bacilli 
often present 

early. 



Previous health 
important. 



CHRONIC ULCERATIVE TUBERCULOSIS 

Definition.— .4 tuberculous disease of the lung characterized by chronicity, 
variability in severity and frequent intermissions. Aside from individual 
resistance, its termination in recovery or death depends upon the promptness 
with which a diagnosis is made and rational measures instituted. 

Pathologic Anatomy.— The lesions are ordinarily those of a slowly pro- 
gressive chronic tuberculous broncho-pneumonia; the terminal bronchioles 
and the alveoli being the seat of a sluggish inflammation forming areas of 
peribronchial pneumonia which may advance rapidly, remain almost un- 
changed over long periods or undergo complete arrest. The tendency in bad 
cases is toward fusion of areas, ulceration and cavity formation. 

Favorable cases result in fibrosis, capsular limitation and arrest more often 
than is ordinarily supposed. Spontaneous recovery from unrecognized 
tuberculosis is extremely common, as shown not only by routine X-ray ex- 
aminations and the results of the various tuberculin tests, but also by the 
post-mortem records at home and abroad; contracted apices, peribronchial 
nodules and adhesions being frequently found. 

Inflammation of lung tissue in this disease leads to reflex defensive limi- 
tation of lung movement. The areas involved present more or less 
imperfectly, the signs of broncho-pneumonia either sharply localized or 
disseminated and often over extremely small areas; but large tracts may 



The common 
form. 



The sine qua 
non. 



Chronic 
localized 
broncho- 
pneumonia. 



Fusion of 
areas. 



Fibrosis. 



Frequency of 
arrest. 



Limitation 
of lung 
movement. 



408 



MEDICAL DIAGNOSIS 



Cavity 
formation. 



become involved with a corresponding increase in the frankness of the 
pulmonary symptoms. 

By necrosis of the bronchial walls through inflammation aided by the 
pressure of retained secretion and a destructive ulceration, cavities are 
formed, the physical signs of which are fully discussed elsewhere. 




Fig. 153. — Calcified hilus and lung foci. Probably due to fungus infection in old pul- 
monary tuberculosis. {Dr. Frank S. Bis sell.) 



Cases of 
dubious signs. 



New cavities without a firm limiting membrane may yield doubtful signs, 
particularly if they occur in the center of a caseous area lacking bronchial 
communication. These vomicae vary in size, sometimes representing almost 



DISEASES OF THE LUNl'.S AM) PLEURA 



409 



the whole right or left chest as in the case already mentioned.* Small 
cavities are obliterated by a process of absorption, fibrosis and contraction; 
large cavities may be partially obliterated by the same processes and become 
inactive. 

Hemorrhage may occur at any stage of a chronic ulcerative tuberculosis 
and though the arteries are usually resistant, may be the first symptom. 
The amount varies from a mere streak of blood to the rarer flooding that 
kills almost instantly. 

Bronchiectases are common in advanced cases, the intestines are often 
involved and this complication, like ulceration of the larynx, is painful, ex- 
hausting, and tends to greatly shorten life. 

A Word of Warning. — A large proportion of persons who have reached full 
maturity have at some time acquired a tuberculosis focus at an earlier period, in 
most instances trivial, latent or obsolete, at the time of examination, but sufficient 
to yield at any subsequent time a reaction to tuberculin and, in most instances, 
to show suggestive abnormalities in the X-ray photograph. 

It is the duty of the physician to strive to detect even the latent foci by all 
safe means, but costly and burdensome therapeutic measures can properly be 
imposed only upon reasonable proof of the existence of active processes. 

There can be little question that too great a dependence upon mere signs 
of past infection has often resulted in much unnecessary hardship to per- 
fectly healthy individuals. On the other hand, one must be prompt and 
decided in the presence of any definite evidence of an active process, however 
slight. • 

Phthisiophobia. — The necessary and proper dissemination of knowledge 
concerning phthisis has- developed to a considerable degree a morbid fear of 
infection and as a result one encounters many sound phthisiophobes who need 
a careful and thorough examination and positive reassurances based upon 
impeccable and defensible negative findings. 

SYMPTOMS. — Early Symptoms. — The modern theory of the curability 
of tuberculosis depends upon early diagnosis. 

Every physician who uses the X-ray knows that cases referred to him as 
latent or incipient are likely to be far advanced, i.e., in the second or even 
third stage of the disease. They should be recognized before the stage of 
extensiveUnfiltration and certainly before softening has begun if the best 
results are to be obtained. When so recognized at least 80 per cent, can be 
restored to apparent good health, and the larger number of these should 
remain well under proper conditions. 

Aside from tubercle bacilli and cavity signs, no one symptom is conclusive, 
but those following should be considered. 

(a) Loss of Weight. — The present weight, the best weight, and the weight 
prior to any noticeable impairment of health should be ascertained, as few cases 
develop activity without progressive weight loss.i 

* Case of Dr. B. J. Merrill, of Stillwater, Minn. 

f Robust-appearing heavy-weights may have lost 30 or 40 pounds and such patients 
often receive scant sympathy and no proper examination. 



Variable size. 



Processes of 
obliteration. 



Hemoptysis. 



Laryngeal 
cases. 



Almost 

universal 

prevalence. 



Question of 
activity of foci. 



Unnecessary 
and unjustified 
hardships. 



Early 
diagnosis. 



Curability 



Progressive loss. 



4io 



MEDICAL DIAGNOSIS 



Common. 



Often denied 
when obvious. 



Usual 
character. 



Excessive 
secretion. 



Often absent. 



Open vs. closed 
cases. 



Variable. 



Seldom 
extreme. 



Often 
confusing. 



Suggestive 
types. 



May be early. 



Labile pulse. 



Very 
important. 



Afebrile cases 



(b) Indigestion. — Dyspeptic symptoms are common in the early stages 
of tuberculosis, and loss of weight is often attributed to that cause when it 
should be traced farther back. 

(c) Cough. — This may be entirely absent and is frequently unnoticed and 
denied by the patient, even though obtrusive during examination. It is often 
harassing and troublesome, particularly at night and, even in the advanced 
stage of the disease, may be entirely unproductive, hardly more than a clear- 
ing of the throat, or, associated with profuse cavity expectoration, bron- 
chorrhea or even hemoptysis. It is oftentimes bronchiectatic in inveterate 
cases. 

(d) Sputum. — The sputum may be absent, mucoid, mucopurulent or puru- 
lent, according to the stage of the disease. Cases may show marked infiltra- 
tion even before sputa are obtainable. Tubercle bacilli are present in all 
advanced cases, but a diagnosis must often be made in their absence. When 
found by proper staining methods the evidence is positive and final. 

(e) Pain may or may not be present, and is often represented by a feeling 
of mere oppression, at other times being distinctly pleuritic in type or dull 
and ill-defined. 

(/) Anemia is frequently present in the early stages of the disease, and 
always in advanced cases. In the former it is sometimes of the chlorotic 
type, but usually one finds a secondary anemia. 

(g) Dyspnea. — Dyspnea on exertion is not uncommon early and is an 
invariable late symptom. 

(h) Bronchitis. — A diffuse obscurant bronchitis or even spasmodic 
asthma is sometimes present and may mask the true lesion. In other in- 
stances it is a localized and suggestive bronchitis. 

(i) Pleuro-pericardial Friction. — The author has learned to regard with 
great suspicion frictional murmurs, pleuro-pericardial in type and site, not 
associated with a definite attack of pericarditis or pleurisy, but with impair- 
ment of the general health. In many instances these have proven the first 
demonstrable physical signs of a rapidly destructive tuberculous process. 

(j) Night Sweats. — This troublesome symptom is ordinarily associated 
with the final stage, but may be encountered at any time in the course of the 
disease. Such sweats are both chilling and exhausting. 

(k) Pulse. — In connection with other symptoms the excitability and undue 
rapidity of the pulse is extremely important. 

(/) Temperature. — In advanced tuberculosis, the temperature is simply 
that of a septic process, being distinctly intermittent or hectic in type and 
associated with night sweats. When new areas of the lung tissue are invaded, 
the temperature is likely to be continuous or only remittent. One is 
chiefly interested in the variations in incipient cases and here one must 
emphasize the importance of any persistent rise above the normal, however 
slight. 

In febrile tuberculosis cases, the maximum rise is usually in the evening , 
but we may have an inverse temperature with the evening reading normal. 

Some cases have no temperature, and one under the author's observation 



DISEASES OF THE LUNGS AND PLEURA 



411 



a few years ago, went through the various stages of the disease to death with- 
out a rise above 99°F.* 

/;/ many cases a temperature will be found only after exertion, and this is 
a matter of the greatest importance in relation to both diagnosis and treat- 
ment. Furthermore, in such cases a wide variation between a subnormal 
morning reading and the evening temperature, though the latter be within 
normal limits, may be as serious an indication as the abnormal rise. 

Hemoptysis. — Although the fact is well known that hemoptysi> 
without detectable cause is almost invariably due to tuberculosis, one hnds 
many instances of most unfortunate time-loss due to a failure to put this 
practical knowledge into the form of early diagnosis. 

Tuberculosis, pulmonary infarct, and syphilis are the three causes chiefly 
to be considered. Of these the two former are overwhelmingly the more 
frequent. 

The term "hemoptysis" should not be applied to blood-streaked or even 
bloody sputum such as occurs in severe bronchitis, the pneumonias, or 
passive congestion of the lung. Its use should be limited to the actual 
hemorrhages of bronchial or pulmonary origin. 

Aside from the three leading causes mentioned above, one must bear in 
mind bronchiectasis, pulmonary abscess and gangrene, aneurysm, malignant 
growths, actinomycosis, aspergillosis, streptothricosis. echinococcus. dis- 
tomiasis, hemophilia, scurvy and the purpuras. 

Fluoroscopy. — The skilful use of the fluoroscope and X-ray plate 
throws much light upon the condition of the lungs in incipient cases and by 
the former method one often finds a marked limitation of lung movement 
(''Francis Williams' Sign") as measured by the descent of the diaphragm, 
quite disproportionate to the amount of lung involved. .Areas of extensive 
infiltration show as shadows, and cavities of considerable size as bright 
spots. 

Litten's sign may be used to test the diaphragmatic movement in the 
absence of the fluoroscope. 

Tuberculin. — The subcutaneous use of tuberculin as a diagnostic agent 
has its many advocates and its few bitter opponents. 

It is argued that inasmuch as the physical signs produced are due to the 
production of congestion in tuberculous areas, every dose subjects the patient 
to unnecessary risks. 

On the other hand, its advocates claim that the importance of " absolute" 
diagnosis and the rarity of bad results following its use serve as its justifica- 
tion. This might readily be admitted if the results obtained were positive 
for active lesions only, for bad results from diagnostic doses are extremely 
rare, but '"' absolute" information means usually nothing more than the fact 
that at some time, somewhere, the patient has been infected and, in the adult 



Exertion 
temperature. 



Important 
clinical fact 



Ertremelj 
valuable. 



Varying views 



Extreme 
frequency of 
reaction. 



* The case was not observed in its incipiency though the infiltration was only slightly 
advanced, but as no temperature was shown during the stage of softening and when the 
sputum was filled with tubercle bacilli, it is to be presumed that it was absent in the ear 
lier stages. The patient was a congenitally asthenic girl of 17. 



412 



MEDICAL DIAGNOSIS 



Fallible. 



Routine use 
unwise. 



Differential 

t€6tS. 



one might " guess" correctly seven times out of ten without even seeing the 
patient. It does not prove the activity of an infection* 

The author believes that the routine use of the subcutaneous method is to be 
condemned and that the methods of Moro and Von Pirquet are adequate. 

The fact that it is capable of producing a rise of temperature in so many 
apparently, healthy controlsf and in certain cases of syphilis, and the 
additional fact that from 60 to 70 per cent, of apparently normal individuals 
above the age of thirty react, certainly makes its findings less positive than 
might be wished. 

Furthermore, the recent attempts to differentiate the reactions quanti- 
tatively and read into them special diagnostic meaning are not convincing, 
despite the brilliant work of Wolff-Eisner, Teichman, Ellerman and Erland- 
sen, and others. J 

Some of the most striking reactions ever observed by the author have occurred 
in vigorous individuals wholly unconscious of any health impairment present 
or past and now enjoying good health after the lapse of years. 

Preparation of Tuberculin for Subcutaneous Use. — "Alt-tuberculin" may- 
be had in i-c.c. (1000-mg.) ampules and one uses this content as follows: 

Using sterile normal salt solution make a dilution of 1 in 10; with 1 c.c. 
of the 1 in 10 make another in the same manner and so on until four have 
been prepared. 

Then 1 c.c. of dilution No. 1 =0.1 = 100 mg. 
1 c.c. of dilution No. 2 =0.01 = 10 mg. 
1 c.c. of dilution No. 3 = 0.001 = 1 mg. 
1 c.c. of dilution No. 4 = 0.0001 = Ko nig. 

Thus by successive dilutions one may obtain any required lesser fraction 
of the milligram of old tuberculin. 

The addition of 0.2 c.c. trikresol for each J-f c - c - °f solution will maintain 
its sterility or one may use a 0.5 per cent, soluti'on of carbolic acid. 

The Subcutaneous Tuberculin Test. — In adults Ko to 0.5 mg.of a//-tuber- 
culin in normal salt solution is first injected according to the condition of 
the patient. If no reaction occurs, 1 to 2 mg. are injected forty-eight hours 
later, and still later if the reaction fails 5 or even 10 mg. 

Reaction Signs. — (a) Fever. (ioo°F. represents the "mild reaction," and 
io2°+F., the "severe form.") 

* Chas. E.. Simon gives the following table as illustrating the extraordinary frequency 
of the reaction: 

Known pulmonary tuberculosis 90 to 100 per cent., positive. 

Suspected cases 92.1 per cent., positive. 

Supposedly normal cases 56.1 per cent., positive. 

f Robert Koch himself developed a severe general reaction following the injection of 
0.25 c.c. of tuberculin in the course of his experiments. 

% Only the proof of marked superiority of this test, a proof not yet forthcoming, can 
justify its use in preference to the simple, safe and equally accurate test of von Pirquet.' The 
author gives the test, nevertheless, because of the existing difference of opinion and its 
use and attempted justification by some of our ablest medical leaders. 



DISEASES OF THE LUNGS AND PLEURA 



413 



(b) General malaise, aching and depression, prostration, sometimes nausea 
and vomiting. 

(c) Swelling of regional glands in many instances. 

(d) Allergic reaction, i.e., redness and swelling at the site of injection. 

(e) Physical signs may appear, or increase if preexistent, indicating a 
temporary glowing or lighting up of old foci. Such are harsh breathing, 
crepitations, or crackles, increase or marked diminution of sputa, etc. 

Precautions. — Injections should be made only in the forenoon lest an 
early temperature rise occurring in the night may be overlooked. 

If fever is present one must await its subsidence over a period of several days. 

If small doses are used, from ten to sixteen hours may be required before 
reaction occurs. 

If the patient has any persistent fever the test is of little value. 

Pregnancy, heart disease, diabetes, nephritis and laryngeal tuberculosis 
contraindicate its employment. 

Modifications of the Tuberculin Test. — Von Pirquet's vaccination test 
depends upon the fact that hypersensitization of the tissues of an individual 
affected by an infectious disease (allergie) induces a specific reaction to the 
toxic substance even in the skin. This is merely an application of the 
doctrine of anaphylaxis. 

The Von Pirquet Test. — Any good tuberculin, preferably the alt-tuberculin 
of Koch, is diluted by adding 1 part of 0.5 per cent, carbolic solution 
and 2 parts of normal saline solution; the patient's arm is prepared as for 
ordinary vaccination and three areas are lightly scarified, two through a drop 
each of the test solution in situ, the other similarly treated with the dilut- 
ing fluid alone. The test and control punctures may be but slightly apart 
so as to be covered by the one vaccination shield or they may be on 
opposite arms. Both should be carefully protected. 

The test as usually outlined at the present time demands the use of the 
undiluted old tuberculin. The special " '"impfbohrer" of von Pirquet is not 
essential. 

Usually redness and more or less infiltration will appear at the site of the 
test abrasion within twenty-four to forty-eight hours, but even a vigorous 
reaction may be delayed for seventy- two hours or even more. No consti- 
tutional or localizing physical signs appear, and, though occasionally the 
reacting area appears angry and inflamed, all untoward signs soon 
subside. 

In all cases the author tests the degree of infiltration by pinching both the 
vaccination and control areas between the thumb and forefinger. This enables 
one to detect reactions in cases yielding little redness. 

Wolff-Eisner and later Calmette attained the same result by instilling a 
0.5 per cent, solution into the conjunctival sac where it was retained for a 
moment or two and in from twelve to forty-eight hours produced decided 
congestive or inflammatory signs in affected individuals. 

Moro prepares an ointment of 50 per cent, strength, rubbing up alt- 
tuberculin with dehydrated lanolin. A pea-sized portion of this unguent is 



Focal. 



Simplicity. 



Absolutely 
harmless. 



Conjunctival 



test. 



Moro's test. 



414 



MEDICAL DIAGNOSIS 



Relative value 
of tests. 



Conclusions. 



Results 
essentially 
those of old 
test. 



The "von 
Pirquet" the 
most reliable. 



"Arrest" 
reactions. 



Prognosis. 



Advanced 
cases. 



True value of 
tests. 



Valuable in 
exclusion. 



gently rubbed into the skin of the chest or abdomen over an area of 5 cm., 
and this surface is left uncovered for from ten to fifteen minutes. 

Papules in varying number with or without erythema appear within a 
period varying from a few hours to three days. Moro divides reactions into 
three grades, viz.: (1) mild; (2) moderately strong; (3) severe. 

From personal experience with all three tests the author believes the first 
(von Pirquet) and the last (Moro) to be quite as valuable and far safer than 
the tuberculin injections hitherto and even now extensively practiced, but 
as in the case of the older method, they fail to prove in adults much more 
than the fact that at some time the individual has been infected* 

The following conclusions represent the author's views as based upon the 
results of a series of tests undertaken with the three modified methods and 
a somewhat extensive later experience. 

(a) The von Pirquet reaction is comparable and probably runs nearly parallel 
to the old injection test,\ inasmuch as the percentage of reactions closely approxi- 
mates that obtained by Beck and others using the older method. 

(b) No fever or physical sign increase is to be observed. 

(c) The three tests are almost equally valuable, though, in the author's hands, 
the von Pirquet proved the most reliable of them and should supplement any 
negative "Moro." The conjunctival test is the least certain and the only one 
of these three possessing elements of risk. 

(d) Active-incipient or moderately advanced cases in apparently resistant 
individuals and those carrying arrested or obsolete lesions react decisively, the 
last most vigorously and somewhat later in many instances. 

(e) In known active, progressive, but early cases, the more vigorous the reaction 
the better would appear to be the prognosis. 

(J) Advanced cases with low resisting power afford a slight transient reaction 
or none at all, often to be detected only by careful comparisons of the infiltration 
produced. 

(g) As in the case of the subcutaneous test, the positive reactions are so 
numerous and decided in vigorous non-suspects as to be merely suggestive or 
reminiscent. 

(h) The value of the positive test in infants and very young children is con- 
siderable, and that of the negative test in suspects of all ages can harldy be over- 
estimated, in that it practically excludes tuberculosis past and present. J 

Known tuberculous subjects who do not react, almost without exception 

* The value of negative results of these two tests in infants and very young children is 
obviously great and the younger the child the greater is the diagnostic significance of the 
positive test. Infection in children reporting to public clinics is said to reach 35 per cent, 
between the ages of six and ten. 

f The author has made demonstrable preponderance of infiltration at the site of vaccina- 
tion as compared with the control, the test of reaction rather than reddening of the skin 
alone, which sometimes fails especially in cachectic subjects. 

J Franz has reported 61 per cent, positives in apparently healthy young recruits. 
Results obtained in school children as reported by Hamburger and Sluka, Feer, Hillenberg 
and others show positive reactions in from 40 to 60 per cent. Cohn has reported 100 per cent, 
positives in fourteen-year-old children of tuberculous parents. 



DISEASES OF THE LUNGS AND PLEURA 



415 



present advanced, unmistakable and usually terminal symptoms with marked 
cachexia. 

(i) The methods of von Pirquet and Moro are wholly free from danger 
and cause little discomfort. 

The extraordinary prevalence of tuberculous infection in man, again may 
be emphasized by the following tables. 

Staehelin has admirably summarized the evidence which supports the 
oft-quoted dictum, u Jedermann hat am ende ein bischen tuberculose" (every 
one has a little tuberculosis some time).* 

Xaegeli reports as follows on 500 autopsies. 



Age 


Fatal 


Latent 


Latent 


Total infected, 


T.B. 


but active 


inactive 


per cent. 


Under 1 yr. 


O 


O 


O 


O 


1-5 yr- 


17 


O 





17 


5-9 yr. 


25 


8 


O 


33 


9-17 yr. 


15 


15 


8 


38 


18-30 yr. 


35 


36 


24 


95 


30-40 yr. 


47 


28 


39 


94 


40-50 yr. 


22 


23 


55 


100 


50-60 yr. 


20 


18 


62 


100 


60-70 yr. 


9 


25 


66 


100 


Over 70 yr. 


O 


^3 


77 


100 



It appears that practically all in this series above the age of seventeen 
showed previous infection by the tubercle bacillus. 

There is, of course, a considerable margin of error in such figures and one 
cannot properly apply the result of work in the dead house of the city clinic 
directly to the determination of the degree of infection prevailing through- 
out the population as a whole. 

Neither can one consider figures derived from the autopsies held upon 
patients dying in a public clinic as equally applicable to those individuals 
who enjoy a better environment. 

Nevertheless they indicate the extraordinary frequency of tuberculous 
infections in the past, now, happily, lessening. 

Burchardt reported finding evidences of tuberculosis in 91 per cent, of 
1452 autopsies. 

Many other confirmatory investigations are available and one must 
conclude that at least 80 per cent, of living individuals above thirty years 
of age carry tuberculous lesions, for the most part obsolete. 

(j) The absence of the localizing physical signs of the severer positive 
reactions of the old subcutaneous injection test is more than compensated for 
by the lesser risk, the avoidance of confusion due to existing fever or temperature 
lability on the part of the suspect, the simplicity and the definite results yielded 
by the allergic tests. 



* R. Staehelin, "Handbuch der inner e medizin," L. Mohr u. R. Staehelin, 
ii, p. 465-652. 



[914, vol. 



416 



MEDICAL DIAGNOSIS 



Area of in- 
volvement 
exceeds 
physical signs. 



Advanced 
cases. 



Incipient 
cases. 



Value of 
Litten's test. 



Frank cases. 



Misleading 
color. 



Often negative. 



Important 
data. 



Hyper- 
resonance. 



Comment. — All statistics show the great value of a tuberculin test 
(von Pirquet especially) in suspected infants and very young children in 
whom the infection is likely to be, or in infants must necessarily be, recent, 
but the liability to infection with increasing years progressively diminishes 
the positive value of the test. 

(o) Family History. — The family history may throw light upon latent 
infection, predisposition, or the resistance of the patient, and should be 
carefully investigated, as regards both incidence and course of cases, in 
brothers and sisters, parents and collaterals. 

(p) Past Health Record. — This may be of the utmost significance and 
importance. Past pleurisy, " winter cough," " inflammation of the lungs" 
of suspiciously long duration, "spitting of blood," and the like, merit careful 
investigation. 

PHYSICAL SIGNS. — A diagnosis must often be made in the absence of 
positive physical signs, as is evident from the genesis of the disease. Further- 
more, the X-ray negative will reveal always changes of far greater extent and 
importance than those elicited by the physical examination of the same case. 

Inspection. — The physiognomy of advanced tuberculosis is too well known to 
need a description, the laity recognizing it as readily as the physician. 

It is merely a composite of emaciation, hectic, exertion-dyspnea, and 
usually of faulty congenital chest conformation. 

Incipient cases have no distinctive physiognomy, though an asthenic build 
is usually present, and anemia may or may not be evident. Unilateral 
wasting of muscle in the suprascapular region is of much importance. 

The impairment of chest movement may be imperceptible in the incipient 
stage, though reduced expansion may be shown by the diaphragm phe- 
nomenon or the fluoroscope. 

Advanced cases show marked impairment of chest movement, and often- 
times localized contraction, abnormal pulsation along the pulmonary-cardiac 
boundaries and the characteristic, phthisical chest. 

Some cases present a high color similar to that noted in the mitral disease 
of young persons and due, apparently, to interference with the pulmonary 
circulation. 

Palpation. — Palpation may be wholly negative in the incipient stage, 
though yielding most exquisite signs in the advanced cases where it reveals 
lack of expansion, inequality of voice transmission, signs of cavity or marked 
infiltration (see " Consolidation" and "Cavities"). 

Percussion. — In the earliest stages percussion may be negative or actually 
misleading. 

Any decided inequality in the percussion notes of the two sides, particularly 
at the apex, should attract attention. It should be remembered that, 
normally, the note on the left side is less intense but lower pitched than that 
of the right. 

Hyperresonance at the apex, especially if unilateral, is a valuable suggestive 
sign of an incipient process; in the later stage it is of course likely to indicate 
vicarious emphysema or the presence of cavities. 



DISEASES OF THE LUNGS AND PLEURA 



417 



Patches of d nines s may be made out, or extensive areas of infiltration, with 
or without cavity formation, according to the status of the case. 

Auscultation. — This is by far the most important procedure. 

Unilateral diminution of the breath sounds or of voice conduction may be 
as significant as an increase in their intensity. 

Harsh breathing and the so-called "cog-wheel" inspiration must be carefully 
noted and the latter must not be confounded with the inspiration associated 
with an overacting heart, such a condition being frequently met with in tuber- 
culous subjects. 

Undue prolongation of expiration, though it be low-pitched, may be a 
sign of importance and in advanced cases with marked infiltration and cavity 
formation the breath sounds are frank and characteristic. 




Fig. 



154. — Various types of cavitation, illustrating some of the various factors affecting 

physical signs. 



Rales may be absent for a considerable period in the incipient stage. One 
often hears only fine sibilant sounds, most significant if detected at the 
apex even in the absence of other signs, and particularly so if unilateral. 
Every patient should be made to cough in order to bring out rdles, and deep 
inspiration following cough may be attended by sibilant, crackling or bubbling 
rales or by the so-called mucous click, according to the stage of the disease. 
In advanced cases the rales are of all types as described elsewhere. 

Comment. — Certain points are absolutely essential to the proper examina- 
tion and early diagnosis of tuberculous cases. A knowledge of the sounds 
produced by the various maneuvers in the normal chest is absolutely necessary. 
Unilateral variations are infinitely more important than bilateral ones in the 
incipient or early cases. Inasmuch as the disease usually commences at the 
apex, this region is the most important for the diagnostician. (Both are 
affected almost coincidently far more often than is generally supposed.) As 
judged by the physical signs, the earliest recognizable primary lesion is com- 
monly slightly posterior to the center and about 1 to 1^ inches below the 
apex. The disease tends to extend both upward and downward along the 
interlobar fissure and in front along the inner margin of the upper lobe. 



Unilateral 
variation. 



Cog-wheel 
breathing. 



Cough 
maneuver. 



Know the 

normal. 



Apex signs 



Line of march 



4i8 



MEDICAL DIAGNOSIS 



Posterior vs. 
anterior. 



X-ray. 



Height 
important. 



Associated 
ailments. 



Peculiar area. 



Great 
variation. 



Posterior apex auscultation is usually more productive than anterior 
auscultation in the early stages of the disease. 

The important auscultation areas are the apex, anteriorly and posteriorly, 
the inner lung borders anteriorly, the apex of the axillary space, and the region 
of the interlobar fissure posteriorly as roughly indicated by the scapular border 
when the arm is placed upon the opposite shoulder. 

As previously stated the lungs are usually much more extensively involved 
than physical signs would indicate, as anyone may prove by the use of the 
X-ray and this fact no doubt accounts for the errors in prognosis and failure 
in treatment in cases judged wholly by the physical findings. 

In fact, the systematic use of fluoroscopy or skiagraphy in these cases has a 
most chastening effect upon any man who believes himself able to accurately 
determine the number, position, character and extent of tuberculous lesions 
by other physical metJiods. 

Apex Movement. — It is important to employ auscultatory percussion 
over the apices in order to determine the height at which they stand and the 
difference in level as between inspiration and expiration. Marked retraction 
of one apex is an important sign of either an old apex lesion or an active and 
advancing one, but does not absolutely prove it tuberculous. The diaphragm 
phenomenon ("Litten's Sign") has already been described. 

Warning. — Tuberculosis is not the only disease capable of producing ab- 
normal signs at the apices. 

PULMONARY INFARCT 

{Pulmonary Apoplexy, Hemorrhagic Infarct, Pulmonary Embolism) 

Genesis. — All emboli in the branches of the pulmonary artery originate in 
the right heart, in thrombotic systemic veins, or from a thrombus in the artery 
itself, and may be septic or non-septic. 

The former occur in pyemia, ulcerative endocarditis, septicemia and ex- 
ceptionally severe acute febrile infections. The latter result from the detach- 
ment of vegetations from the tricuspid or pulmonary valves, from globose 
thrombi or polypoid vegetations, from the trabecular of the right auricle, from 
the chordae tendineae or apex angle, or from a more remote non-septic thrombus. 

In severe infections associated with marked myocardial toxemia the 
disengagement of such particles may follow sudden movement of the 
patient. 

The result is usually the blocking of a branch of the pulmonary artery 
which causes a localized pneumonia primarily representing the distribution 
of the affected vessel and in some instances leading to abscess or gangrene. 
The areas are usually wedge-shaped with their bases at the periphery and 
may vary in size from those no larger than a tiny seed to the huge infarcts 
affecting an entire lobe. 

SYMPTOMS. — Sometimes Obscure. — Tiny infarcts may be wholly 
symptomless or produce only slight cough, dyspnea, and perhaps hemoptysis. 



DISEASES OF THE LUNGS AND PLEURA 



419 



If branches of moderate size be involved these symptoms are more pronounced or 
indeed extreme and if the pulmonary trunk itself or its main branches be wholly 
blocked , rapid dissolution or instant death results. * 

Frank Cases Easily Recognized. — A sudden onset with such symptoms as 
are described below, accompanied by the physical signs of circumscribed pneu- 
monia, pleuro-pneumonia or possibly an acute edema, over an area usually 
basal or primarily axillary in location, together with the presence of recognized 
causative factors makes the diagnosis easy. 

If the embolus be septic the case becomes one of septic pneumonia with 
pulmonary abscess or gangrene. 

If the septic element be absent prognosis is favorable as regards the lung 
condition. Multiple successive small infarctions may occur and their location 
sometimes may be determined easily, as in a case recently observed, and, in 
typical cases, the picture presented, viz., sudden localized pain, dyspnea and 
bloody sputum, is characteristic even though the physical signs be obscure. 
The middle and lower lobes of the right lung are the regions most affected. 

It must be remembered that even large pulmonary infarcts may be 
unattended by bloody sputum. 

Thrombi of the Pulmonary Branches. — Ribbert maintains that throm- 
bosis is far more common than has formerly been supposed and that many 
of the silent infarction areas owe their presence to gradually induced thrombi 
in the pulmonary branches, rather than to embolus. 

PULMONARY ABSCESS. — The abscesses may be single or multiple and 
due to tuberculosis, septicemia, pyemia, septic emboli, lobar and broncho-pneu- 
monia, malignant endocarditis and indeed to suppurative disease of any organ 
or structure adjacent or remote. 

There is usually an associated empyema with embolic-infarction abscesses 
which are often multiple. Other abscesses may be distinctly localized pri- 
marily, but tend to extend. 

Symptoms. — The symptoms are those of sepsis (see " Septicemia" and 
"Pyemia") and the physical signs may be vague or lacking if the septic focus 
is central, or simulate an encysted empyema if superficial. Perforation 
readily occurs (most commonly in a bronchus) and is associated with the 
sudden appearance of a considerable quantity of purulent sputum which then 
persists with or without distinct and demonstrable cavity signs. g 

The sputum is then usually foul, and, in contradistinction to gangrene, 
contains elastic tissue. At first or at intervals it often shows more or less 
blood. It will be noted that the symptoms of sepsis apply to all forms; but 
closed abscess may yield no symptoms whatever or only percussion dulness 
and compression. 

Difficulties Seldom Insurmountable. — Despite this fact, in actual practice 
the author has not found the diagnosis of even closed pulmonary abscess so 
difficult a matter as one might assume. 

* It has seemed to the author that otherwise silent blocks in the pulmonary area may 
account best for many of the extreme abrupt, but transitory periods of urgent dyspnea and 
precordial oppression so often observed in decompensated cardio- vascular cases. 



Diagnosis 
easy, or 
impossible. 



The typical 
case. 



Multiple 
lesions. 



Sudden pain. 

Dyspnea and 
hemoptysis. 



Silent infarcts. 



Often obscure. 



Perforation. 



Foul 
sputum. 



Silent cases. 



420 



MEDICAL DIAGNOSIS 



The septic temperature is rarely absent and if localized dulness (often showing 
a central maximum and shading into a circumferential hyperresonance) can be 
determined, the free use of a clean aspirating needle introduced if possible at the 
center of maximum dulness point usually makes the diagnosis positive. 




Fig. 155. — Closed abscess in left lung. 

The roentgen-ray is often of the utmost value in these cases. 

In localized and walled-off (encysted) empyemas the symptoms may be 
precisely the same as closed pulmonary abscess, though the area of percussion 
dulness or flatness is usually more sharply delimited than is that of abscess. 

Prognosis. — Embolic abscess is almost invariably fatal and the prognosis 
is bad in all, though their course may oftentimes be prolonged or recovery 
achieved through surgical interference. 

PULMONARY GANGRENE.— The etiologic factors are chiefly those of 
septic pneumonia and pulmonary abscess. It is a rare complication of diabetes 



DISEASES OF THE LUNGS AND PLEURA 



421 



and pneumonia, exceptionally rare in tuberculosis, and varies greatly in extent, 
being either circumscribed or diffuse and usually but not always affecting the 
lower lobe. 

The involved areas are surrounded by consolidated, congested or edematous 
areas. An associated empyema is common and pleurisy invariable in the 
peripheral lesions. 

It shows the same tendency to perforation as does abscess, most commonly 
into a bronchus, more rarely into the pleura or even the pericardium, esopha- 
gus, or through the diaphragm. 

Symptoms. — The only symptoms differentiating the disease from pulmonary 
abscess or certain excessively foul bronchiectases is the peculiarly horrible odor 
of the sputum and the usual but not invariable presence of shreds or fragments 
of lung tissue, characteristically gangrenous and simulated by no other con- 
dition except certain rare cases of putrid bronchitis with interstitial pneu- 
monia and pulmonary carcinoma with gangrene. Owing to some peculiar 
fermentative action, the sputum often contains no elastic tissue, a fact of some 
importance. 

Prognosis. — Embolic, malignant, and diabetic cases invariably die; in 
others the prognosis is unfavorable, but not absolutely hopeless. 

PULMONARY TUMORS.— Only the malignant variety need be con- 
sidered. Primary sarcoma is a cmiical curiosity* an3 carcincrma rare, both 
being usually metastatic. The most common primary focus is of course the 
mammary gland, less often uterine, gastric, rectal and osseous growths. 
Carcinoma is the type of growth oftenest encountered and is most common 
in middle age and in the male. 

Symptoms. — The disease is often strikingly symptomless for long periods 
or baffling and indeterminate, the size and location of the growth being the 
chief factor; obstinate and violent cough may or may not be present. Sputum 
may be entirely absent or like prune juice or currant jelly, blood-streaked, or 
even purulent and of gangrenous odor, and contains compound granule cells. 
Involvement of the pleura may produce severe pain, and the dyspnea usually 
present in some degree may be strikingly paroxysmal; pressure symptoms 
may be marked and are often identical with those of aneurysm. Fever is 
often noted as the disease advances, profuse hemorrhage occasionally occurs 
and there may be marked displacement of the heart. Secondary growths 
are usually suggested by the primary lesion, but primary ones are frequently 
beyond a positive diagnosis. The X-ray may prove valuable in such cases 
and if the growth be accessible and of considerable size it may yield per- 
cussion dulness, usually without tubular breathing, and increased fremitus, 
or, more rarely, if attached to a large bronchus, both phenomena. Cachexia 
is of relatively slow development in carcinoma of the lung. 

* In a case of primary sarcoma of the lung observed recently by the author no positive 
diagnosis could be made during life, though the ailment was suspected by reason of the 
peculiar but extremely faint shadows shown by the X-ray. The physical signs were in- 
determinate, the heart signs and pressure symptoms slight but somewhat suggestive of 
aneurysm and the autopsy showed small disseminated growths, bilateral in distribution 
though chiefly affecting the left lung. 



Perforation. 



Odor 
diagnostic. 



Primary rare. 



Frank or 
obscure. 



Pressure 
symptoms. 



X-ray. 



422 



MEDICAL DIAGNOSIS 



Effusions. 



mportant 
point. 



Important 
areas. 



Age. 



Occupation. 



Tuberculosis. 



X-cay. 



MALIGNANT GROWTHS OF THE PLEURA,.— What is said under the 
head of malignant growths of the lungs applies here save that the primary 
signs and symptoms are pleural. Cardiac displacement is usually less 
marked than in simple effusions, but usually a differential diagnosis depends 
upon the withdrawal of blood-stained fluid in amount disproportionate to, or 
without achieving a proper diminution of, the area of flatness. 

The statement as to the frequency of primary growths of the lung is 
even more applicable to malignant growths of the pleura, but endothelioma 
is more frequent in this region than in any other portion of the body. 

This usually takes the form of multiple nodules with infiltration and 
thickening of the pleura and in full-developed cases may yield to light 
percussion a flatness equal to that of the bloody fluid with which it is 
associated. 

Primary sarcoma is also encountered in rare instances, and sequential 
involvement of the lung is the rule. 

Prognosis. — Death invariably results though only after a period of 
several months. 

DISEASES OF THE BRONCHIAL GLANDS.— The most important 
of these glands lie in the angle of the tracheal bifurcation about the main 
bronchi. The smaller glands follow the course of the bronchi lying in the 
interlobular connective tissue. They must chiefly be considered in connec- 
tion with the ailments of children or adults, as possible sources of secondary 
enlargement with or without symptoms. It should also be remembered that 
gangrene of the lung may involve them and that through dusty occupation 
(inhalation of dust), they may become pigmented and somewhat enlarged. 

Associated Ailments. — The following diseases may affect them: (a) 
Severe acute bronchitis, (b) Scarlet fever, measles, whooping cough, typhoid 
and similar ailments, (c) Broncho- and lobar pneumonia, (d) Pulmonary 
gangrene, (e) Mediastinal, or, by metastasis, remote, malignant growths. 
(f) Hodgkin's disease and leukemia (especially the lymphatic form), (g) 
Pulmonary tuberculosis, (h) Tuberculous or malignant disease of the 
abdominal or retro-peritoneal structures. 

The greater number of cases in children are due to tuberculosis, the pri- 
mary source of infection being either gastrointestinal, tonsillar or bronchial. 

Symptoms. — Many enlargements are symptomless, in other cases the 
effects are those of pressure within the mediastinum combined with physical 
signs chiefly observable in the interscapular region and upper sternum. 
These signs are usually so indefinite, occurring as they do in areas most un- 
favorable for percussion or auscultation, that the early diagnosis rests usually 
upon pressure symptoms, an X-ray picture which is often distinctive, and 
the knowledge of an adequate cause. (The subject of pressure symptoms is 
thoroughly discussed under the head of "Aneurysm.") 

Much stress has been laid upon D'Espine's sign previously described 
(see page 310) and also that of Eustace Smith which is a venous hum 
heard over the jugulars and over the sternum just below the level of its 
notch. To elicit it the head is tipped backward. 



DISEASES OF THE LUNGS AND PLEURA 



423 



Neither sign is of much importance and usually both are absent. 

Pressure symptoms are practically identical in all forms of mediastinal 
growth or tumor, though the most distressing cases ever observed by the 
author have been associated with the glandular enlargement of HodgkhVs 
disease. 

In some cases a mediastinal new growth yields transmitted pulsation 
strongly resembling, though seldom accurately simulating, the expansible 
pulsation of aneurysm. 

The pulsating dermoid cyst is the new growth most likely to cause this 
error. If, however, the clinical auscultatory phenomena of aneurysm are 
demanded as indispensable to a positive diagnosis of that condition no 
mistake is likely to occur. 

MEDIASTINAL ABSCESS.— This excessively rare condition may be 
acute or chronic, and occurs chiefly in the male in connection with traumatism, 
the acute infectious diseases, pulmonary abscess, gangrene or advanced 
tuberculosis. It is recognized by the symptoms of sepsis associated with 
severe radiating substernal pain and marked pressure symptoms. It may 
rupture and produce a fluctuating tumor in an intercostal space or discharge 
into the esophagus or trachea. The danger of confounding aneurysm with 
a pulsating mediastinal abscess is slight save in those cases in which an 
aneurysm by its continued pressure has produced necrosis and ultimate abscess 
in some adjacent structure. The use of a. fine hollow needle involves no con- 
siderable risk and usually establishes the diagnosis. One need never hesi- 
tate to employ such a procedure if other measures of differentiation fail in so 
urgent a condition as acute mediastinal abscess. In this connection the 
cold abscesses usually arising from spinal caries should be borne in mind. 
The X-ray may be of the utmost value in such cases. 

CHRONIC INTERSTITIAL PNEUMONIA {Fibroid Phthisis, Pulmonary 
Cirrhosis). — In spite of years of observation the conditions characterized by 
extensive fibroid changes remain imperfectly classified. In a broad sense it 
is best treated under the one heading and we may assume that lobar pneu- 
monia, broncho-pneumonia, old pleurisies, syphilis, echinococcus cysts and 
tuberculosis may operate to produce a lesion, the chief characteristic of which 
is fibrosis. 

Chronic diffuse interstitial pneumonia is excessively rare as a sequence of 
acute lobar pneumonia, though a few cases have been described with some 
accuracy. Chronic broncho- pneumonia is more common, but is usually 
tuberculous and interstitial pneumonia following pleurisy (pleurogenous) 
undoubtedly occurs as a result of prolonged compression, it being associated 
usually with a greatly thickened and adherent pleura. The cases of inter- 
stitial pneumonia due to continuous dusty occupations (pneumono- 
coniosis) and the syphilitic tuberculous and echinococcus forms are better 
understood. 

Morbid Anatomy. — The process may be lobar (massive) or lobular 
(peribronchial, broncho-pneumonic, insular). The sound lung is markedly 
emphysematous and the heart is thus pushed and drawn toward the diseased 



Pressure. 



Pulsating 
dermoid cyst. 



Rare and 
obscure. 



Possible error. 



Use of hollow 
needle. 



Fibrosis. 



Types. 



Important 

signs. 



424 



MEDICAL DIAGNOSIS 



Retraction. 



The heart. 



Consolidation, 



Extreme 
chronicity. 



lung, pulmonary shrinkage and adhesions being usually marked, though 
sometimes lacking (e.g., in pneumonoconiosis). 

The lung itself may be marvelously shrunken and show chronic bronchitis, 
multiple bronchiectases and perhaps aneurysmal dilatations of the pulmonary 
artery. The heart is enlarged, its right chambers being especially dilated. 

The" varied nature of the lesion makes possible wide differences in post- 
mortem findings. The most extreme cases represent the massive form of the 
disease, while gummata, apical tuberculous cavities or echinococcus cysts 
may indicate the specific primary cause as may the peculiar pigmentation 
of the tissue observed in cases of anthracosis (coal miner's disease) and 
siderosis (due to metallic particles), chalicosis (grinder's rot, stone cutter's 
phthisis). 

Symptoms. — The symptoms accurately follow the morbid anatomy as stated, 
being those of emphysema, chronic bronchitis, pleural adhesion, bronchiectasis 
or chronic phthisis, according to the nature and extent of the lesions, combined 
with physical signs bearing the same relation to causation. 

The displacement of the heart, retraction and immobility of the thorax 
on the affected side, scoliosis, and the depressed shoulder are emphasized 
by comparison with the voluminous opposite side. Symptoms of marked 
infiltration are usually found, but vary widely with the degree of involvement. 

The drag exercised by the diseased lung upon the mediastinum and its 
contained structures reenforced by the thrust of the bulky emphysematous 
opposite lung may produce an extraordinary displacement of the heart and 
its great vessels. 

The disease is not only remarkably chronic but one which permits con- 
siderable activity for many years or even for a reasonably long lifetime.* 

PULMONARY SYPHILIS.— There are no characteristic symptoms of this 
disease which most commonly manifests itself as interstitial pneumonia. 
It occurs both in congenital, and tertiary acquired, syphilis. The so-called 
white pneumonia is of no clinical importance, being found only in the lungs of 
dead babes usually stillborn. The latter process is frequently associated 
with tuberculosis. In acquired syphilis, gummata, single or multiple, vary- 
ing in size from a small seed to a hen's egg may be encountered. The physical 
signs are in no way peculiar to syphilis. Whether there is an actual destruct- 
ive disease of the lung and true syphilitic phthisis is still debatable. There 
are certainly rare cases in which softening is associated with caseous gummata 
and similar cases not infrequently occur in connection with tuberculosis. f 

The lower lobes are usually sites of election. 

* One case observed by the author during a period of nearly twenty years has passed 
through several severe illnesses and has lived to see his two healthy brothers die of acute 
disease; another case, showing the classical signs of inherited syphilis and every evidence of 
massive chronic fibrosis, has undergone an appendectomy and nephrotomy and several 
attacks of influenza. Both men have been almost continuously at work during the whole 
period. 

t No one can have failed to encounter cases of undoubted acquired syphilis in which a 
rapidly advancing proven tuberculous process showed a marked improvement following the 
use of specific medication. 



DISEASES OF THE LINOS AX1) PLKURA 



425 



Differential 
factors. 



Resembles 
tuberculosis. 



PULMONARY ACTINOMYCOSIS.— In all essential particulars this 
disease presents the picture of chronic bronchitis, pulmonary tuberculosis, 
or pulmonary abscess, and its diagnosis almost invariably depends upon the 
recovery of the specific organism from the sputum. It should be suspected 
if in such cases tubercle bacilli are absent, the bases chiefly or primarily 
involved and superficial swellings or brawny inflammations noted. 

In several cases encountered by the author it has taken the form of 
" closed" pulmonary abscess revealing its true nature only when explored. 

ASPERGILLOMYCOSIS — This rare disease is due to the aspergillus 
fumigatus and has been observed chiefly in those who handle infected flour, 
meal or grain. The symptoms are essentially those of pulmonary tuber- 
culosis lacking the tubercle bacilli and the diagnosis can be made only by 
the discovery of the mycelium. It may also occur as a secondary disease in 
connection with the various chronic pulmonary ailments and may assume a 
predominatingly bronchial, nodular, or cavernous form. 

OIDIOMYCOSIS. — This curious ailment sometimes closely simulates 
pulmonary tuberculosis. 

NOCARDIOSIS. — The nocardia are peculiar microorganisms resembling 
bacteria on the one hand and moulds upon the other. They are branching, 
thread-like, aerobic, spore-producing bodies, growing readily upon nearly 
all culture media at ordinary temperatures. 

They are widely distributed, are found especially on grasses and grains 
and their point of entrance is usually the pulmonary tract. 

They produce symptoms and actual pathologic changes closely resemb- 
ling tuberculosis, the germs of which disease they may closely simulate if 
fragmented. 

They are readily distinguished by their behavior on culture material and 
by their staining properties. 

The pulmonary symptoms are in themselves identical with those pro- 
duced by the tubercle bacillus. 

They do not resist acid and are decolorized by alcohol. 

These three conditions are dealt with more fully in their appropriate 
section. 

PULMONARY DISTOMATOSIS.— ("Lung Fluke disease").— See 
Paragonimus Westermanni. 

PULMONARY AND PLEURAL HYDATIDS.— Diagnosis.— So long as 
hydatid cysts are central and small, few or no symptoms are produced. If 
they enlarge, and particularly if they reach the pleura, cough and pain may 
be severe. Fever is usually absent, and dyspnea slight. Physical signs may 
be baffling, indeterminate, or merely those of consolidation with weakened 
breath sounds, as in an area of massive pneumonia (blocked bronchi) or a Peculiar cases, 
closed pulmonary abscess. The superficial (pleural) cases will strongly 
resemble encysted empyema but are more often like superficial pulmonary 
abscess in their central intensification of dulness and may reveal a most 
suggestive friction opposite this point, pleuritic effusion with the usual 
pressure displacements, weakened breath sounds and diminished fremitus. 



Symptoms 
variable. 



426 



MEDICAL DIAGNOSIS 



Exploratory 
puncture. 



If rupture occurs, the immediate symptoms may be urgent, the watery 
nature of the fluid is suggestive and characteristic and hooklets and frag- 
ments of the membrane may be present. Hydatid thrill and superficial 
rounded tumors may be found. Fowler emphasizes the relative absence of 
mediastinal pressure symptoms (see " Aneurysm") despite the evidences of a 
large tumor or exudate. 

Zapelloni has reported positive results with the " deviation of complement" 
test in 93 out of 114 operated cases of echinococcus disease. Eosinophilia was 
present in but 60 per cent. 

Echinococcus cysts usually involve the right lower lobe and in open 
pulmonary cases may show the characteristic hooklets in the sputum. 

DERMOID CYSTS OF THE LUNG.— Dermoid cysts in the lung are 
of rare occurrence, usually originating in the anterior mediastinum. They 
offer great difficulties to the diagnostician and may vary in size from that 
of a small marble to that of a large grapefruit. Occasionally rupture occurs 
into a bronchus or into the pleural space or the lung itself. In rare instances, 
through pressure, escape of the fluid may occur into, the pericardial cavity 
or the great vessels about the heart. 

Chylous Pleurisy. — A true chylothorax results, rarely, from occlusion 
or rupture of the thoracic duct or receptaculum chyli, usually as a result 
of malignant or tuberculous disease. The diagnosis can only be made by 
the discovery of a pleural effusion and the removal of a portion for examina- 
tion. Such cases lack any history of acute pleurisy. 



THE EXAMINATION OF THE HEART 



427 



EXAMINATION OF HEART AND BLOOD VESSELS 

THE HEART. — Boundaries Usually Encountered. — The heart lies in 
the mediastinum between the lungs and presents, when the patient is recum- 
bent: 




Fig. 156. — The two dimensions of chief importance in teleroentgenography, viz., 
Mr. at level of 4th interspace; and Ml. at level of 5th. Both Ml. and Mr., however, 
should represent the maximal distances from the median line to the heart borders. 




Fig. 157. — Silhouette of the "sthenic" or "ideal" heart. The single convexity on the 
left of the diagram represents the right auricle. The four convexities on the right, from 
above downward are: 1st, the aorta; 2d, the pulmonary artery; 3d, left auricle; 4th, 
a narrow strip of the left ventricle. This figure would represent the heart outline when 
the diaphragm is in the neutral position. Compare with the ptotic type of heart shown 
on the following page. 

(a) A base at the level of the upper border of the third costal cartilages. 

(b) A right border formed chiefly by the right auricle, save in the case of 
the " drop heart," curving from the right base downward to the sixth chondro- 
sternal articulation and attaining in robust individuals a distance from 3.0 
to 4.5 cm. from the midstemal line under the fourth interspace. 



428 



MEDICAL DIAGNOSIS 



The total of the right and left transverse heart diameters seldom exceeds 
13.5 cm. and may not be greater than 8 or even 7.5 cm. in emaciated con- 
genially asthenic subjects (see "Drop" Heart). 

In the latter cases the right border may not pass beyond the right edge of 
the sternum. 

(c) A left border, which sweeps outward, downward, and then slightly 
inward, to a point in the fifth interspace, varying between 5.0 and 9.0 cm. 
(2% to 3% inches) from the median line, according to the weight and build 
of the patient and the type of heart. 



Small hearts. 




Fig. 158. — The "drop" heart of congenital asthenia and visceroptosis. Normal heart 
contour and elevation shown by dotted lines. (Schivarz modified.) * Found in a consider- 
able proportion of the population and in all grades it constitutes a most misleading variant 
and is responsible for a vast number of missed diagnoses of an existing cardiac en- 
largement. 

In persons of the congenital asthenic type, be they fat or thin, the total dimen- 
sions normally fall short of the measurements ordinarily given as the normal. 

(d) A lower border connecting the lower extremities of the lines represent- 
ing the right and left borders. 

Variations in posture as between the sitting and recumbent position affect 
the total transverse measurement but slightly. 

* The position of the auricle in the typical "drop" heart is indicated also by a dotted 
line. The angles or notches of the left border are exaggerated as compared with the usual 
roentgenographic picture. Such hearts obviously must be so modified by the effects 
of valvular diseases and myocardial degenerations as to largely lose their characteristics. 
Whenever decided visceroptosis is present, whatever the apparent or actual heart lesion, 
a "drop" heart may be assumed as having existed primarily. 



THE EXAMINATION OF THE HEART 



429 



In order that the relatively small size of the average normal heart may 
be the better appreciated, the author has inserted the tabulation of Dr. 

Data and Measurements of the Hearts of Soldiers Examined 



174 
162 
164 
183 
174 
170 



No. 


Weight Kg. 


Height Cm. 


Age Yrs. 


Transverse 

diameter 

Cm. 


1 


53 


157 


21 


134 


3 


54 


164 


40 


12 .0 


5 


55 


158 


29 


12.8 


8 


56 
56 


173 


24 
27 


13.8 
12.3 


10 
11 


57 

57 


160 
168 


19 
24 


12.3 
12.6 


15 
16 


58 
58 


168 
170 


25 
.25 


11. 4 
11 .2 


17 


59 


J 75 


19 


12.5 



"Rule of 

thumb" 
inapplicable. 



II. 3 

13-3 
13-3 

12. 5 
10.8 
12. 5 



11. 8 




62 


65 


177 


28 


I4.2 


64 


65 


168 


20 


12.8 


66 


65 


176 


21 


12.8 


68 


65 


172 


27 


12.8 


69 


65 


170 


23 


12.7 


72 


66 


164 


27 


135 


74 


66 


167 


26 


12.4 


77 


67 


161 


25 


14-5 


78 


67 


173 


29 


14.6 


79 


67 


167 


25 


13-7 


81 


67 


I7S 


23 


12.4 


82 


67 


167 


26 


14.4 





430 








MEDICAL DIAGNOSIS 






Alfred E. 


Cohn 


of 


the 


Rockefeller Institute for Medical Research* very 




slightly abbreviated 














Data and 


Mi 


.ASUREM.ENTS 


of the Hearts of Soldiers 


Examined 


















Transverse 




Xo. 




Weight Kg. 




Height Cm. 


Age Yrs. 


diameter 
Cm. 




83 






67 




175 


28 


12.4 




84 






67 




168 


27 


14.0 




85 






67 




169 


23 


13 2 




86 






67 




170 


24 


150 




87 






68 




167 


49 


1.3 5 




89 






68 




171 


21 


13-4 




90 






68 




175 


24 


12.8 




9i 






68 




174 


iS 


n. 8 




94 


1 




68 




175 


26 


14.0 




97 






69 




175 


42 


15-7 




100 






69 




169 


26 


14.8 




101 






69 




174 


3i 


13.8 




103 






69 




177 


25 


11. 8 




106 






69 




172 


26 


13.6 




108 






69 




180 


28 


12.3 


- 


III 






70 




171 


30 


12.8 




113 






70 




176 


29 


133 




117 






70 




175 


- 


11. 8 




118 






70 




175 


18 


130 




119 






71 




172 


22 


137 




122 






71 




170 


29 


14.2 




123 






71 




177 


34 


13-3 




125 






71 




178 


23 


12. 1 




126 






71 




172 


23 


11. 3 




127 






72 




179 


24 


12.7 




129 






7 2 




174 


22 


14.O 




132 






72 






174 


20 


v 12.4 




133 






72 






174 


29 


14-7 




135 






72 






173 


21 


12.8 




. 137 






73 




178 


21 


14. 1 




138 






74 




174 


28 


14-4 




140 






74 




171 


24 


13-7 




141 






74 




172 


23 


12.3 




142 






74 




172 


25 


130 




143 






74 




178 


27 


13-3 




144 






74 




186 


23 


12.7 




147 






75 




173 


25 


16.O 




149 






75 




165 


27 


13 .0 




150 






75 




175 


30 


13-2 




154 






77 




179 


28 


12.3 




155 






77 




181 


30 


12.8 




157 






78 




170 


28 


14.3 




158 






83 




180 


2" 


14-3 




160 






S3 




179 


26 


13.8 




l6l 






86 




180 


26 


13.8 



THE EXAMINATION OF THE HEART 



431 



All transverse measurements given are those of returned soldiers who 
had been subjected to the privation and exertion incident to active service 
on the Western Front during the "Great War" just past. 

Infantrymen were chosen by preference or those whose service entailed 
an equivalent amount of privation and exertion. 

All measurements included in this modified table were made in the 
inspiratory phase by fluoroscopy at a six-foot focal distance. 

No special criteria other than those mentioned above governed the 
choice of these men and obviously a considerable number of hearts 
abnormally enlarged must have been included. 

Nevertheless the table abundantly supports the contention made originally 
by the author over a decade ago and set forth in the paragraphs following: 

Variations in Size of the Heart. — The size of the normal heart varies con- 
siderably in different persons and its bulk in general corresponds to the osseous 
and muscular development of the individual, not to his weight, breadth or thick- 
ness, though height and muscular development combined are important factors. 

A Source of Gross Error. — A general lack of appreciation of the relatively 
narrow maximal limits allowable for normal hearts and a disregard of the 
structural factors necessary to the just application of a maximal allowance 
of 14 cm., even for robust, mature men, lead, to a multitude of serious 
errors with relation to minor but not negligible incompensations and 
enlargements and the existence of serious myocardial disease.^ 

Forced expiration materially increases the transverse diameter. 

Many cases of cardiac dilatation of pathologic degree, especially (but by no 
means exclusively) such as occur in the extremely common, narrow, so-called 
"drop heart," of the congenitally asthenic individual, are overlooked and neg- 
lected because of a general adherence to u rule of thumb" measurement and faulty 
initial concepts. 

Furthermore, the application of the same rule may result in errors of the 
grossest type with relation to major dilatations of the small hearts. 

The Aorta. — From the base of the heart, the aorta sweeps upward and to ! 
the right, its right border projecting slightly beyond the sternal margin. 
It then passes backward and toward the left in such a manner as to leave the 
manubrium resonant under normal conditions. 

This area assumes great importance in certain cases of aneurysm or 
enlargement of the thyroid or thymus gland. 

Mobility of the Heart. — Suspended within the pericardial sac by the great 
vessels at its base, the heart is movable, responsive to all changes of posture, 
and laterally displaceable to an astonishing degree in cases of "drop" heart 
C cor pendulum") or under certain pathologic conditions (ascites, tympanites, 
pleural effusion, pneumothorax, etc.). 



Total 

transverse 

measurements 



Neglected 
at dilatations. 



Manubrial 
percussion 
note. 



"Corpen- 
dulum." 



* Archives of Internal Medicine, May 15, 1920, vol. xxv, No. 2. 

t Up to the present time the author has encountered no heart exceeding (teleoroent- 
genographically) 14 cm. in total transverse diameter in the inspiratory phase whose 
possessor did not show positive evidence of heart disease. This has held true even in 
the case of men of unusual musculature and athletic tendencies. 



43 2 



MEDICAL DIAGNOSIS 



Chiefly rights 
ventricle and ] 
auricle. 



Of utmost 
value. 



Relation to Anterior Thoracic Wall. — Anteriorly it presents its right 
chambers; chiefly the right ventricle to the left of the mid-sternal line, and the 
right auricle from midsternum to the true right border which it wholly forms. * 

The left ventricle is normally represented by a mere strip of heart muscle 
along the left border and the normal left auricle is hardly in evidence. 




Fig. 159. — "Drop" heart. 



An extreme example in the adult male, 
diameter 7.5 cm. 



Total transverse 



Cardiac Outline.- — Changes in the shape of the relative cardiac dulness 
or the radiographic shadow usually indicate enlargement of the heart itself, 
suggest the individual chambers involved and hence the underlying lesions. 

As will be seen later, such changed outlines serve as a check upon the 
diagnosis of valvular lesions and pericardial effusions, and the student must 

* Save in the " drop " heart and its minor modifications. 



THE EXAMINATION OF THE HEART 



433 



never forget that even serious dilatation thus indicated may be unattended by 
any valvular murmurs. 

THE HEART VALVES. — The mitral, tricuspid, aortic and pulmonary 
valves are anatomically located within so small a space that a large stethoscope 
bell wiU n-early cover them all, but their exact position is of little importance in 
clinical work. 

THE CLINICAL VALVULAR AREAS.'— The points of maximum audi- 
bility arbitrarily fixed for auscultation are: 

(a) The mitral area which corresponds to the heart apex. 

(b) The tricuspid area, corresponding to the lower half of the sternum. 




Fig. 160. — Dilated "drop" heart. (Outlines drawn from original roentgenograms.) 
Cause of dilatation, over-exertion following an unusually prostrating attack of influenzal 
bronchitis. Note that breadth of the dilated heart was but 12.1 cm. and after treatment 9 
cm. (See also case of D. B. under "Drop" Heart, successive roentgenograms.) 

(c) The pulmonary area, corresponding to the second left intercostal space 
at the left sternal edge. 

(d) The aortic area, corresponding to the second right and third left inter- 
costal spaces, adjacent to the sternum, the former being most useful in connection 
with aortic systolic murmurs and aortic second sound accentuation; the latter, 
in auscultation of diastolic aortic murmurs. In this last lesion one also finds 
the lower end of the sternum a point of aortic transmission. 

The Suprasternal Notch. — The use of this area may enable one to hear 
weak heart sounds not audible over the selective areas mentioned above. 

INSPECTION 

FACIES. — No internal ailment presents more external signs to the ob- 
server than does established heart disease in many instances. In some forms 
the external signs are relatively prompt in appearance and apparent at a 
glance. In others they are obscure and relatively late or never appear. 

The most strikingly objective lesion, over periods embracing many years, 
28 



Murmurs may 
be absent. 



Anatomic 

position 

unimportant. 



Arbitrary 

auscultation 

areas. 



Often 

strikingly 
objective. 



434 



MEDICAL DIAGNOSIS 



Jerking 
vessels. 



is aortic regurgitation, usually associated with pallor and meagerness of 
face, yet seldom with marked actual anemia. In such cases the jerky throb 
of the carotid, temporal, or any other superficial artery, may at once strike 




Capillary pulse. 



Fig. 161. — "Drop" heart with evidence of slight dilation. Note borders, equidistant 
from median line. Calcined focus in upper left lung field. A mitral systolic murmur 
was present in this case. {Dr. Frank S. Bissell.) 

the eye, and even the head nods rhythmically in some cases or the foot jerks 
in time with the heart beat if the knees are crossed. 

In rare instances the eye may catch the rhythmic blushing and paling of 
the capillary pulse if some skin area becomes congested or even in the lips 
or nails. 

One may find jerking vessels and a capillary pulse in thyroid cases, 



THE EXAMINATION OF THE HEART 



435 



lacking aortic regurgitation, but possessing overacting hearts and extreme 
vasomotor relaxation, and the condition of this gland should always be 
noted, together with the presence or absence of the peculiar stare, actual 
exophthalmos, or tremor", which may indicate a frank hyperthyroidism. 

In rare instances the tracheal tug of aortic aneurysm may exist in so 
marked a degree as to catch the eye, ot pupillary inequality or unilateral 
flushing or sweating may point to this or some other form of mediastinal 
tumor and resultant pressure. 

Facial edema will of course be noted and in cardiac disease will seldom be 
marked, unless as a part of general edema or when actually due to a com- 
plicating or primary nephritis. 

Mitral Stenosis. — Mitral stenosis is 
cyanotically objective in some in- 
stances and its outward signs are 
chiefly those indicative of oxygen 
deficit and may be closely simulated 
by advanced mitral regurgitation 
whether valvular or primarily myocar- 
dial, or, by certain pulmonary diseases 
which cause a relative blocking of the 
lesser circulation and insufficient venti- 
lation of the blood. 

In advanced mitral stenosis, espe- 
cially, and particularly in young women, 
the rosy cheeks may appear vouchers 
for good health if the eye fails to note 
the duskiness which clouds the red and 
shows especially in the lips and ears. 
In terminal mitral lesions, especially, 
the countenance may appear blurred and an orthopneic mitral case, if breath- 
ing hard and rolling the head listlessly from side to side is almost certainly 
nearing the portals of the hereafter. 

All grades of cyanosis must be noted and investigated and, as stated 
previously, but three forms of extreme cyanosis in walking cases are en- 
countered: That of the child with congenital heart disease, and advanced 
emphysema or the red cyanosis of " erythremia" in the adult. 

In old cases of right heart decompensation of long standing, a subicteric 
facies is common and underlain by a pallor, contrasting sharply with deeply 
cyanotic lips. 

INSPECTION OF THE NECK AND TRUNK.— This should be both 
direct and tangential, general and local. The most important regions and 
the conditions to be noted are: 

i. The valvular areas already described. Important pulsations may 
often be observed and their character may yield information of value. 

2. The manubrium and its neighborhood. Here is found most com- 
monly the expansile pulsation of aortic aneurysm. 




Fig. 162. — Peculiar orthopneic variant. 
Urgent dyspnea associated with listless 
rolling of the head from side to side. 
Usually a forerunner of death. 



"Tracheal 
tug." 



Misleading 
"color." 



A striking 
picture. 



Ambulants. 



Subicteric 
facies. 



\ » 



X 



436 



MEDICAL DIAGNOSIS 



Area and 
position. 



Force. 



"Heaving" 
vs. "wavy" 
apex beats. 



Systolic 
recession. 



Extreme type. 



May deceive 
the eye. 



A misleading 
sign. 



3. The area lying between the inner edge of the left scapula and the 
spinal column, in which the heaving pulsation of an aneurysm of the descend- 
ing thoracic aorta sometimes appears. 

4. The Superior Abdominal Quadrants. — In these we may find: The 
presence of manifest enlargement, pulsation, or rhythmic displacement of the 
liver; ascites; epigastric fulness, pulsation or retraction; pulsation of the 
abdominal aorta. 

The fulness and rigidity of vessels and the number, nature and time of pulsa- 
tions in the veins of the neck must be noted. 

General or localized edema, any evidence of marked sclerosis, local or gen- 
eral, venous or arterial, should catch the eye. 

Bulging or deformities of any portion of the thorax together with its form and 
movements should be carefully investigated. 

Dyspnea in all its forms from Cheyne-Stokes breathing, BioVs periodic 
apnea, or an exertion dyspnea, to a mere inability to hold the breath, is of 
importance and orthopnea is always a serious matter. 

THE APEX BEAT.— This should be represented normally by a gentle 
rhythmic uplifting of the fifth interspace over an area not more than an inch 
in diameter, well within the mid-clavicular line. 

It is not always present either in health or disease, because of overlying fat, a 
weak impulse, emphysema or an intervening rib, and the beat is often excess- 
ive, even in the case of a normal heart, because of temporary excitement, 
exertion, indigestion, narcotism, psychasthenia, and like conditions. 

A heart that is the seal of extreme hypertrophy causes a distinct and widespread 
heaving {uplifting) impulse, and the beat of a badly dilated righ heart is wavy, 
diffuse and indeterminate. In either case the area of pulsation is greatly 
increased. 

Reversed Apex Beat. — In hypertrophy or dilatation of the right heart the 
right ventricle may wholly form the apex beat, in which event there is visible in 
the area between the left sternal and parasternal lines, a recession of the third, 
fourth and fifth or even the second left interspaces, along the region adjacent 
to the left sternal border, with each systole. In many such cases the left 
ventricle does reach the wall for a fleeting interval. 

In cases of extreme right heart dilatation, usually associated with relative 
tricuspid insufficiency, systolic recession may occur in the fourth and fifth 
right interspaces and even in the third, though the last is rare. 

Indeed the combination and coincidence of a visible left ventricular sys- 
tolic apex beat with a right ventricular retraction is by no means uncommon 
in cases of mitral stenosis with thin chests and gives a peculiar appearance of 
undulation. 

Various Precordial Retractions. — A strongly acting nervous heart and 
thin chest wall may cause systolic recession (right heart) in the second, third, 
fourth or fifth left interspace and in the upper portion of the epigastrium, 
even though the organ shows little or no departure from the normal outline, 

* The lesser and commoner degrees of hypertrophy do not reveal themselves by a 
heaving apex beat. 



THE FA'AMINATION OF THE HEART 



437 



but in such cases it is often associated with ailments which end to overtax 
the right heart, such as pulmonary tuberculosis, pulmonary fibrosis and em- 
physema of the lungs. 

Congenital asthenia with psychasthenia and subnutrition , hyperthyroidism 
and profound anemias, are quite competent to produce such visible pulsations 
in thin chests and especially in those of reduced anteroposterior diameter. 
In most of these instances an atonic, irritable and overacting "drop" heart 
is present and the actual apex beat is systolic, diffuse, sharp, and left ven- 
tricular in origin. 

Pulsation Adjacent to or Involving the Manubrium.— Swc/j an impulse, 
if marked and deliberate, always suggests aneurysm of the aortic arch, and pulsa- 
tion of the manubrium itself is of special significance, because of its association 
both with aneurysm and certain vascular forms of mediastinal new growths. 

Systolic Retraction Extending Beyond the True Apex Beat. — This is 
commonly mistaken for a systolic thrust and leads the unwary to overesti- 
mate the enlargement of an hypertrophied or dilated heart. 

It may be caused by the drag of pleuro-pericardial adhesions with or 
without shrinkage or retraction of the lung itself, but can result when the 
contraction of any very greatly enlarged heart causes negative pressure areas 
in the lungs. 

Solitary systolic pulsation over the second left interspace near the sternum 
is an exceeding common event as a result of right ventricular overaction. 
It is also observed early in certain cases of pericarditis and in the rare in- 
stances of pulmonary regurgitation. 

Pulsation over the second right interspace is a well-known accompaniment 
of free and established aortic regurgitation. It is wholly different from 
the heaving expansile and usually deliberate pulsation of aneurysm of the 
first portion of the aortic arch. 

Systolic Retraction in Mediastino-pericarditis. — It is one of the signs of 
adhesion of the pericardium to the heart itself, when associated with an in- 
durative mediastinitis or general polyserositis. It causes a systolic drag upon 
the diaphragm, but to be of diagnostic value in this connection it should 
involve the posterior interspaces or ensif orm cartilage as well and be unaffected 
by respiration (Broadbent's sign). 

Precordial Lifting. — This may occur in great hypertrophy or dilatation 
or, in minor degrees, even in the case of strongly beating, excited, normal 
hearts in chests of small anteroposterior diameter. 

The Position of the Apex Beat. — Abnormalities of position must follow 
inevitably any decided changes in the cardiac outline or actual displacement 
of the heart. 

Displacement of the Apex Beat. — Upward, (a) High position of diaphragm, 
(b) Tympanites, (c) Ascites, (d) Abdominal growths, (e) In some cases of 
pericarditis with e fusion {often at nipple level). 

Upward and to Left. — Effusion into right pleural sac; (a) Liquid, (b) 
Gaseous. 

Downward. — (a) Aortic aneurysm, (b) Mediastinal tumor, (c) Senility. 



Aneurysm. 



Mediastinal 
tumor. 



Broadbent's 
sign., 



438 



MEDICAL DIAGNOSIS 



Important in 
diagnosis. 



Often mis- 
interpreted. 



Value in 
diagnosis. 



Right heart 
dilatation. 



Aortic 
pulsation. 



Left 

ventricular* 

pulsation. 

Hepatic. 



(d) Hypertrophy of left ventricle {downward and to the left), (e) Collapse of 
abdominal viscera. 

To Right or Left. — (a) Effusion of gas or liquid into pleural sac, i.e., pneu- 
mothorax, hydrothorax, etc. (b) Unilateral or vicarious emphysema, (c) 
Pleural adhesion and retracted lung, (e) Marked solid enlargements of lung or 
of the left lobe of the liver. (/) Respiratory lateral displacements may occasion- 
ally be visible in right- sided pleural effusion. These are best demonstrated by 
fluoroscopy, as originally reported by the author. 

The assumption of the lateral posture results in a corresponding displacement 
of even the normal heart, but is incredibly exag- 
gerated in certain cases of "drop" heart {cor 
pendulum). 

The apex beat may be invisible by reason 
of: {a) Interposition of a rib. {b) Fat chest 
wall, {c) Feeble heart, {d) Emphysema, (e) 
Edema of chest wall. (/) Pericardial effusion 
{marked), {g) Pleural effusion, {h) Trans- 
position of the viscera. ' In this condition the 
beat is present on the right side. 

Its area and apparent force may be 
increased because of : {a) Mere over action, 
(b) Hypertrophy or dilatation, {c) Retraction 
of lung. 

Precordial Bulging.— Aside from the pres- 
ence of an actual growth this is usually due 
to three causes, viz.: aortic aneurysm, mas- 
sive pericardial effusion, or, most commonly, 
excessive enlargement of the heart. It is 
most marked in those cases originating in 
early childhood in which the growing osseous 
structures have yielded readily to the pressure beneath. One may thereby 
often approximately fix the date of the heart lesion seen in advanced life. 
Such a precordial prominence is known as the "precordial boss" or 
"voussure" (arch). 

Epigastric Pulsation. — This may be of several types: (i) A systolic reces- 
sion as timed by the carotid beat, in right heart dilatation (Mackenzie).* 
(2) A systolic pulsation, as timed by the abdominal aorta, in certain cases of 
free aortic regurgitation, goiter hearts, anemias, or any case combining an 
overacting heart with decided vasomotor relaxation. A relaxed abdominal 
wall makes these pulsations obtrusively manifest. Transmitted aortic 
pulsation and true aneurysm are always to be considered. The latter is 
always expansile and usually deliberate. (3) A systolic protrusion in exces- 
sive left heart hypertrophy. (4) Actual systolic pulsation of the engorged 
liver as seen in certain cases of tricuspid insufficiency. 

* Mackenzie found that in one such case a needle, introduced after death, over the 
maximal area of epigastric pulsation, entered the right ventricle. 




Fig. 163. — The production 'of 
the apex beat by the normal heart. 
(After Staehelin and Ortner.) 



THE EXAMINATION OF THE HEART 



439 



PALPATION 

Palpation serves to confirm and amplify inspection, and to detect thrills 
associated with valvular lesions or anemia, together with points of tenderness 
and the general characteristics of tumors of any kind. It is of special value 
in connection with the expansile pulsation and " diastolic shock" of aneurysm 
and the apical presystolic thrill and systolic shock of mitral stenosis. 

No examination of the diseased heart is complete that does not include the 
palpation of such related organs as the lungs, liver and spleen and determine the 
presence or absence of ascites in the presence of abdominal distention. 

Thrills. — A systolic thrill in the second right interspace (aortic area) 
suggests aortic sclerosis, aneurysm or aortic stenosis. In the second left, 
if maximal at that point and associated with extreme cyanosis, it points to 
pulmonary stenosis, usually encountered in congenital lesions. Such thrills 
are common in exophthalmic goiter. Lacking cyanosis, a diastolic thrill in 
the second left interspace means aneurysm or aortic regurgitation. A pre- 
systolic or diastolic apex thrill is almost pathognomonic of mitral stenosis. 
A systolic apex thrill usually means mitral regurgitation; over the lower 
sternum or at its left edge, tricuspid regurgitation; and in children or young 
people, with profound cyanosis it points to congenital defects. The pre- 
systolic thrill of a tricuspid stenosis is very rarely encountered. 

PERCUSSION 

Percussion is often decisive in the differential diagnosis of heart lesions. 

One usually percusses from the more resonant to the less resonant areas, 
save in determining the superficial dulness and seeks to determine (a) the 
deep or relative cardiac dulness; (b) superficial dulness; (c) the resonance of 
the region of the aortic arch. 

Abdominal distention and pulmonary hepatic or splenic engorgement are 
also important factors if the heart is abnormal. 

The prevalent "flat-finger" percussion must not be used, nor is any 
method unfailing in results, but by orthopercussion, auscultatory percus- 
sion, threshold percussion, or a combination of these, it may be very closely 
approximated in most cases.* 

The student should accustom himself to the sound of the normal dull 
tympany of the manubrium sterni, as this is one of the most important 
regions. 

He should also carefully note and localize any pain or tenderness attending 
percussion. Syphilitic periostitis, for example, may be encountered over the 
sternum and ribs and might prove of the utmost importance in a diagnosis. 

In many atrophic or degenerated hearts, and in minor dilatation or mere 
atony, associated with chronic overstrain, tenderness often is marked at the left 
lower border and perhaps within it. 

* In skilled hands the correspondence of outlines obtained by such methods of 
percussion to those obtained by long-focus roentgenograms (teleoroentgenography) or the 
orthodiagram is usually relatively close, but ivTtertain cases the grossest error occurs. 



Scope and 
value. 



Caution. 



Aortic. 



Pulmonary. 



Mitral. 

Congenital 
defects. 



Never 
omitted. 



Cardiac 
boundaries. 



Manubrium. 



Tenderness. 



44o 



MEDICAL DIAGNOSIS 



Enlargement 
to the right. 



Extension to 
the left. 



During and following Angina Pectoris major most extensive areas of 
hyperesthesia may exist and often prove misleading if their maxima are 
remote- from the heart itself. 

Superficial Cardiac Area. — The notched inner border of the left lung leaves 
a portion of the right ventricle uncovered and in such close proximity to the 
chest as to yield decided percussion dulness over a somewhat triangular space 
having its base at the left sternal margin from the fourth to the sixth chondro- 
sternal articulation and its apex at or just within the apexA>eat, the triangle 
being completed by lines connecting these points. 

Determination of the Superficial Cardiac Area. — In determining the 
superficial cardiac area it is best to 
commence at its known normal 
center and percuss from that lightly 
and in radiating lines. 

Significant Changes in Per- 
cussion Area. — An increase in the 
area of superficial dulness may 
mean: (a) Enlargement of the 
heart. (b) Retraction of the 
lung. (c) Pericardial effusion. 
(d) Pleural adhesions, solidified 
lung, or new growth. 

An Important Region. — This 
area of marked dulness is of great 
importance inasmuch as its exten- 
sion to the right indicates clearly 
displacement of the heart as a 
whole, enlargement of the right 
ventricle, or pericardial effusion. 

A valuable sign differentiating 
between displacement and en- 
largement of the right heart is 
given us by von Oestreich. 




Fig. 164. — Superficial and deep relative 
cardiac percussion dulness, flat-finger method. 
This actually outlines only the exposed area 
(cross-hatching) and the general profile of the 
anterior surface of the right and left ventricles. 
More accurate delineation of the entire cardiac 
outline is now possible by means of a modern- 
ized technic, the results closely approximat- 
ing the roentgenographic outline in most 
instances ; though gross error is possible. (Repe- 
tition of figure 92 for added clearness.) 



If the superficial dulness 
passes to the right as a straight border or one concave and opening to the 
right, we may assume that the heart as a whole is displaced or that a 
greatly enlarged left ventricle is crowding over its fellow of the right side 
(v. Jagic). If its right percussion boundary is broken by a bulge to the 
right the change represents right ventricular enlargement. 

On the other hand, extension of the superficial area to the left alone or 
to the left and downward indicates left ventricular hypertrophy or dilatation, 
and if to the left and upward, an added left auricular enlargement. Cases 
in which decided right and left extension both are encountered are common 
as the result of combined valvular lesions. 

In pericardial effusion it may be carried far beyond the right edge of 
sternum as a parabolic curve, joining hepatic flatness below. 



THE EXAMINATION OF THE HEART 



441 




Area of Relative Dulness. — It has been so difficult formerly to accurately 
outline the normal right heart that many modern diagnosticians still use the 
flat-finger method and the two arbitrary percussion areas shown in Fig. 
163 as representing the normal, and these serve fairly well to determine 
and measure any variation in the precordial area of ventricular dulness. 
The orthopercussion method is far more accurate and greatly to be preferred. 
(See next page.) 

The most valuable information with relation to the right border lies, as 
stated, in the extension of the superficial cardiac area to the right beyond the 

median line as indicating right ventricular 
dilatation or hypertrophy or pericardial 
effusion and the determination of an 
unduly wide extension of relative dulness 
to the right, as determined by orthoper- 
cussion, threshold percussion or ausculta- 
tory percussion, indicating right auricular 
dilatation.* 

Value of the Sensation of Resistance. 
— In the case of the highly trained ob- 
server, percussion is almost as well carried 
out on the basis of the resistance felt as on 
quality and pitch of elicited notes. 

The direct method of Ebstein is prac- 
tically a soundless percussion, and in fact, 
mere thrusting will determine a cardiac or 
hepatic boundary with considerable ac- 
curacy and constitutes an excellent drill 
in concentration of attention. 
The sense of resistance may be intensified by various forms of plessimeters 
which also sharply delimit the areas of differing resistance and pitch, or, by the 
use of the flexed finger in orthopercussion, which is quite as accurate and 
more convenient. 

Firmness and equality in pleximeter pressures and plexor strokes over the 
contrasted areas under percussion is of cardinal importance. 

The pressure may be varied to suit the conditions and need never be made 
painful to the patient. 

An Uncertain Method. — The old flat-finger percussion, still in general use, 
and most valuable for other purposes, is extremely uncertain and inaccurate in 
relation to right heart boundaries and the true left heart profile, and should 
be wholly abandoned in cardiac percussion. 

Threshold Percussion. — Goldscheider's method of heart percussion demands 
the lightest percussion stroke audible to the percussor and is at present much 
used. 

If a heart border be approached with a stroke so light as to be barely 
audible to the percussor's ear when applied over the adjacent resonant lung 
tissue, it should be entirely lost with the shortening of the vibrations induced 
* Save as stated in the case of "drop" heart. 



Fig. 165. — Note that in the normal 
heart the right border is formed by 
the right auricle. Compare with 
Fig. 158 ("drop" heart) showing 
right ventricle forming this border. 



Working 
outline. 



Value of 
orthopercus- 
sion. 



"Tast per- 
cussion." 



"Schwellen- 

werts" 

percussion. 



Threshold of 
audibility. 



442 



MEDICAL DIAGNOSIS 



A measure of 
inaccuracy. 



by an underlying heart border. -The contrast between "little" and "noth- 
ing" is sharper than that representing mere differences of degree. 

// is difficult to carry out in any place not absolutely quiet and, in the author's 
hands, no more accurate than the combined method next to be mentioned, indeed 
much less so if the heart dulness passes Jar to the left. 

It is an excellent method for the expert, but in using it the inexpert 
are likely to carry borders too far out. The greatest obstacle to its applica- 
tion lies in the difficulty of maintaining an exact equality in the force of the 
percussion strokes and the extremely quiet environment necessary to its 
most effective employment. 




Fig. i 66.- — The illustration demonstrates the technic to be preferred in delineating 
outline by percussion. The actual stroke is, as nearly as possible a mere dropping of the 
wrist varied, as may be necessary, however, by a modulated stroke of bare audibility 
(threshhold percussion) or the strong stroke sometimes most effective. This may readily 
be combined with auscultation and constitutes a good method. The need of preserving 
the vertical direction of the stroke itself is manifest. The upper hands define the true 
profile boundary; the lower, a false one. 

Orthopercussion.— As previously stated, in the percussion of a widely ex- 
tended left heart border in a chest which falls away at the sides before the limit of 
relative dulness is reached, one must maintain a stroke vertical to the anterior 
plane of the body rather than to the curving lateral surface of the chest. 

If this technic is not observed, one carries the border of a "cor bo vis" 
around the curve of the chest into the axilla. One merely needs to lay off the 
distance thus obtained upon a centimeter rule to demonstrate the absurdity 
of this older method. He will find his heart border thus projected into space 
beyond the left thoracic border, for he will follow the heart too far and elicit 
the relative dulness of the lateral aspect of the left ventricle (see Fig. 166). 



THE EXAMINATION OF THE HEART 



443 



The older tecknic does not meet the modem demand for accuracy, 
emphasized by the frequent occurrence of great disparities between roentgeno- 
graph ic outlines and those obtained by the older methods. 

Methods of Preference. — The author personally prefers to carry out percus- 
sion with a light yet firm, sustained and clearly audible stroke. The impact of 
the percussing fingers falls, not upon the base of the flexed terminal phalanx of 
the pleximeter finger as recommended by Koranyi and Goldscheider, but upon 
the base of the second phalanx of the middle finger which is flexed at the prox- 
imal phalangeal joint and with the hyperextended tip applied firmly to 
the chest.* 

The more nearly this represents the mere dropping of the hand, with a 
loose wrist, the more uniform are the strokes. If this method is employed, 
the" tip of the pleximeter finger should be so firmly applied to the surface of 
the body as to overextend its terminal phalanx and render the vertical pha- 
langes as rigid as possible, but need not constitute painful pressure save 
in exceptional instances. 

Such percussion seems to check accurately with the "threshold" method, 
which should always be used secondarily and is preferred by many for right 
border percussion. One will find usually the former method the more useful 
and greatly value the sense of resistance and sharp definition which it yields. 

According to the author's experience almost equally good results may be 
obtained by lightly tapping the surface with the finger-tips of one hand during 
auscultation over the heart, at distance, i.e., combining direct percussion and 
auscultation. No assistant is needed if this last method be used. A proce- 
dure of still greater accuracy in the author's hands has been the use of ortho- 
percussion by the method here described combined with auscultation over 
the heart. Results so obtained seem to check more accurately with fluoro- 
scopic or plate work than any other. 

The author personally violates established usage by percussing from 
within outward until the sudden and decided change of note marks the cross- 
ing of the frontier. 

The student should try out the various modern methods and choose that 
which he finds most suitable to his own needs and most accurate in his own 
hands. Almost every clinician develops his own preferences and obtains 
better results by so doing. In the modern clinic many opportunities offer 
to compare percussion outlines with the chastening orthodiagraphic and 
teleoroentgenographic findings. He should remember however that when a 
busy practitioner he cannot always secure such quiet as is necessary to 
the use of threshold percussion. 

AUSCULTATION 

Auscultation aids in determining: (a) The condition of the heart muscle, 
(b). The competence and condition of its valves, (c) The abnormal increase or 
decrease of tension present in the aortic and pulmonary circuits, (d) The 

* This technic is generally credited to Plesch, but has long been used by various clini- 
cians as an alternative method. 



Older 

methods 

inadequate. 



Pleximeter 
finger. 



A simple 
method. 



444 



MEDICAL DIAGNOSIS 



Of fundamental 
importance. 



Avoids 
blunders. 



Systolic tone. 



Diastolic tone. 



condition of the lungs (congestion, edema, effusions), (e) Abnormalities 
oj the aortic arch. (/) The presence or absence of murmurs in the tributary 
veins and arteries, (g) The presence or absence of extracardial sounds of cardiac 
rhythm, (h) The determination of abnormal sounds of cardiac origin, not the 
result of primary valvular defects. 

The first and most important consideration is the quality of the heart 
sounds in the valvular areas and the carotid arteries. 

Know and Seek the Normal. — As in the case of the lungs, a common mis- 
take in the teaching of students lies in the failure to drill them thoroughly in the 
normal characteristics of, or common variations in, the heart sounds. Students 
and physicians alike are too often satisfied if no murmur is heard, and do not seek 
and demand normal heart sounds and accentuation. 

In no other way can we explain the frequent failures to recognize the serious 
significance of abnormal quality and accentuation, the decided diminution or 
almost complete absence of heart sounds, associated with some of the most serious 
lesions of the heart. 

The student should possess a thorough knowledge of normal heart 
tones, permissible variations and normal heart border limitations, and must 
then primarily seek to determine their presence. Abnormalities exist- 
ing will thus be emphasized. 

HEART SOUNDS* 

The First Sound. — A thorough understanding of the mode of produc- 
tion, quality and accentuation, of the normal heart sounds is absolutely 
essential to the intelligent interpretation of heart murmurs. 

At the Apex the Normal Accentuation is on the First Sound; at the 
Base on the Second. — Disregarding conflicting theories and fine distinctions, 
one may say that the essential elements in the production of the first sound are 
the initial, sudden sharp contraction of the ventricular walls and the coincident 
closure of the auriculo-ventricular valves. 

The Second Sound. — The second sound is produced by the simul- 
taneous closure and tension of the aortic and pulmonary valves immediately 
following ventricular contraction. 

Hence this second sound must primarily depend upon the integrity of the 
valves themselves, and measure the amount of that recoil which is the result- 
ant of the forces of propulsion and the resistance encountered in the artery. 

Abnormal Accentuation of the First Sound. — // follows that abnormally 
increased accentuation of the first sound, as heard in any of the four auscidtation 
areas, usually indicates an overacting ventricle whether this overaction is tem- 
porary, and caused by excitement or overexertion, or persistent, and due to mere 
increase in strength, as in hypertrophy from valvular disease, to excessive radius 
of contraction of a partly filled ventricle, as in mitral stenosis, or to aortic rigidity 
or heightened arterial tension, as in arteriosclerosis and interstitial nephritis. 

Pulmonary and Aortic Accentuation. — The aortic valve being sound, any 
increase in general arterial tension will produce an accentuation of the aortic 

* See also "Rationale of Organic Heart Murmurs," page 455. 



THE EXAMINATION OF THE HEART 



445 



second sound and similar increased pressure in, or obstruction to, the pulmonary 
circulation will result in an accentuation of the pulmonary second sound. 

The degree will depend largely upon the soundness of the valves, the 
strength of the ventricles and the integrity of the mitral and tricuspid leaflets. 
The second sound may also be markedly intensified in sclerosis of the first 
portion of the aorta or pulmonary artery. 

"The Diastolic Echo." — The "third sound" reported by Barrie in 1893, 
and again by W. S. Thayer and the late Dr. Geo. Gibson of Edinboro in 
1906, is present occasionally in normal individuals; is often extremely faint; 
and audible over the apex in certain slowly beating hearts when the patient is 
lying on the left side. It seems to correspond in time to the protodiastolic 
"h" wave of Hirschf elder as occasionally seen in the venous tracings of the 
polvgram. It constitutes the protodiastolic element of the "protodiastolic 
gallop-rhythm" and has long been recognized as occurring in certain cases 
of mitral stenosis and aortic regurgitation, but though interesting is of slight 
practical importance. 

The term "diastolic echo" well describes it, for it immediately follows the 
second sound and probably corresponds to the termination of the primary 
rapid rush of blood into the ventricles and preliminary apposition of the 
auriculo-ventricular valves (Hirschf elder) . 

Practical Applications. — Much information is afforded in both acute 
and chronic disease by a study of the variations in accentuation. For 
example, lobar pneumonia must inevitably be accompanied by marked 
accentuation of the pulmonary second sound and a dangerous tendency to 
dilatation of the right ventricle. If this dilatation becomes extreme the 
\ pulmonary second sound is markedly weakened and if tricuspid regurgitation 
occurs it may be wholly lost, a sign of the gravest import. 

The pulmonary congestion incident to mitral stenosis and regurgitation 
makes accentuation of the pulmonary second sound an important diagnostic 
feature, and, as in pneumonia, a loss of this accentuation or of the entire 
sound may be a serious symptom.* 

Changes in Timbre. — A tone may be weak, short, sharp, muffled or distant, 
" murmurish" or impure, hollow or ringing, "slamming," "fetal" or metallic. 

The first sound, as heard al the apex, may be wholly lost or replaced by the 
murmur in some cases of mitral regurgitation or aortic stenosis. To a less 
degree, aortic incompetence tends to obscure the second sound alike in the aortic 
area and in the carotid artery, though in the latter lesion a marked accentuation 
may be present if a high degree of sclerosis is present in the cusps, or when, 
in spite of incompetence, the valve segments still swing freely and achieve 
an imperfect apposition. 

It is probable that in most instances of diminished intensity some degree of 
actual aortic stenosis co-exists. 

In mitral stenosis the aortic second sound is weakened, the mitral first sound 

* As stated elsewhere a diminution of the pulmonary second sound accentuation in 
mitral regurgitation may mean a small leak or a powerfully acting left ventricle which keeps 
the pathway clear. 



Of slight 
importance. 



Probable 
cause. 



Pneumonia. 



Tricuspid 
leakage. 



Mitral 
lesions. 



Important 
variants. 



Modified ist 
sound and 
aortic 2d. 



446 



MEDICAL DIAGNOSIS 



Lost or ob- 
scured tones. 



Multiple 
factors. 



A duty often 
disregarded. 



Deceptive 
conditions. 



at the apex being accentuated and sharp or slamming unless extreme regurgitation 
co-exists. 

In aortic regurgitation and stenosis the first sound at the apex is dulled and 
in combined mitral and tricuspid regurgitation all sounds are greatly diminished. 

An excessively weak heart may yield relatively loud, sharp, short tones if, 
as is usually the case, the rhythm is rapid and hurried. 

A distinctly weakened first sound at the apex, in the absence of emphy- 
sema or purely external factors interfering with sound conduction, should 
always suggest cardiac weakness with or without silent leakage, and demands 
a thorough investigation of the cardiac area and the symptoms presented by 
the patient, whether these be subjective or objective. 

"Metallic clacking" is frequent in tachycardial arrhythmias, especially 
if the stomach be distended by gas. Fetal sounds and a slamming mitral 
first sound are always pathologic. A ringing, accentuated second aortic 
tone is often associated with aneurysm of the arch; commonly, with sclerosis 
of the vessel, high arterial tension and, in many instances, with pure aortic 
regurgitation. 

Murmurish Sounds. — The same may be said of persisting "murmurish," 
impure, unduly sharp and short, or muffled sounds, though due allowance must 
be made for mere pulse acceleration and disturbances of rhythm. 

Acute Infections.— In acute infections such as rheumatism, prostrating 
diphtheria, influenza, scarlet fever, and the like, both during the attack and 
in and after convalescence, the heart must be carefully watched for signs of 
serious myocardial or endocardial mischief, such as may be indicated only by 
subjective weakness or dyspnea, minor dilatation, and a labile pulse. 

Mere Muffling of Both Sounds. — When this is evident especially at the 
apex, it may be due to a fat or edematous chest wall, to emphysema, exuda- 
tive pericarditis, fatty overgrowth, serious myocardial disease, or cardiac 
displacement. 

Attention to these changes in quality, intensity and character of the heart 
sounds are of special importance in connection with early endocarditis, acute 
or subacute myocarditis and the silent, often abrupt, dilatations and insufficiencies 
so often encountered in chronic primary myocardial degenerations, atrophy, and 
in the narrow ptotic hearts of congenitally asthenic individuals. 

Displaced Heart.— In fibroid phthisis, pleural effusion, mediastinal growths, 
diaphragmatic hernia or even extreme meteorism or ascites, the. cardiac dis- 
placement may be suggested by the changed site of audibility of the sounds 
or murmurs, the whole mediastinum being oftentimes markedly displaced. 

One can seldom with certainty assign to the individual valves, murmurs 
heard under conditions of cardiac displacement, as they may disappear wholly 
or in part when the dislocation is corrected. The pressure of pleuritic 
effusion and that of ascites or meteorism offer the most frequent examples. 
In excessively dilated hearts, and especially in such of these as show 
marked associated arrhythmias, an accurate primary interpretation, differ- 
entiation and summary of the murmurs, and hence of the individual 
lesions present, is usually impossible. 



THE EXAMINATION OF THE HEART 



447 



A Useful Maneuver. — It is well to become accustomed to the auscultation 
of the normal heart sounds as heard in the median inferior hollow of the neck 
u font i cuius gutturis" as one may often test there the legitimacy of the basal 
heart sounds. 

Increased Audibility. — Aside from cardiovascular causes already given, 
this may result if the lung is retracted from the heart, and hence at times Extracardia 
coincides with a change in the site of maximum audibility, e.g., fibroid lung or 




0> j r~ 




^ _. r- 


3- <o 


ns± 


3"2±S±o 
to 


■■^H MHH ^- i^ 


_■■■■_■■■ 


■ > — -* 


. Pouse. 
Pause. 

E 




Pause. 
. Pause. 



Fig. 2. 




Fi S .3 



Fig. 167. — Division and reduplication of the heart sounds. Upper figure. — Splitting 
of first sound (blup dwp). Mid- figure. — Division of the first sound apex (lupup dup). 
Lower figure. — division of second sound (Lub letup). 

adjacent excavation. Sounds are occasionally transmitted loudly and over 
wide areas by such pulmonary consolidations or cavities. 

Reduplication of Heart Sounds. — The normal heart sounds consist of two 
systolic and two diastolic sounds so blended as to form one systolic and one 
diastolic tone because of the synchronous closure of the valves of the right and 
left heart. 

Under many conditions this synchronism is so interfered with as to 
produce splitting or actual reduplication of either sound. 

In true reduplication the elements of the double sound are clear and well- 
defined though short. In other words, a third sound appears in the cycle. 



The triple 
rhythm. 



448 



MEDICAL DIAGNOSIS 



Curiously 
circumscribed. 



The split sound elements are less clearly separated and sometimes cannot be 
differentiated from the shortest possible murmur. 

The phenomenon of reduplication has been compared aptly to the sound 
produced by the asynchronous closure of double swinging doors. A normal 
heart, if temporarily overacting, may be the seat of doubling or splitting of 
the heart sounds, but, in general, it may be said that, hearing an apparent 
reduplication of the second sound (a presystolic third sound) at the apex only^ 




Fig. i 68 — Reduplication and division of the heart sounds. Upper figure — Redupli- 
cation of second sound (lub tlup). Mid-figure. — Presystolic gallop rhythm (lup lup dup). 
Lower figure. — Proto-diastolic gallop, rhythm (lup lup lup). Gallop rhythm is always a 
suggestive and serious phenomenon and probably represents in many instances a unilateral 
block. (See "Heart-block.") 

and especially if it be associated with diastolic blubbering or a bruit, one may 
assume that it is due to the presence of mitral stenosis.* 

If a reduplicated second sound is heard over the aortic area and, perhaps, 
the whole heart, myocardial degeneration often combined with cardiac 
overstrain and arterial hypertension is the probable cause. 

A Split Second Tone. — A split second sound at the base, limited usually 
to the third left interspace, has been found by the author with especial fre- 

* Less commonly in regurgitation unless associated with myocarditis of marked degree 
or arteriosclerosis. 



THE EXAMINATION OF THE HEART 449 



quency in slightly dilated or merely atonic insufficient hearts, usually 
with a history of past temporary prostration from acute illness or 
overstrain. 

It has been present in certain cases of early luetic aortic disease, in the 
"drop" hearts of persons of the congenitally asthenic type, who so often 
present the picture of so-called "neurasthenia," and in middle-aged males 
with minor signs of arteriosclerosis and various grades of dilatation with or 
without arterial hypertension. It has been associated invariably with a 
distinct capillary pulse and increased "pulse pressure." An intermittent 
short diastolic murmur in the third left interspace is occasionally observed 
which may wholly disappear under treatment, revert from time to time to 
the original split second sound, or, especially in middle-aged patients, be- 
come after months or years a persistent, short murmur of aortic regurgi- 
tations.* 

Many of these "split-second" cases, with or without "drop" hearts, have 
been under the observation of the author over long periods. The periods 
of to-and-fro shifting from the split sound to the actual diastolic bruit some- 
times observed are most interesting. 

Fetal Rhythm. — {Embryocardia) . — In this the heart sounds are rapid 
and equally distant, resembling the actual fetal heart sounds, and the con- 
dition has been well named " embryocardia " (Stokes-Von Huchard). The 
expert clinician recognizes its significance and importance, as indicating a 
marked enfeeblement of the heart muscle associated with excessively rapid con- 
tractions. Certain cases of auricular flutter, alternation and paroxysmal 
tachycardia must be placed under this head. 

Auscultation Areas. — The four primary surface areas for auscultation are: 

1. The mitral area {apex). 

2. Tricuspid area {lower half of sternum). 

3. Pulmonary area {second left intercostal space). 

4. Aortic area {second right intercostal space and along the line connecting 
this point with the third left interspace). 

As stated previously, these points, all adjacent to the sternum, do not corre- 
spond to the exact anatomic location of the valves which may be all included in 
the area of a large stethoscope bell, but represent the region in which the sounds of 
the respective valves or their associated murmurs are best heard. 

HEART MURMURS. — Definition. — A heart murmur is an extraneous 
sound of cardiac site and rhythm tending to obscure, partly or wholly replace, 
or immediately or laggardly precede or follow, a heart sound. 

* The author feels that possibly minor aortic insufficiencies, transient or permanent, 
may be less rare than has been believed and has found no clinical evidence to sustain the 
theory that a pulmonary insufficiency is responsible for the murmurs, or, that in young in- 
dividuals, an aortic ring which yields under excessive temporary strain is of necessity per- 
sistently damaged. 

Any one familiar with the "drop" heart and its modifications must recognize the 
special liability of its possessors to cardiac overstrain, especially when such individuals form 
as they do a considerable proportion of those seeking athletic honors and entering into 
the more strenuous forms of labor and recreation alike. 
29 



Ticking 
rhythm. 



45o 



MEDICAL DIAGNOSIS 



A reiteration 
for emphasis. 



Common Sources of Error. — It should never be forgotten that, as stated, all 
the extraneous sounds produced by a heart that is overacting, excessively weak or 
dilated, tumultuously beating, or mechanically dislocated, can seldom be accu- 
rately interpreted. Under such conditions, existing organic murmurs may be 
obscured or unplaced in rhythm; or, as more commonly happens, murmurs may 





Fig. 169. — Usual site of murmur associated 
with anemia and asthenia. (Sansom.) 



Fig. 170. — Murmur over conus arteriosus 
in anemia and myocardial asthenia. 



be present, purely temporary in character, which may be and often are wrongly 
regarded and treated as organic. 

The utter impossibility of accurately differentiating all the murmurs heard over 
extremely weak and widely dilated or dislocated hearts should be better understood. 

Transient Murmurs. — Transient dynamic or accidental murmurs and harsh 
heart sounds, associated with abnormal accentuation, are extremely common. 





Fig. 171. — Murmur limited to {supra) 
aortic area in anemic cases. (Eleven per 
cent, of cases, according to Sansom.) 



Fig. 172. — Coexisting pulmonary and 
apex murmurs in anemia. The apex ele- 
ment must be viewed with suspicion in all 
such cases of assumed hemic origin. Sansom 
held such to be true mitral regurgitations. 



They call for rest, reassurance, the administration of test doses of such drugs as 
digitalis and the bromides and always for repeated examinations. 

Postural Modifications. — All patients should be examined, if possible, 
both when recumbent and when erect, after a rest period, and, if their condition 
permits, after some brief brisk exercise. 



THE EXAMINATION OF THE HEART 



451 



Useful 
maneuvers. 




The murmurs of valvular leakage are usually best heard in the recum- 
bent position, those of narrowing (obstruction) in the erect posture; while 
sometimes, as in the case of mitral or tricuspid stenosis, a typical presystolic 
murmur may appear only at the moment when the patient reaches the 
upright position and then rapidly subside. The diastolic murmur of aortic 
leakage often may be increased by raising the arms above the head or may 
require brisk exercise to make it audible. 

The Intensity of the Murmur. — The stronger the heart and the narrower 
the affected opening, the louder and higher pitched is the murmur, and, speaking j Loud vs. soft. 
roughly and broadly, it may be said that the louder the endocarditic murmur the 

better is the prognosis, inasmuch as it often 
indicates an hypertrophy of the chamber 
most affected and most vital to compensation. 
The general rule previously stated is, 
of course, a rough one subject to many 
exceptions, nor would it cover certain 
excessively loud or even musical murmurs 
which are often associated with and derive 
their loudness and peculiar quality from 
calcareous vegetations. Murmurs must, 
in any event, take their pitch and timbre 
in large degree from the form of the orifice 
and the density, tension, shape or surface 
irregularities of its margins. 

Cases with manifest signs of inveterate 
and extreme cardiovascular disease, but 
yielding faint murmurs elicited with diffi- 
culty, or those in which no murmur is 
present though the heart is manifestly incompetent, are oftentimes of the most 
serious import, as indicating extreme myocardial exhaustion and at times an 
excessively large leak. 

Variations in Timbre. — The greatest possible diversity of timbre is en- 
countered in murmurs of cardiac origin. " Blowing " of all degrees, " sighing, " 
"cooing," "gurgling," "whistling," "hissing," "sawing," "grating," "musical," 
"squeaking," "blubbering," "rolling," "roaring," and "rumbling," are some 
of the terms quite applicable to the varied sound expressions of cardiac l 
regurgitations and stenoses quite apart from the "shuffling," "creaking," j 
"squeaking," "grating" and "rubbing" of pericardial or pleuro-pericardial 
friction. 

ASTHENIC AND "HEMIC" MURMURS.— The murmurs associated Related to 
with decided anemia are systolic in time and soft and blowing in character,* 
seldom widely transmitted, and usually best heard over the pulmonary area Usual 
(second left intercostal space). 

* Rarely they may be loud and harsh as in a case of exsanguination due to acute hemor- 
rhagic gastric ulcer observed by the author. In this case the murmurs were auto-audible 
and to be heard when the ear was several inches from the chest. 



Fig. 173. — Systolic murmur, at 
apex only, in cases of anemia. All 
such murmurs justly may be regarded 
as only in part, if at all due to the 
physical condition of the blood. 
They probably represent actual 
though often transient and atypical 
mitral regurgitation. 



Faint 
murmurs. 



maximum. 



452 



MEDICAL DIAGNOSIS 



Lack of ' 
transmission. 



Associated 
anemia. 



Cardio- 
pulmonary 
murmurs. 



Papillary 

muscle 

insufficiency. 



They are heard less frequently over the apex, aortic area, etc., and such 
apex bruits differ from the true murmur of endocarditic mitral regurgitation 
in the fact that they are usually softer and less clearly defined; are almost 
invariably associated with a more decided murmur of the same type in 
the pulmonary area, and have not the same transmission to the axilla 
and back. 

They do not, however, differ from many relative and consecutive mitral 
insufficiencies, either as to quality, or imperfections in transmission. 

So also, when heard over the aortic area proper (second right intercostal 
space), they lack the transmission into the carotids and subclavian, charac- 
teristic of true aortic stenosis. 

Their association with anemia and disappearance under appropriate 
treatment further serve to differentiate them in practice from true endo- 
carditic murmurs, but involves as well factors quite apart from the condition 
of the blood. Associated dilation is far from uncommon and is itself often 
attended by apex murmurs of a similar quality in undernourished individuals 
of the asthenic habitus, even when any marked degree of anemia is lacking. A 
few cases of diastolic hemic murmurs have been reported.* 

Adequate Factors. — The author can see no vital objection to the assump- 
tion that, in marked degrees of anemia with or without associated asthenia, 
a lowered specific gravity and diminished viscosity of the blood combined 
with hypotonia, and a rate of flow which may reach five times the normal, 
may readily produce audible murmurs. 

On the other hand, it would appear to him that, in the greater number of 
instances, other associated factors play a large part; for such murmurs often 
persist after all signs of anemia have disappeared, subsiding only when co- 
existent general muscular weakness and subnutrition have been overcome. 

The author believes, therefore, that many of the so-called accidental murmurs 
heard at the apex or over the superficial cardiac area, now classed as hemic, cardio- 
pulmonary and the like may be in whole or part murmurs of papillary muscle 
insufficiency due often to mere temporary heart muscle atonicity. In some 
instances the yielding of these structures might throw the murmur into the meso- 
systolic or prediastolic phase (post-systolic) which is precisely the rhythm of 
1 ' cardiopulmonary ' ' murmurs. 

In the anemias of pronounced congenital asthenia the elements of 
myocardial atony and slight chronic or recurrent dilatation are usually 
superadded. 

The great majority of such persisting murmurs of apical site act with 
respect to audibility as exactly like endocarditic murmurs as they could be 
expected to do when produced by the insufficiency of structurally normal 
valves and constitute most valuable signs when occurring in association 
with subjective symptoms of myocardial inadequacy. They, of course, merely 
reflect deficiencies pi tonus but these may be associated with myocardial 

* One case of typical diastolic murmur of aortic localization reported by the author 
occurred in the terminal stage of pernicious anemia, the autopsy showing a normal valve. 
He would now regard it as a dilatation of the aortic ring. 



THE EXAMINATION OF THE HEART 



453 



degeneration, and if we are not to note these deficiencies we are not to go far 
in early diagnosis. Furthermore their changes under treatment are exactly 
what one expects under the foregone assumption and not in the least what 
would be the case were they cardio-respiratory or cardio-pulmonary. 

The author does not believe that, in general, murmurs heard over the 
apex of the heart, even though they lack the quality, transmission, and 
secondary signs of organic valvular lesions are to be classed as trivial, 
especially in the case of men and women above thirty or thirty-rive years 
of age. 

To admit this is to permit the elimination of an important symptom of 
minor myocardial insufficiency associated with actual disease. 

A review of recent literature balanced against a large personal experi- 
ence with bruits of this type has convinced him of the falsity of any such 
assumption, whether the murmur heard be directly systolic or post-systolic. 
It is to be feared that there is a general lack of understanding of the 
readiness with which, in the tonus deficiencies, the mitral ring or the papillary 
muscles become incompetent and permit leakage in a structurally sound 
valve. 

One is impressed by the apparent lack of appreciation of the extreme 
readiness with which myocardial tonus is impaired even in health in the 
vastly greater number of instances temporarily and harmlessly. Any 
exertion which is excessive for the individual and produces profound fatigue 
means temporary trifling impairment of tonus. Excessive heat and vitiated 
warm air affects it in many individuals. Nutritional deficit tends to impair 
it. Psychic stress, strain and shock, if intense, may be subtly as potent as 
physical overstrain; and finally, the first effect of toxemia from whatever 
source upon heart muscle is the reduction of tonicity. One has only to review 
experimental work done not only upon the heart but upon other hollow 
muscle organs to realize how exquisitely sensitive such tissue is to such 
influences. 

In the diseased or congenitally inadequate hearts, every fresh accession 
of an existing concealed septic focus; any decided advance in an already 
seated inflammatory or degenerative process, will affect to a greater or less 
degree myocardial tonus and consequently the reserve power of that heart. 
Many or most of these impairments will be temporary and trivial, but 
from time to time those of a severer grade or greater persistence occur, the 
existing pathologic process is accelerated, or the primary congenital weak- 
ness is intensified. 

As stated previously, the more pronounced systolic hemic murmurs have 
their maximum at the pulmonary area in nearly every instance and hence 
simulate in time and -location a murmur of pulmonary stenosis, but the harsh 
murmur of this rare and almost invariably congenital lesion is wholly dif- 
ferent in intensity, in its common association with a systolic thrill, intense 
cyanosis, and other striking and extreme clinical phenomena. 

Other Forms of Accidental Murmurs. — A cardiorespiratory or cardio- 
pulmonary murmur is a ''systolic whirling'' heard best during inspiration 



Impairment 
of tonus. 



454 MEDICAL DIAGNOSIS 



and in the region of the left lung border, along the lines of the maximum reces- 
sion due to the systolic contraction and recession of the right ventricle. 

It is superficial and usually mid-systolic or post-systolic in time and is 
most likely to be heard when the heart is overacting. If true to type it 
should be absent in forced expiration over the area of cardiac flatness or move 
inward in full inspiration and outward in expiration. 

These murmurs are supposed to be due to the influx of air into interposed 
lung during right ventricular systolic recession. 

Their frequency is probably not nearly as great as has been supposed 
but, undoubtedly, they deserve mention. 

Pleuro-pericardial Murmurs. — When the apposed layers of the pleura 
and pericardium become inflamed in the extension of a pleuritis or pericarditis, 
a murmur may be present which is usually distinctly frictional and superficial 
in character and heard best usually along the border of the superficial cardiac 
area. 

This sometimes endures for a long time after the original disease subsides, 
usually lacking the quality, and, almost invariably, the transmission, of a val- 
vular murmur. The murmur corresponds to cardiac rhythm but is dis- 
tinctly affected by the phases of respiration. It is obvious that the dis- 
appearance of such a murmur in full inspiration would indicate that contact 
of the costal pleura and pericardium was responsible for the murmur and that 
this has been destroyed by the interposition of the inflated lung. 

Disappearance of the murmur in full expiration would indicate that it 
arose from contact between the pulmonary (visceral) pleura and pericardium 
which has been broken by the expiratory recession of the lung. 

Conversely the appearance or intensification of such a murmur in full 
expiration indicates inflammation of costal pleura and pericardium and its 
appearance or intensification in full inspiration points to involvement of 
the visceral pleura and pericardium. The sign is occasionally one of great 
importance as indicating a more or less sinister extension of an acute or 
chronic pericardial or pleural infection or the presence of tuberculosis. 

Curious Crackles. — Some curious showers of tiny crackling murmurs may 
be heard rarely along the left edge of the sternum, particularly in connection 
with advanced and extreme pulmonary emphysema. 

Mediastinal Emphysema. — The presence of air in this space may be due 
to external injury, the induced pneumothorax at present so much in vogue, 
or to ulceration or rupture of any portion of the respiratory tract in direct 
relationship. 

There may be subcutaneous or subfascial crepitation, often first observed 
in the cervical region, or merely crepitation of cardiac rhythm and loss oi 
heart dulness. 

Splashing. — If the pericardium contains both air and liquid, churning or 
splashing sounds of cardiac rhythm may be audible. This may be simulated 
by sounds produced in large contiguous cavities as in marked gastric distention, 
pneumothorax and advanced phthisis, but the true murmurs are so bizarre and 
peculiar as to be practically pathognomonic of the pericardial condition. 



THE EXAMINATION OF THE HEART 



455 



THE RATIONALE OF ORGANIC HEART MURMURS.— Varieties.— 

Organic murmurs may be valvular, arterial, myocardial, pericardial or pleuro- 
pericardial in origin. 

The valvular murmurs are of two kinds, namely, the regurgitant and the 
obstructive; the one being due to a leakage and back flow, the other to a 
narrowing of the valvular opening, a stenosis. 



From 
Upper Extremities.,: 




IV.C 



'N RA. 

From Trunk and 
Lower Extremities. 



To Trunk 4nd 
Lower Extremities. 



Fig. 174. — The right and left hearts. S.V.C. Superior vena cava. I.V.C. Inferior 
vena cava. P. A. Pulmonary artery. P.V. Pulmonary veins. AO. Aorta. The lungs 
are in the position of a self-cleansing blood filter and purifier, receiving venous blood from 
the right ventricle and delivering arterial blood to the left auricle. 



Preliminary Remarks. — For the sake of clearness and vividness of descrip- 
tion in relation to the production of heart murmurs, no effort to attain a 
finically technical description is attempted. 

The student needs to create primarily a simple mental picture such as 
he may retain and readily reproduce when in contact with the patient. 

Mode of Production. — The heart must be regarded simply as a double 
pump in constant action, or, as two double-chambered hearts, firmly united and 
synchronous in action. It may be represented diagrammatically as two hearts 
with the lungs between them; the systemic arteries, capillaries, and veins 



Cardiac pump 



45 6 



MEDICAL DIAGNOSIS 



Relation of 
lungs. 



Ventilation. 



Course of 

blood. 



Ventricular" 
contraction. 



carrying the blood from the left ventricle through the tissues and back to the 
right auricle, whence it passes to the right ventricle, is driven by it through 
the lesser (pulmonary) circuit and returned to the auricular reservoir of 
the left heart, for such is the plan of the circulation. 

Practical Synchronism. — Pouring constantly into the right and left 
upper chambers, respectively, comes the blood from both the greater and 
lesser circulations, led through the lower and upper caval conduits to the 
right auricle and through the pulmonary veins to its fellow of the left heart. 




Fig. 175. — The normal heart in \ beginning) systole. The ventricles, filled with 
blood which they have received from the auricles during diastole, are now contracting 
and driving their contents through the semilunar valves, just now forced open, into the 
pulmonary artery and the aorta. The mitral and tricuspid valves have just closed (first 
sound), shutting off any reflux from the ventricles to the auricles which latter must fill 
during the period of this ventricular contraction {systole). M.V., mitral valve. T.V., 
tricuspid valve. A.V., aortic valve. P.V., pulmonary valve. L.A., left auricle. R.A., 
right auricle. L.V., left ventricle. R.V., right ventricle. V.C.S., superior vena cava. 
V.C.I., inferior vena cava. AC, aorta. P.V.. pulmonary veins. P. A., pulmonary 
artery. 

Into the right auricle the superior and inferior venae cavae pour their 
dark, impure, venous blood, while to the left auricle the four pulmonary 
veins bring a constant supply of bright, red. arterial blood that has undergone 
ventilation and purification in the pulmonary air cells. 

During the recurring periods of ventricular relaxation (diastole) which 
follow each ventricular contraction, the blood passes from the auricles into 
the ventricles through the opened auriculo-ventricular valves; the mitral on 
the left, the tricuspid on the right. 



THE EXAMINATION OF THE HEART 



457 



Systole. — With the initiation oi systole ipresphygmic period) these 
valves abruptly close (first sound) the inlets to prevent backrlow into the 
auricles and the blood is forced by the continuing ventricular contraction 
(systole) along the paths of least resistance, i.e.. through the pulmonary valve 
and into the pulmonary artery on the right, and through the aortic valve and 
into the aorta upon the left; these exits remaining fully open during sys- 
tole, but shutting smartly as the systolic ventricular contraction ends Sa^oTe 
{second sound). 



First sound 

initiates 

systole. 



Second sound 




Fig. 176. — The normal heart in beginning diastole. The ventricular contraction has 
ceased, the aortic and pulmonary valves, closed (second sound,) , are shutting oft and 
supporting the blood column; the ventricles are filling from the open mitral and tricuspid 
orifices above. M.V., mitral valve. T.V., tricuspid valve. A.V., aortic valve. P.V., 
pulmonary valve. L.A., left auricle. R.A., right auricle. L.V., left ventricle. R.V., 
Right ventricle. V.C.S., vena cava superior. V.C.I., vena cava inferior. P.Vn. ; pul- 
monary veins. 

Blended Sounds. — As both sides of the heart contract simultaneously, 
or practically so, the sounds produced by each double valvular closure 
whether of systole (mitral and tricuspid) or diastole (aortic and pulmonary), 
are ordinarily coincident and blended into one ; ' tone" for each of these phases. 

The "first sound" obviously corresponds to the initiation of the period of 
ventricular contraction and the complete closure of the mitral and tricuspid valve; 
i.e., systole. 

Its time is practically that of the carotid pulse beat, a fact of much clinical 
importance. 

Diastole. — The instant that this systolic contraction is completed the 



45§ 



MEDICAL DIAGNOSIS 



Auricular 
contraction. 



Mental 
ptetare. 



aortic and pulmonary gateways close, the emptied ventricles relax, the mitral 
and tricuspid open. The aortic and pulmonary valves must be shut smartly 
to prevent backflow into the ventricles from the overfilled and distended 
great arteries, and thus they produce the "second sound" which initiates 
"diastole." During this, the period of ventricular relaxation, the blood that 
has been accumulating in the auricles during ventricular systole pours down 
through the opened mitral and tricuspid valves to fill the emptied ventricles, 



^Systole. Diastole. 

Tricuspid),,, Tricuspid) 
Mitral ) aosed Mitral |°P en 
Aortic ) Aortic \ 

Puln)onaryj 0pen Pulmonary J Closcd 



Fig. 177. — Position of the valves of the heart in beginning systole (first sound) and 
diastole (second sound). 

and just before the next systole the auricles themselves contract vigorously 
and ventricular systole almost immediately follows. 

Presphygmic Period. — The brief interval of time elapsing between the sharp 
closure of the mitral and tricuspid valves at the onset of systole and the further 
rise in ventricular pressure, necessary to open the aortic and pulmonary valves 
against the arterial pressure is called the presphygmic period and varies from 
0.07 to 0.09 seconds. 

Practical Application and Importance of a Mental Image. — For the pur- 
poses of the auscultator, systole is assumed to be initiated by the first sound 
and diastole bv the second, and in the mind's eve he sees the evele of events. 



THE EXAMINATION OF THE HEART 



450 



Systolic Events. — Thus when hearing the first sound, he sees the ventricles 
contracting, the mitral and tricuspid valves closed, the aortic and pulmonary 
valves freely open, the blood surging into the pulmonary artery and aorta, and the 
auricles refilling from the venous trunks (see Figs. 175 and 177). 

Diastolic Events. — With the second sound he sees an exact reversal of 
conditions: the aortic and pulmonary valves tightly closed; the mitral and tricus- 
pid freely open and the blood rushing through them from the auricles above to the 
ventricles below (see Figs. 176 and 177). 

IMPORTANT DEDUCTIONS.—// is obvious that any organic valvular 
murmur that is coincident with, immediately follows, replaces, or itself modifies, 
the normal first sound (systolic murmur), must arise either from leakage in the 
valves which should be absolutely closed and water-tight in this phase 
(mitral and tricuspid) or from an obstruction in those that should be freely 
open (aortic and pulmonary). 

Hence any organic valvular systolic murmur must be due either to 
mitral or tricuspid regurgitation or to aortic or pulmonary obstruction 
(stenosis). 

In diastole the opposite conditions prevail; the mitral and tricuspid valves 
being open and the aortic and pulmonary valves closed. 

It is evident that any murmur coincident with, immediately following, 
modifying, or replacing the second sound I diastolic murmur is due to aortic 
or pulmonary leakage or to mitral or tricuspid obstruction. 

Nin-e out of ten murmurs have their origin in the left heart — the hard-working 
side. 

Presystolic Murmurs in Mitral or Tricuspid Stenosis. — If the auricles 
contract as they normally should in presystole this final contraction will increase 
abruptly the force and rapidity of the flow from auricle to ventricle just before the 
closure of the auriculo -ventricular valves {first sound) terminates diastole. The 
diastolic murmur of mitral or tricuspid obstruction will assume therefore a 
presystolic crescendo intensification. If the auricle is incapable of its normal 
contraction, the murmur is diastolic purely, lacking all presystolic accentuation 
or being actually diastolic-diminuendo because the highest speed of the blood 
stream is attained under the initial intra-auricular pressure, accumulating during 
systole and highest at the instant the second sound announces the close of the 
ventricular outlets and the opening of the auriculo -ventricular gateways. 

In typical cases the 'Tumbling'' or ''thrilling'' crescendo murmur seems to 
run against and be abruptly terminated by an intensified slamming first 
sound. 

AGAINST THE STREAM. — 77 is at once evident that if at any point there 
is created a serious impediment to the free onward flow of the blood, an 
increased strain is thereby thrown upon the cardiac mechanism and a tend- 
ency to passive congestion or stasis in the area whose drainage is thereby 
impaired is at once established (see Fig. 173). 

Therefore, if any damming of the flow of pathologic degree is present 
or any portion of the pumping machinery is defective, the ultimate bad effects 
will appear chiefly and first in those portions of the heart next nearer the 



Inevitable 
conclusion. 



Systolic 
murmurs. 



Diastolic 

murmurs. 



Rule of 
incidence. 



Auricular 

systole. 



Crescendo 
murmur. 



Diminuendo 

murmur. 



Logical 
sequence. 



460 



MEDICAL DIAGNOSIS 



An 

extracardial 
obstruction. 



Accentuated 
aortic ad. 



Heart 
response. 



Relative 
insufficiency. 



Extremely 
common. 



Auricular 
dilatation. 



Right ventric- 
ular response. 



Accentuated 
pulmonary 
2d sound. 



Pulmonary 
stasis. 



Tricuspid 
leakage. 



Systemic 
stasis. 



Symptoms 
often mis- 
interpreted. 



venous sources of the blood than is the lesion itself. In short, if one may use 
an old expression, in the main the bad effects of a cardiac lesion work backward 
against the blood stream. 

ILLUSTRATION. — Interstitial nephritis raises systemic arterial blood 
pressure to an extraordinary degree and the left ventricle responds to the challenge 
of the narrowed arteries by drawing upon its reserve and increasing the strength 
of its individual contractions. 

The blood is then forced so vigorously into the aorta as to make its elastic 
recoil and the closure of the aortic valve unusually violent. As a result 
there is an " accentuation of the aortic second sound." 

Hypertrophy. — Like every other muscle under sustained unusual exercise 
and overload, the ventricle tends to hypertrophy and to increase its strength; the 
wear and tear of the aortic valve and the aorta itself is also increased and an 
unusual and excessive pressure is exerted upon the mitral valve, which alone 
stands between the overacting ventricle and the weak-muscled left auricle. 

Secondary Mitral Leakage. — If then the mitral valve becomes the seat 
of acute inflammation or of sclerosis, if the papillary musculature loses its 
strength and can no longer stay the leaflets (papillary insufficiency), or, if 
the heart itself dilates so widely through high pressure, toxemia, and degen- 
erative changes, and muscle tonus becomes diminished so greatly that the 
mitral ring which supports the valve yields (relative insufficiency), in any 
or all of these events mitral leakage occurs. 

Consecutive Involvement of the Right Heart. — A backflow into the left auri- 
cle then is established; that chamber is dilated and embarrassed, and the incoming 
current of blood from the lungs is obstructed . The right ventricle is immediately 
called upon for increased action in order to relieve the passive congestion of the 
lungs by an extra drive. The blood is then forced so strongly into the pulmonary 
artery as to intensify the shock of its valvular closure and produce an " accentua- 
tion of the pulmonary second sound" 

The lungs may thus be placed between two fires through the continued 
back pressure of blood associated with a weak left ventricle, a leaky mitral 
orifice and weak or fibrillating left auricle in front, and increased pressure 
from the overacting right ventricle behind. This effect is greatly intensified 
if the left heart continues to weaken. 

A persistence of these conditions would tend to cause ultimately a dilatation 
of the right ventricle with or without a temporary or permanent leakage through 
the tricuspid valve and a transfer of part of the overload to the great systemic 
veins. The effects of stasis might be manifested then in the general venous 
circulation by congestion of the viscera and ultimate edema or general anasarca. 

Such a complete cycle of pathologic events is common enough in practice 
though by no means invariable, and usually covers many years in its full course 
and develops but a part of the complete cycle. 

Realizing what marked local symptoms may arise from even a slight 
chronic congestion of the brain, stomach, liver, intestines, kidneys and lungs, 
one can readily understand how easily in such cases misinterpretation may 
occur because of the misleading localization of the symptoms and how readily 



THE EXAMINATION OF THE HEART 



461 



the true primary and basic cause namely, cardiovascular insufficiency, may 
be overlooked.* 

The Causative Factors. — Practically all true valvular murmurs are due 
either to stenosis or to abnormal patency of one or more of the valvular 
openings and these conditions result from inflammation of the valves (endo- 
carditis), chronic sclerosis (arteriosclerosis), from associated secondary or 
primary myocardial degeneration, actual myocarditis, or from mere toxic or 
congenital myocardial asthenia (atonicity) which results in insufficiency of 
the papillary muscle or stretching of the" valvular ring (relative insufficiency). 
The causative conditions are fully described elsewhere, and a study of these 
factors makes clear the etiology of the actual lesions. 

Relative Frequency. — Mitral regurgitation is by far the most common ; 
mitral stenosis, aortic regurgitation, aortic stenosis and tricuspid regurgita- 
tion follow in order; the remaining lesions being rare. 

As to combined lesions, double mitral and double aortic are most common, 
some placing the latter first in frequency, which is against the author's per- 
sonal experience, and would vary greatly in different clinics according to the 
predominant sex and age of the patients. 

THE DIFFERENTIAL POINTS.— Jo differentiate heart murmurs the fol- 
lowing points are determined primarily: (a) Time or rhythm, (b) Point of 
maximum clearness and intensity, (c) The direction and extent of trans- 
mission, (d) The quality of the abnormal sound, (e) The associated 
signs, viz., arterial and venous pulsation, the radial pulse, increased area of 
cardiac dulness, accentuation of heart sounds, cyanosis, edema, etc. 

RHYTHM. — Organic murmurs occurring with the first sound. (Period 
of ventricular contraction) : (a) mitral regurgitation; (b) tricuspid regurgitation; 
(c) aortic stenosis; (d) pulmonary stenosis (rare). 

Systolic murmurs, nine times in ten, are due either to mitral regurgitation or 
aortic stenosis or are purely accidental or hemic. 

Murmurs Heard with the Second Sound. — (Period of ventricular relaxa- 
tion): (a) aortic regurgitation; (b) pulmonary regurgitation (rare); (c) mitral 
stenosis; (d) tricuspid stenosis (rare). The mitral and tricuspid stenosis 
murmurs may be purely diastolic if the auricles are fibrillating or impotent; 
presystolic, or diastolic with presystolic intensification, if the auricles are 
capable of contraction just before the first sound occurs. 

Pure diastolic murmurs maximal at the base are almost invariably due 
to aortic regurgitation. 

A presystolic murmur is almost invariably due to mitral stenosis and 
is maximal at, or, oftener, just within, the apex-beat. 

To Determine the Rhythm or Time. — This should be positively de- 
termined by taking the carotid pulse while listening to the murmur. The 
radial pulse should not be used for this purpose, and in dilatation of the right 
heart, the apex-beat is far less constantly reliable and clean-cut than the 
carotid beat which can easily be felt at the anterior border of the sterno- 

* The patient with a nephritis of the extremely chronic type is likely to be snuffed out 
by an apoplexy or uremic seizure before he can complete this disastrous cardiac cycle. 



Endocarditis 
and sclerosis. 



Myocardial 
defects. 



Double lesions. 



Systolic 
murmurs. 



Diastolic 
murmurs. 



Time variable. 



Pulmonary 

regurgitation 

rare. 



Importantrrule. 



Use carotid for 
timing sounds. 



462 



MEDICAL DIAGNOSIS 



Meets vital 
needs. 



Arterial 
currents. 



Capillaries 
and veins. 



Arterial 
pressure. 



Pathways of 

least 

resistance. 



Sustained 
flow. 



Necessity of 
vasomotor 

control. 



mastoid muscle when the head is turned to the side corresponding to the 
artery palpated. 

Hypertrophy and Dilatation. — Under their appropriate headings the 
variation in cardiac outline in the chief pathologic conditions and their in- 
fluence upon the heart sounds will be fully shown and discussed. 

"Simple hypertrophy" is usually associated with chronic interstitial 
nephritis, aortic stenosis or arteriosclerosis, and "simple dilatation" repre- 
sents a stage of adaptation or actual incompensation in such lesions, or, in 
some form of myocarditis, myocardial degeneration or congenital asthenia. 

As a matter of fact the occurrence of hypertrophy without some degree 
of dilatation is doubted at present by the greater number of experienced 
pathologists and the so-called "simple dilatation" (lacking hypertrophy) can- 
not exist in any decided degree without producing decided symptoms subjec- 
tive or objective together with a limitation of the field of cardiac response. 

CERTAIN FACTORS BASIC IN THE CONSIDERATION 

OF THE DISORDERS OF THE HEART AND 

BLOOD VESSELS 

What the Heart Must Do. — In conjunction with the vascular mechanism 
it supplies the initial propulsive impulses and the sustained force necessary 
to maintain that uninterrupted flow of Hood throughout the systemic and pul- 
monary vascular circuits, which is indispensable to the physical and chemical 
exchanges essential to health and indeed to life itself. 

The Transformer. — In the aorta and pulmonary artery alike, both pres- 
sure and rapidity of flow are excessive and rhythmically interrupted, but the 
shock of the expelled blood column is taken up by the elastic arterial walls. 
In the capillaries, the flow is sufficiently slow and uninterrupted to permit the 
vital tissue exchanges of waste and repair, and a slowed current and lowered 
pressure are present with slight modification in the veins. 

Arteries Auxiliary Hearts. — The sustained arterial pressure necessary 
to produce a continuous current is dependent upon an adequate initial impulse, 
a sufficient blood volume, efficient vasomotor control, and normal elasticity of the 
vessel walls. 

The great arteries at first yield to the shock of systolic outflow but in their 
recovery exert a sustaining pressure upon the blood column which, being 
shut out of the heart during diastole by closed semilunar valves, must of 
necessity move forward along the vascular pathways of least resistance. 

Arterial Conservation of Initial Energy. — Obviously the driving force of 
ventricular contraction is largely conserved and compensated by this primary 
arterial distention of the aorta and pulmonary artery which serves to main- 
tain the flow during the entire period of ventricular relaxation. These great 
vessels constitute a storage plant, rhythmically charged and discharged. 

The Role of the Vasomotor System. — It is evident also, not only that the 
capillary flow must be continuous, but that it must be controlled to a degree that 
will secure the automatic satisfaction of the periodic or even momentary variations 
in the needs of the body tissues. 



THE EXAMINATION OF THE HEART 



463 



Hence quite aside from reflex increase of heart strength, acceleration of 
primary outflow and rise in pressure, tissue needs are met by a slowing or 
quickening of the peripheral stream and a coincident local increase or 
decrease in intravascular pressure through automatically regulated dilatation 
or contraction of the capillary channels. 

Speed of the Blood Stream. — In the great arteries the normal flow varies 
between 200 and 400 mm. per second as contrasted with a capillary flow 
of but 0.6 to 0.8 mm. per second. In the normal individual the body circuit 
is completed in about fifty-five seconds requiring about 55 heart beats. In 
strenous physical effort the time required is but four and one-half seconds and 
in marked anemia, with lowered specific gravity and decreased blood viscosity, 
the circuit consumes but thirteen and one-half seconds, the required beats 
being reduced to 23 (C. Hirsch). In erythremia, on the other hand, increased 
erythrocytes and a heightened viscosity are associated oftentimes with a 
doubling of the total blood content of the body, heightened arterial pressure, 
cardiac overaction, and vasomotor constriction, and the resultant slowing of 
the circulation becomes an important factor. 

Extreme Vasodilatation. — This may obtain in disease to a degree which 
actually threatens the life of the individual, such indeed as would be the dila- 
tation if the medullary center were paralyzed, as in certain cases of sudden 
death from diphtheria, or if the splanchnic nerves were divided. 

Excessive Vasoconstriction. — Conversely, vasoconstriction may become 
so extreme through direct overstimulation of the vasomotor centers in the 
medulla or the action of circulating toxins (uremia), as not only to raise arte- 
rial pressure to a dangerous degree, but also, when exerted locally, to cause 
actual gangrene of the part affected, as in Raynaud's disease, in which there is 
extreme vasomotor constriction alternating with excessive local vasomotor 
dilatation. 

Conflict of Opposing Forces. — In certain ailments, as in aortic regurgita- 
tion, there is a compensatory effort on the part of the body tissues to neutralize 
the effect of the unsupported blood column (at the aortic outlet) and modify 
the necessarily excessive strength of the primary flow by means of a persistent 
mild vasodilatation. 

In a case of interstitial nephritis the resulting tendency to adverse 
toxemic vasoconstriction is further aggravated by a coincident impetus given 
to arteriosclerotic changes. This not only weakens the heart, but, by im- 
peding conservative vasodilator action, produces a decided impairment of 
body nutrition. The vasomotor center itself not only may become markedly 
irritable or weakened through the toxins of disease or the imperfect blood 
supply it receives in certain cases of incompensation, but is extremely 
susceptible also to adverse psychic influences.* 

The Heart's Capacity for Work. — The miraculous perfection of this com- 
plete, wholly automatic, hydraulic plant is shown by the fact that each day's work 
of the normal heart is equal to 20,000 kilogr ammeters (Zuntz), viz., the power 

* The Dastre-Morat Law. — Dilatation of the splanchnic vessels is accompanied usually 
by contraction of the surface vessels. 



Rate of flow. 



Great arteries. 
Capillaries. 



Physical 
exertion. 

Complete 
circuit. 



Anemia. 



Erythremia. 



A. cause of 
death. 



Uremia. 



" Raynaud's 
disease." 



Compensatory 
vasodilatation. 



Super- 
imposed 
nephritis. 



Daily task. 



464 



MEDICAL DIAGNOSIS 



Life's work. 



Dependent 
upon chemical 
processes. 



sufficient to raise 20,000 kilos of water to the height of 1 meter. In a lifetime 
of sixty years it pumps 2,800,000,000 liters of blood (Plesch). 

Varied Demands. — The output of the heart must be such as will satisfy 
the extremes represented by absolute rest on the one hand and the most 
violent exertion on the other, and this means that the normal heart must be 
able to meet instantly and adequately at least a thirteenf old increased demand. 

One of the earliest, most important, and least recognized symptoms of insuffi- 
ciency is an inability on the part of the individual to meet hitherto well-borne 
variations in the demand upon his heart strength without conscious effort or 
actual discomfort. The daily work hitherto done easily becomes a burden. 

Metabolism in Insufficiency. — It is evident that any decided interference 
with efficient circulation must affect the supplies of nutrient material and 
oxygen which in health are steadily and continuously carried by the blood 
to the chemically active tissues, no less than the proper combustion and com- 
plete disposal of the waste products of body metabolism which are removed 
through various channels in like manner and by the same mechanism. 

Acceptance of Myogenic Theory. — No attempt will be made to set forth 
in detail the claims .of the neurogenic and myogenic theories relating to the con- 
traction of the heart. The latter, for the most part, stands upon a firm experimental 
basis, so admirably serves diagnosis and therapy alike as to have immeasurably 
advanced the proper clinical conception and management of cardiac derangements, 
and is accepted by most physiologists. 

WHAT THE NORMAL HEART MUST POSSESS 

MYOGENIC THEORY.— The heart cells must possess: (a) The power 
to generate stimuli to contraction, i.e., "stimulus production." 
{b) The ability to receive stimuli, i.e., "excitability." 

(c) The power to respond to stimuli by contraction, i.e., "contractility." 

(d) Conductivity. 

(e) The power to maintain continuously a le sser but vastly important tonic 
contraction or muscle tonus apart from periods of active contraction, i.e., 
tonicity. 

Stimulus Production. — The myogenic theory also assumes that the highly 
specialized heart muscle cells when normal, properly nourished, and free from 
disturbing extracardial influences, can elaborate and maintain rhythmic chemical 
exchanges which stimulate the muscle fibers to a constant maintenance of proper 
tonus and efficient rhythmic contraction (rhythmicity) . 

Explosions of Energy. — Irritability remaining constant, temporary exhaus- 
tion attending each systole is complete, but is rapidly repaired during diastole, 
and, in health, stimulus production and irritability constantly readjust themselves 
to adequate recurrent rhythmic discharge. 

Refractory Stage. — By reason of its rhythmically recurring exhaustion, the 
heart muscle is wholly unresponsive to stimulation during the period of its 
actual contraction, i.e., it loses its excitability {refractory stage). The prompt 
restoration of excitability and contractility, as seen in health, depends'upon 



THE EXAMINATION OF THE HEART 



465 



a proper maintenance of the balanced chemical exchanges necessary to the 
renewal of the cell activity. 

Rhythmicity. — The rhythmicity of those explosions of energy which give 
rise to the normal heart beat depends upon the generation of periodic stimuli 
apparently determined by the rhythmic chemical interaction of inorganic salts 
of potassium, calcium and sodium and their ion-proteid combinations present 
in the blood in certain definite proportions (balanced solution). 

In such combinations the substitution of one ion for another can change 
the physical properties of the " ion-proteid " compound and it is assumed that 
the quality of recurring irritability (recharge of the exhausted cell) indis- 
pensable to contraction is thus explained. 

The theory of Gaskell which assumes a rhythmic alternation of assimila- 
tion and dissimilation (anabolic and katabolic processes) would seem well 
suited to this assumption. 

Restoring the Heart Beat Post-mortem.— By proper perfusion with 
Ringer's solution,* H. E. Hering restored and maintained for three and one- 
quarter hours the heart beat of a man eleven hours dead and Kuliabko 
obtained contraction of the heart of a dog five days dead. 

Adequate rest periods must be had between the recurrent discharges 
or neither stimulus production nor contractility of normal degree can be 
retained. 

Therefore, the work of the normal heart is dependent upon a series of rhythmic 
explosions and these in turn are contingent upon the maintenance of an efficient 
balanced metabolism. 

From the foregoing it is clear that the possession of a certain degree of ana- 
tomic integrity of the heart muscle is a paramount necessity and that the matters 
of nutrition and proper conduction are alike vitally important. 

Efficient Contraction. — A point or points of maximum irritability, free 
conductivity and definite open channels of conduction are essential to efficient 
and orderly contraction. 

As Hirsch well says, "the heart muscle is a homogeneous plasma mass with 
nuclei," a veritable aggregation of specialized cells. Its fibers freely anasto- 
mosing, are naked, wholly lack the connective tissue sheath of the skeletal 
muscle, and conduct almost as freely as nerve fibers. Thus every facility exists 
for rapid and harmonious stimulus transmission and coordinated response. 

It has been clearly, and apparently conclusively, shown by Wm. His, 
Jr., that the embryonic heart can act by virtue of its own intrinsic powers of 
conduction before its ganglion cells are demonstrable. This does not 
prove that a function possessed in embryonic tissue may remain dominant 
after the nervous mechanism develops but is a strong link in a long chain of 
evidence. 

Gaskell's Bridge.— (Bundle of His). — The apparent barrier to the full 
acceptance of the theory of the heart's potential automatism was represented 
by the anatomic break evident in the separation of the auricles from the 

* Ringer's solution is an artificial blood serum containing sodium, calcium and potassium 
chloride and sodium bicarbonate. 
30 



Chemical 
exchanges. 



Modern 
miracles. 



Fiber 
conduction. 



Heart fibers 
naked. 



Free inter- 
conduction. 



Automatism. 



4 66 



MEDICAL DIAGNOSIS 



Purkinje 
fibers. 



Increased 
"a-c interval. 



Partial block. 



Ventricular 
rhythm. 



Adams-Stokes 
syndrome. 



Sino-auricular 
node. 



Position. 



ventricles by the auriculo-ventricular septum, a non-muscular structure, 
but this gap has been bridged by Gaskell of Cambridge and Wm. His, Jr., 
who have shown that the interruption of normal stimuli passing from auricle 
to ventricle is not accomplished by cutting the nerve bundles, but rather 
the "bundle of His." 

Gaskell foreshadowed and foretold,* and Stanley Kent and Wm. His, Jr., 
proved, for the human heart, that the apparent barrier between auricle and 
ventricle was bridged by a bundle of peculiarly modified muscle fibers ("auri- 
culo-" or " atrio- ventricular bundle"). 

Auriculo-ventricular Bundle. — Tawara described clearly the course of 
these fibers, whose point of origin forms the so-called auriculo-ventricular 
node of AschofT and Tawara at the posterior right border of the base 
of the auricular septum, and showed that the bundle represented an 
aggregation of the Purkinje fibers which ramify to every part of the 
ventricles. 

Heart Block. — Any disease process or the administration of any drug 
tending to obstruct the free passage of impulses through this bundle must at 
least increase the time interval normally existing between auricular and 
ventricular contraction {conduction period) as expressed clinically by that 
separating the jugular wave (a) from the carotid wave (c) of the polygram. 
If the block interposed is still more decided, certain auricular contractions will 
fail to carry through and both delays (prolonged a-c interval) and elisions of the 
"c" wave ("dropped" ventricular contractions) will appear on the record, 
and show a rhythmic ventricular disregard and pretermission of fixed 
groups of auricular beats. The auricle may beat two, three, four or more 
times to each beat of the ventricle. 

Complete Block. — This may reach a point where entire dissociation of 
auricle and ventricle is present and the two chambers beat quite independently, 
each of the other, the latter developing a slow deliberate rhythm of about 30 
beats to the minute, while the auricle pursues its own rate which may be 
two, three, or four times that of the ventricle. 

It is in such cases of heart block that periods may occur when 
the over-deliberate, and oftentimes weakened ventricle fails to send 
sufficient blood to the brain, thus causing convulsive seizures. It may 
cease for short periods, moreover, to beat at all, in which case syncopal 
attacks may occur and thus round out the classical "Adams-Stokes 
syndrome." 

The Pace Maker of the Heart. — Whence come the rhythmic impulses which 
induce coordinate contraction of the auricles and ventricles? 

There is a normal point of maximum irritability represented by a network 
of specialized muscle cells richly supplied with nerves and imbedded in the 
upper anterior end of the sulcus terminalis, which sulcus runs from the in- 
ferior vena cava to the junction of the superior vena cava with the right 
auricular appendix. 

*W. H. Gaskell of Cambridge University, England, actually demonstrated both 
myogenic conduction and heart block in the frog and tortoise in the year 1883. 



THE EXAMINATION OF THE HEART 



467 



This is the sino-auriciilar node of Keith and Flack which, from its station 
in the wall of the right auricle at the mouth of the superior vena cava, normally 
initiates each contraction of the heart. 




Fig. 178. — " GaskelPs Bridge," "His 1 Bundle." Interior of the right atrium and ven- 
tricle. The atrio-ventricular bundle dissected out. {Morris- Jackson.) 

i, Aortic arch. 2, Vena cava superior. 3, Right pulmonary artery. 4, Right superior 
pulmonary vein. 5, Right atrium. 6, Right inferior pulmonary vein. 7, Crista termi- 
nalis. 8, Cut anterior tricuspid cusp. 9, Fossa ovalis. 10, Valvula sinus coronarii. n, 
Valvula venae cavae. 12, Vena cava inferior. 13, Left common carotid artery. 14, 
Innominate artery. 15, Reflexion of pericardium. 16, Pulmonary artery. 17, Ascend- 
ing aorta. 18, Left pulmonary valve. 19, Conus arteriosus. 20, Crista supraventricu- 
laris. 21, Papillary muscle of conus. 22, Atrioventricular (His) bundle. 23, Medial 
tricuspid cusp, partially removed. 24, Anterior papillary muscle. 25, Part of posterior 
mitral cusp. 26, Posterior papillary muscle. 



Sinus oode. 



468 



MEDICAL DIAGNOSIS 



Course of 
impulses. 



Normal con- 
duction time. 



Thence the wave of impulse spreads over the auricular walls, causing 
auricular contraction, then crosses the bridge of Gaskell (bundle of His, 
Jr.) to the papillary muscles and walls of the ventricles, which begin to con- 
tract from o.i 2-0.18 of a second later (normal a-c interval of the venous 
tracing). 




Fig. 179. — "GaskelTs Bridge," "His' Bundle." Left ventricle and part of the 
atrium. (The aorta is opened through the medial cusp of the mitral valve. The plainly 
visible left limb of the atrio-ventricular bundle has been accentuated.) {Morris- Jackson.) 

1, Pulmonary artery. 2, Right auricle. 3, Right aortic valve. 4, Anterior mitral 
cusp. 5, Atrioventricular bundle. 6, Anterior papillary muscle. 7, Cut wall of left 
atrium. 8, Membranous ventricular septum. 9, Left atrium, io, Part of posterior 
mitral cusp. 11, Vena cava inferior. 12, Coronary sinus. 13, Posterior papillary 
muscle. 14, Fine mesh work of columna carnae at apex. 

Right vs. Left Auricle. — As might be expected from the position of the 
pace maker, the beginning of right auricular contraction actually precedes 
that of its fellow, the left auricle, by 0.01 to 0.03 second but clinically their 
contraction may be considered as simultaneous. 



THE EXAMINATION OF THE HEART 



469 



Extrasystoles. — In certain pathologic conditions the heart may develop 
abnormally placed areas of irritability which initiate imperfect beats dis- 
turbing normal rhythm though usually leaving the rate unaffected. 

The Strength of Extrasystoles. — Given equal stimuli, the strength of any 
extrasystole is mainly dependent upon the time elapsing since the initial 
contraction of the beat preceding it, i.e., upon the duration of the antecedent 
rest period. 

Stimulus Conduction. — As stated previously, conduction by the muscle 
fibers themselves, while a trifle less perfect than that of systemic nerves, is re- 
markably good. It is greater in the contractile fibers of the auricle and 
ventricle than in the auriculo-ventricular bundle and, as in the case of 
other functions of heart muscle, is momentarily exhausted by each systolic 
contraction. 

Tonus. — A s in the case of all other muscles a certain degree of muscle tonus 
is normally well maintained and during life complete relaxation never occurs in 
the normal myocardium. 

The Neurogenic Theory. — This hypothesis assumes that the intrinsic 
stimulus to contraction originates in the ganglion cells adjacent to the sinus 
node or in those of the interauricular septum. Thence it is supposed to be 
transmitted by axones to the "sinus node" (of Keith and Flack), the auriculo- 
ventricular node ("node of Tawara"), the "bundle of His" (His-Tawara 
system), or directly to the muscles. 

Independence of the Heart. — It is obviously possible that the two sys- 
tems may prove to be interdependent or simultaneously active, but it is 
certain that the heart muscle itself is perfectly capable of automatic rhythmic 
activity wholly apart from the nervous system. 

The Influence of the Vagus and Sympathetic Cardiac Nerves. — The vagus 
and the sympathetic nerve fibers are physiologic antagonists with relation 
to heart action. 

Normally tonic vagus influence exists and manifests itself chiefly in the 
maintenance of a normal rate. When abnormal vagus excitation occurs, 
the rate of heart beat is slowed, and the interval between the auricular and 
ventricular contractions ("conduction time, a-c interval") is increased. 
Certain auricular contractions may fail to excite the ventricular contraction 
of the heart or either or both auricle and ventricle may stop temporarily. 
These constitute examples of partial or complete vagus heart block (delayed 
and interrupted conduction in the His bundle), such as may be seen in digi- 
talis poisoning or in the toxemias of infections.* 

It would seem that the direct action of the vagus is exerted upon the sinus 

* Whether the older conception of "conduction time," which assumed that impulses to 
ventricular contraction were passed through the auricular tissues, was correct may be 
doubted. It would appear that strictly speaking the "a-v interval" represents the fraction 
of time intervening between an auricular and a ventricular response to individual and 
separate stimuli from the sinus node. The ventricular impulse passes through the 
auricular-ventricular node, the His bundle, and the two branches of the His-Tawara 
system. The distinction is of slight importance in this elementary discussion. 



Premature 
contractions. 



Auriculo- 
ventricular 
node. 



Physiologic 
antagonists. 



Vagus 
block. 



47° 



MEDICAL DIAGNOSIS 



Action^ 

of 
sympathetic. 



Effect of 
atropin. 



Reinforcing 
spirals. 



Marvelous 
regulation. 



Cardiac 
response. 



Cardiac 
endurance. 



node (node of Keith and Flack) and that it is left vagus stimulation which 
chiefly affects the conduction time. 

Conversely, stimulation of the sympathetic tends to increase the rate of 
the heart beat, shorten the conduction time and increase contractility and 
irritability. In health, these accelerator nerves constantly exert a tonic 
influence opposed to that of the vagus. 

Common Causes of Vagus Overstimulation. — Aside from poisoning by 
digitalis, strophanthus, aconite, etc., vagus overaction may occur in varying 
degree in dyspnea and cyanosis (lack of oxygen and excess of C0 2 ), in tobacco 
poisoning, in cerebral compression, and in arterial hypertension. 

On the other hand, vagus influence is diminished or suspended under full 
doses of atropin and this fact is utilized in the differentiation of the slow pulse 
of vagus overstimulation from that due to organic disease. 

Vagus overeffects may be easily obtained by deep thumb pressure over 
the right carotid at the middle or lower third of the neck, but the maneuver 
is not wholly safe. 

To what an extent the diseased heart can escape the normally balanced 
influences of the accelerator and cardio-inhibitory nerves and run amuck 
through sheer disorganization of its own automatism and intrinsic rhyth- 
micity, is shown later in our discussion of the " arrhythmias " associated with 
organic disease. 

Remarkable Anatomic Structure of Heart. — The arrangement of the 
muscle fibers of the heart is peculiarly adapted to coordination in that the 
ventricular musculature constitutes two spirals (Mall) each consisting of two 
layers running at right angles to each other. One of these spirals passes from 
the tricuspid area to the apex of the right ventricle, the other from the aortic 
and mitral orifices to the apex of the left ventricle, each being connected to 
the other by twisted strands running from the papillary muscles of one ven- 
tricle to those of the other. 

Coordination of Function. — This is indispensable to the normal heart 
action and in addition to a marvelous correlation of functions we find a certain 
automatically regulated sequence of stimulation and contraction which permits 
selective muscular activity on the part of different portions of the heart. 
Thus a given stimulus being received, the sequence and degree of the resulting 
contraction is exactly that necessary to the economic and efficient contrib- 
utive action of each part of the heart. 

An understanding of this beautiful mechanism enables us to comprehend 
more readily the newer nomenclature of heart disorders, and the mechanics and 
modern interpretation both of disturbances of rhythm and of actual cardiac 
insufficiency. 

Possibilities of Cardiac Reserve. — Extraordinary possibilities of emergency 
response to effort are possessed by all normal hearts and affect both rate and force 
of contraction. 

Much cardiovascular overwork may be borne for long periods without 
producing symptoms, and actual insufficiency can be present for years without 
obtrusive manifestations. 



BLOOD PRESSURE 



471 



Fundamental 
requisites. 



Determining Factors in Cardiac Insufficiency. — 77 is the degree of impair- 
ment or exhaustion of the reserve force, the sudden or gradual narrow-lug of the vital point. 
field of response, which determines cardiac insufficiency, one or all of the heart 
functions being affected. 

Therapeutic Objective. — Our object in treatment is to amplify, restore, 
or rehabilitate impaired reserve, and the main object of diagnosis is to detect To maintain 
early, and, so far as possible, measure the degree of, its impairment. 



BLOOD PRESSURE 
Factors Basic in its Determination and Interpretation 

ADAPTIVE CARDIOVASCULAR AUTOMATISM.— In order that a 
state of perfect body health may be maintained without undue and ultimately 
damaging strain upon the heart and blood vessels, it is necessary that the 
heart, that automatic generator of energy in the cardiovascular power 
plant, be itself measurably perfect as regards its controlling mechanism, and 
possessed of the attributes necessary to the generation of adequate horse- 
power and its economic delivery to the storage plant represented by the aorta 
and its main arterial service lines. 

Transformation and Conservation. — It is also requisite that the turbulent 
intermittent outrush of blood from the ventricles into the aorta should 
be so controlled automatically as to replace the primary jerky intermittency 
and rhythmic variations in the velocity of the blood stream by conditions of 
relative uniformity and constancy of flow, and such gradual reduction of 
speed, as best suits the needs of the tissues fed and drained by the capillary 
deltas. 

Selective Adaptation and Distribution. — There must also be a selective 
adaptation of the local rate of flow and actual blood supply to the ever-vary- 
ing demands of body metabolism. Obviously there is equal need of a 
relatively constant capillary blood pressure, varying only as may be neces- 
sary to meet the demands of tissue metabolism by means of a frictionless 
automatism. 

A Marvelous Mechanism. — The anatomic structure of the arterial sys- 
tem is beautifully adapted to these purposes, and the exquisitely balanced and 
adjusted control exercised by the vasomotor system in health adjusts to a 
large degree the speed of the capillary current and the local supply of blood 
without any special demand upon the heart for decided changes in rate, 
rhythm, force or output. 

Systolic and Diastolic Pressure in the Aorta. — Inasmuch as the systolic 
pressure and energy transmitted from the heart to the aorta far exceed 
primarily the amount needed to move the blood column onward, these must 
be husbanded in order that blood flow may be steadily maintained during the 
entire diastolic period. One per cent, is the amount of pressure energy 
immediately applied to support the forward movement of the blood column. 
Ninety-five per cent, is expended in distending the elastic arterial walls and 
thus becomes potential pressure-energy, the gradual release of which during 



472 



MEDICAL DIAGNOSIS 



Adjusts to 
tissue needs. 




diastole serves to keep the column of blood moving steadily onward without 
permitting a descent of pressure below that representing the minimum 
("diastolic pressure") of the preceding diastole. 

Pulse Pressure. — Hence both systolic and diastolic pressure levels are 
maintained in the arteries, the former (systolic blood-pressure) representing 
the maximal level for the cycle, and becoming lowered as potential energy 
is converted into kinetic drive for the blood column. The difference between 
these two levels ("pulse pressure") of pressure energy represents under 
absolutely normal conditions the reinforcement, 
rhythmically dispatched to the arterial system 
by the heart through its recurring systolic con- 
tractions. 

Regulation of Rate of Flow. — Both initial 
current velocity and initial blood pressure, as 
demonstrable in the larger arteries, would be 
disastrously excessive both in the lesser and 
least arteries and in the capillary spaces if the 
primary rate of flow was maintained through- 
out. Therefore, as we have seen, the rate of 
flow which in the large arteries varies from 200 
to 400 mm. per second becomes reduced to 0.6 
to 0.8 mm. in the untroubled waveless capillary 
lakes (C. Hirsch). 

Blood Pressure in the Small Arteries and 
in the Veins. — The systolic blood pressure, 
which in the aorta is about 150 and in the 
brachial may average 125 mm. of mercury, is 
reduced to the diastolic level of constant 

pressure (60 to 70) in the lesser arteries. In the capillary deltas it varies 
from 45 to 15 mm. of mercury and, in the veins, is reduced to a maximum 
of 20 in the superficial venous channels and 10 to 15 in the subpapillary 
venous plexuses (C. L. Wiggers). 

DETERMINATION OF BLOOD PRESSURE.— Preliminary Considera- 
tions. — It is evident that in clinical work we are chiefly concerned with the cir- 
cumferential pressure exerted by the blood column upon the walls of the brachial 
artery during systole and at the end of diastole, together with the difference be- 
tween these two which is u pulse pressure" 

Fundamental Factors. — furthermore, that variations in arterial pressure 
are dependent chiefly upon the volume and energy of ventricular systolic dis- 
charge, its rate, and the resistance offered by the lesser arteries and capillary 
field. 

It must not be considered the measure of the heart strength, which is but one 
factor. 

Importance of Pulse-pressure. — In health the average * 'pulse pressure" 
varies between 35 and 50 mm. and this and the diastolic pressure are actu- 
ally far more important in a diagnostic sense than the systolic pressure. 



Fig. 180. — Gartner's tonom- 
eter. One of the first blood- 
pressure instruments applied 
widely to clinical uses. It is 
used still occasionally for com- 
parison of peripheral with 
brachial blood pressures. 



BLOOD PRESSURE 



473 



A diastolic pressure reaching or exceeding ioo mm. Hg. is almost in- 
variably pathologic. 

It should represent normally about 70 per cent, of the systolic reading. 

Simple Device. — Fortunately for the clinician, blood pressure may now 
be measured quickly and with sufficient exactitude by simple and relatively 
inexpensive instruments nearly all of which depend upon the same general 
principles, viz., the translation of the pressure required to obliterate the 
arterial pulse, into the height of a mercury column in a manometer tube. 





Fig. 181. — One of the several forms 
of pocket sphygmomanometers of the 
aneroid type. Convenient, compact and 
portable, but needing standardization 
from time to time. 



Fig. 182. — New Nicholson Princo 
sphygmomanometer. Small, portable 
and accurate. (Courtesy of Precision 
Thermometer and Instrument Co., Phila.) 



The portable instruments now available are, for the most part, sufficiently 
accurate for ordinary clinical work, but systolic blood pressure readings 
which depend upon the usual and least accurate method of determination, 
i.e., the first palpable return of a radial pulsation after obliterative compres- 
sion, involve an underestimate of from 5 to 15 mm. of mercury. 

The Older Technic of Blood-pressure Determinations. — The hollow 
armlet, applied midway between shoulder and elbow, is inflated by the hand 
bulb until the radial pulse is lost, then by the outlet thumb-screw the pres- 
sure is lowered until the pulse return is just perceptible. As the pressure is 
equal in all parts of the closed system, the height of the mercury column in 
the manometer tube is an exact index, and the reading represents the" maxi- 
mum" or "systolic" pressure. 



Systolic,|»dias- 
tolic and ; 
"pulse" 
pressures. 



474 



MEDICAL DIAGNOSIS 



"Diastolic" or "minimum" pressure is determined by noting for ten 
to twelve pulsations the increasing amplitude of the pulse wave registered 
by the mercury column as the pressure is reduced in 5- mm. series. The 
point representing the base line of the maximum excursion is the index 
of diastolic pressure. Below that is a limited pressure area of equal 
amplitudes. 

The "mean" pressure represents the average of systolic and diastolic 
readings and the "pulse pressure" or "pulse amplitude" represents, as has 
been stated, the difference between the systolic and diastolic readings. 

Pulse pressure is usually about one-fourth the systolic pressure and runs 
between 35 and 50 mm. Eg., as 



Pulse pressure 
variations. 



Sources of 
error. 



Sclerosis. 



Sex and 
attitude. 



Auscultation 
method. 





stated above. A pulse pressure 
which falls below 25 or exceeds 60 
is almost certainly pathologic. 

Diastolic readings run normally 
about 25 to 40 below the systolic; 
in low tension, varying from 50 to 
80 mm. ; and in aortic regurgitation 
; 150 mm. or more. An excessively 
rapid, persistently irregular or 
unequal pulse makes palpatory 
diastolic pressure determination 
impossible. 

In every case the arm band 
should be closely adjusted, the arm 
supported at the heart level and the 
same position taken for a series of 
tests. 

The limit of error in calcareous 
arteries is but 10 or even e mm. 
and is negligible or easily esti- 
mated. The same figures respec- 
tively represent the difference between females and males and the standing 
and sitting posture. 

The limits of error in respect to the state of contraction or relaxation of 
the arterial wall itself are probably considerable and quite beyond accurate 
determination. 

Muscular movement and the presence of edema alike introduce a variable 
element of misinterpretation. 

An error of 20 mm. Hg. may result from the use of an improper rubber 
tube and old tubes should be replaced frequently by new ones. 

Koratkow's Method. — This simple, clinically accurate, and recommended 
method consists merely in auscultating over the brachial artery below the 
point of constriction, the sounds produced during the obliteration of the 
brachial pulse by the arm band of any of the ordinary instruments. The 
use of a special arm band carrying a stethoscope is a matter of increased 



Fig. 183. — The illustration shows the 
Pilling bracelet-stethoscope, an ingenious, 
useful, yet dispensable device. It is less con- 
venient but wholly possible to use the binaural 
stethoscope of any type alone. (See Fig. 184.) 



BLOOD PRESSURE 



475 



convenience but is not a necessity. The sounds heard over the brachial 
artery as the obliterating pressure is gradually released are divisible in five 
phases of audibility, viz: 

First Phase. — Systolic Pressure Level. — A clear thumping sound, which 
must be translated into the reading of the manometer scale at the exact time 
of its occurrence represents systolic pressure. This sound remains clear and 
distinct usually until the mercury column has dropped 15 mm. and represents 

the first projection of 
blood into an empty 
artery. 

Second Phase. — The 
clearness of tone of the 
first phase becomes a 
blending of multiple eddy 
murmurs and this blurred 
picture lasts until an ad- 
ditional recession of about 
20 mm. of mercury has 
occurred. 

Third Phase. — A 
sharp sound appears and 
grows progressively more 
distinct and louder dur- 
ing a recession of about 25 
mm. of the mercury in the 
manometer column. 

Fourth Phase. — Dias- 
tolic Pressure Level. — 
This represents the 
abrupt muffling of the 
tone of the preceding 
(third) phase and lasts 
for only a short period 
represented by a reces- 
sion of about 5 mm. of 
mercury. 
The scale reading of the manometer at the exact time of the appearance of 
this dull muffled sound is taken as representing the diastolic pressure. 

Fifth Phase.— This is merely the period initiating entire loss of sounds 
and by Koratkow and others was considered formerly as representing the 
diastolic pressure point. 

The use of the fourth phase is probably the more accurate and certainly 
the more generally applicable method inasmuch as complete disappearance 
of sounds may not occur in aortic regurgitation or in certain cases of exoph- 
thalmic goiter. 

Normal Readings. — The normal systolic pressure readings according to 



A clear sound. 




Fig. 184. — The auscultation method. (A 7 orris.) 



Confused 

multiple 

bruits. 



Reappearance 
and intensifi- 
cation of clear 
tone. 



Abrupt 
muffling of 
tone. 



476 



MEDICAL DIAGNOSIS 



Effect of 
excitement. 



A great need. 



Faulty figures, 



Results in 
practice. 



Janeway are: for young adults, ioo to 130; older adults 100 to 145; children 
90 to no; infants under two years, 75 to 90.* 

Age. — The following table is that of L. Gordon, and represents the results 
of an extensive study of the relation of age in normal children to systolic 
blood-pressure. 

Years Mm. Hg. 

Under one 71.0 

One 73 . o 

Two 79 . 3 

Three 81.0 

Four 83 . o 

Five 86 . 5 

Six • 88.5 

Seven 85.0 

Eight 93 . o 

Nine 100 . o 

Ten 95 . o 

Eleven 104 . o 

Twelve 105 . o 

Excitement may cause a rise of 40 mm. or more and physical effort a slight 
increase or, if extreme or of an unusual nature and abrupt, a rise of 30-60 mm. 
may occur. Accustomed effort of the same grade may cause a rise of only 10 
mm. or less. 

The rise of pressure under exercise and excitement alike is predominantly 
systolic, and, in the case of the former, pressure may actually fall if the 
individual is in good training and the effort is not one of an abrupt, violent, 
nature (high jump, throwing the hammer, 100 yard dash). 

Experience teaches us that a persistent pressure of 130 or more in the 
young adult is a suspicious finding, and that even in middle age a systolic 
pressure of 150 is almost certainly pathologic, f 

We need greatly a large series of " normal" readings based upon the 
auscultatory method and upon cases thoroughly and completely investigated 
with respect to the presence of incipient disease and the structural types 
encountered. The variations in the figures at present available are too great 
to represent wholly normal departures. 

The reported average systolic reading of 1 50 mm. at age sixty for example, 
to which about 10 mm. must be added to allow for the constant error in- 
herent in the palpatory method, must have involved the inclusion of maximal 
readings so high as to raise serious doubts concerning the legitimacy of the 
figures. The mortality reports of life insurance companies show the fallacy 
inherent in the application of the word "normal" to any such figures. 

* The author feels that the lower figures for adults are to be accepted only with decided 
reservation inasmuch as he has usually found them only in association with more or less 
profound subnutrition or circulatory depression. Low readings are especially common in 
tuberculosis even during the incipient stage. 

t The average normal for the sixth decade is 138 mm. Hg. Maximum obtained in 
large group 150 mm. Hg. 



BLOOD PRESSURE 



477 



Important Statistical Data. — /. W. Fisher has recently published a most 
valuable article reporting the average systolic pressures obtained as the result 
°f x 9>339 readings representing that number of accepted candidates for life 
insurance. 




Fig. 185. — The UskoflE sphygmotonometer. This instrument simultaneously records 
blood pressure in millimeters of mercury, together with the brachial pulse at varying 
pressures, and one other tracing (jugular, carotid, apex beat, etc.). (Courtesy, A. H. 
Thomas Co.) 

The following table shows that even those who had attained the later years 
of the sixth decade of life showed an average systolic blood pressure slightly 
under 135 mm. of mercury. 

Dr. J. W. Fisher's Table 



Ages 


Number 


Average blood 
pressure 


15-20 


281 


119.85 


21-25 


785 


122.76 


26-30 


791 


123.65 


31-35 


689 


123.74 


36-40 


2,111 


126.96 


41-45 


6,740 


128.56 


46-50 


4,471 


130.57 


51-55 


2,371 


132.13 


56-60 


I, IOO 


I34-78 


total 


10.310 


tcR r>T 



On 525 applicants accepted in earlier years who showed an average sys- 
tolic pressure of 152.58 mm., the Northwestern Life Insurance Company 



47 8 



MEDICAL DIAGNOSIS 



Excessive 
mortality. 



Important 
temporary 
i ncrease. 



suffered an excess mortality exceeding by over 30 per cent, the general average 
of that company. On another group of 1970 lives showing an average sys- 
tolic pressure of 161.44 mm. representing the rejected risks, followed only in 
part and under great difficulties, the mortality rate was almost two and one- 
half times greater than the general average of the company. 

Yet, of this group, at the time of examination, 1082 showed no other impair- 
ment than this relatively high systolic pressure and the individuals composing 
this subgroup, and showing but the single blemish (B. P. 161.44 »»• Hg.), yielded 
an excess mortality more than double that properly to be expected* 

The experience of Dr. Fisher and other medical directors in relation 
to life insurance corresponds accurately with the clinical observations of the 
author extending over a period of several years. 

Faught's Formula. — Faught suggests that one may determine approxi- 
mately the normal limit of blood pressure (palpatory) for any age by assum- 
ing 120 mm. Hg. as the normal for the male adult of twenty years, and adding 
1 mm. for each two years of added age. 

An arbitrary deduction of 10 mm. Hg. is made at all ages in the case of 
women. 

ABNORMALLY HIGH PRESSURE.— In chronic interstitial nephritis 
the elements of arteriosclerosis, high peripheral resistance from toxic hyper- 
tonus of the blood vessels and increased heart energy bring about high 
systolic readings (160 to 300 or even higher) and a markedly high diastolic 
level. In both " acute nephritis" and "the chronic parenchymatous lesion," 
the pressure is usually decidedly raised though seldom to the same degree 
as in the chronic interstitial save during uremic seizures. It may be sig- 
nificantly high in acute nephritis before edema is manifest and attain and 
maintain a high level throughout the acute stage. In amyloid kidney the 
pressure is not raised, but is usually abnormally or even extremely low. 

In abnormal nervous excitement temporary high pressure may be observed 
and this may be very decided in victims of preexisting chronic hypertension. 

In secondary myocarditis with associated splanchnic spastic crises, lead 
poisoning, gout and actual or impending cerebral hemorrhage, relatively high 
readings are present. 

Cerebral Arterial Crises. — Fleeting aphasia, vertigo and syncope, asso- 
ciated with decided hypertension, have been observed frequently by the 
author. Less often an actual transient hemiplegia has occurred and in most 
instances this has proven a prelude to an actual apoplectic "stroke." 

Lead Poisoning. — The chief characteristics of the arterial hypertension 
of lead poisoning are high systolic and relatively low diastolic pressure resulting 
in increased pulse pressure with a low diastolic level. This is in rather decided 
contrast to the high diastolic and systolic levels of interstitial nephritis. 
The distinction is lost, however, if, as so often happens in chronic plumbism, 
renal involvement develops. Marked exacerbations of pressure occur, es- 
pecially in cases of encephalopathy, and apparently are associated with a 

* "The Value of Blood-pressure Readings in Examinations for Life Insurance," J. W. 
Fisher, M. D., Lancet- Clinic, Cincinnati, No. 7, vol. cxiii, Feb. 15, 1915. 



BLOOD PRESSURE 479 



vascular spasm, usually visibly reflected in the condition of the retinal 
arteries. 

Four-fifths of the workers in lead show high arterial pressure, even in the 
absence of other symptoms of plumbism (Norris and others). Bradycardia 
is commonly observed (55 per cent.). Excessively high (250-300 mm.) sys- 
tolic readings in cases showing tremor and obscure cerebral symptoms in 
renal disease should always suggest the possibility of lead encephalopathy 

Transient stupor or coma, fleeting delirium or transient or persistent delu- 
sions, maniacal excitement, hysteroid manifestations and epileptiform seiz- 
ures are some of the symptoms encountered and uremia may be closely 
simulated. 

In impending uremic seizures a rise in pressure to 300 has been several 
times observed by the author. The pressure may recede sharply but is likely 
to remain high until a balance is again attained or the fatal issue approaches. 

A reading of 420 mm. with recovery has been reported in puerperal 
eclampsia. 

In general arteriosclerosis alone it is unlikely that pressure readings of 
over 170 are often observed and these only in exceptional instances. On 
the other hand, in well-marked instances a distinctly low pressure may be found 
and it is probable that our former views with relation to the matter must be greatly 
modified. 

In aortic regurgitation the " pulse pressure" is unusually high (60 to 120+) 
because of the high systolic and extremely low diastolic pressure character- High pulse 
istic of that lesion, and is largely due to increased capillary flowage, to the 
left ventricular hypertrophy, and the unsustained blood column.* 

In middle-aged individuals carrying this lesion the systolic pressure may 
run from 170 to 230, with diastolic readings of 30 to 60 respectively. The 
highest systolic-diastolic readings with relatively lower pulse pressures are 
seen in cases showing more or less renal involvement and arteriosclerosis. 

In free regurgitation with a large, powerfully contracting ventricle, one 
may obtain systolic readings of 230 mm. or more with a diastolic of 30 mm. 

The pulse pressure in aortic leakage is of some value in determining the 
freedom of regurgitation. An abnormally high variation between the arterial 
tension in the arm and the leg (60-160 mm.) exists in pure and fully com- 
pensated cases. 

Intracranial Pressure. — High Tension. — This form may be due to meningi- Brain center 
tis, tumor, thrombosis, meningeal hemorrhage, and the like and produces asphyxia, 
high pressure through brain center anemia and a reflex extreme vasomotor Misleading 
constriction of the cerebral vessels which in its turn excites the heart to power- 
ful contraction. (Apoplexy is usually included in this group, but is more 
likely to follow a long-sustained hypertension than to initiate it.) In con- Coma. 
ditions of coma this may be most confusing and lead to an erroneous diagnosis 

* Wiggers believes that the element of vasodilatation plays little if any part. From a 
purely clinical standpoint one would strongly affirm the constant presence of moderate 
vasodilatation, meeting in some degree the demand of the tissues for a more stable capillary 
flow. 



hypertension. 



480 



MEDICAL DIAGNOSIS 



Epileptic 
seizures. 



An exception. 



Splanchnic 
crises and 
lightning 
pains. 



Increased 
viscosity 
and blood 
volume. 



Often 
overlooked. 



An asphyxial 
phenomenon. 



A vicious circle. 



Shock and 
hemorrhage. 



of uremia. Some epileptic seizures are also temporarily most misleading 
because of attendant hypertension, but the pressure falls promptly to normal 
or oftentimes below normal as soon as the attack subsides, unless it be of 
1 the Jacksonian type in which event it may behave as do other forms of 
increased intracranial pressure. 

Locomotor Ataxia. — Splanchnic spastic crises and lightning pains may 
produce transitory high arterial pressure and in this, as in intermittent claudi- 
cation, vasoconstriction seems to be the fundamental cause. 

Angina Pectoris. — In most instances, according to the author's experience, 
this is associated with a sharp or even maximal rise in pressure oftentimes 
followed by a sudden drop to or below the antecedent pressure and this 
hypertension is most extreme in cases complicated by interstitial nephritis. 

The Adams-Stokes syndrome may or may not be associated with high 
arterial tension but the readings during the severe seizures with feeble or 
absent systole are, of course, reduced to an approximate zero. 

Erythremia {Chronic Splenomegalic Polycythemia). — Many cases show a 
blood pressure much above the normal. In two, observed by the author, 
the pressure variations resembled those of an interstitial nephritis. One 
showed marked. arteriosclerosis, the other none. 

In these cases both viscosity and total blood volume are greatly 
increased. 

The Heightened Pressure of Stasis. — This is a form of contributory 
hypertension extremely common and unfortunately often overlooked, 
disregarded or misinterpreted. 

It occurs most typically in cases of interstitial nephritis and mitral dis- 
ease with a weakening or failing myocardium and is due to an asphyxial irrita- 
tion of the centers and resulting vasoconstriction associated with an overload 
of carbon dioxide in the blood. 

In such cases an acidosis is usually present which greatly reduces the tolerance 
of the respiratory center to CO2 and may thus produce dyspnea without marked 
pulmonary stasis. 

The fact that digitalis and rest are the best remedies shows that the 
immediate indication is increased heart strength and blood flow. Although 
an asphyxial phenomenon no extreme signs of stasis, such as deep cyanosis , 
need be present. Inasmuch as it is the center itself which is chiefly affected, 
under a carbon dioxide blood overload, the vessels contract and the heart 
coincidently slows and loses tonus, thus increasing the overload and estab- 
lishing a vicious circle. 

In diphtheria the blood pressure may be of the utmost importance in 
relation to the not infrequent deadly combination of acute dilatation and the 
splanchnic paralysis of central origin. It should certainly be watched care- 
fully in such cases for it is unlikely that either condition is unheralded by 
significant blood-pressure variation in the way of hypotension. 

Abnormally Low Pressure. — The conditions giving the lowest readings 
are toxic paralysis of the vasomotor center, shock, collapse, visceral perforation, 
and concealed hemorrhage. 



BLOOD PRESSURE 



481 



The lowest recorded persistent low reading followed by recovery is 50 
mm. Hg. (Xeu). 

In visible hemorrhage attended by nervous excitement, fear, and appre- 
hension the pressure may be raised though if actual exsanguination be in- 
duced it will be low. 

The acute infectious diseases, pleurisy with effusion, cholera, dysentery 
and severe diarrheas, anemias and cachexias and the terminal stages of all 
diseases usually show low pressure. 

Acute Infections with Persistent Hypotension. — The low pressure is 
probably due to vasomotor relaxation from toxemia of the centers together 
with, or without, profound myocardial weakness, and sudden death may occur 
from either one or from both causes. Death may result from mere emotion 
or slight exertion in such toxic cases. 

The degree of the hypotension manifest in all severe cases of diphtheria 
measures roughly the grade of toxemia, but in laryngeal cases an "asphyxial" 
higher level is present until the obstruction is relieved by tracheotomy or 
intubation. 

A sudden drop in blood pressure is an ominous sign, and a progres- 
sive lowering of the level during the second week of the disease is of grave 
significance. 

A similar but less extreme hypotension occurs in dysentery. 

Cholera. — Systolic readings of 60 mm. are reported as occurring during 
the algid stage and 70-75 is a relatively common reading. 

As stated by Dr. G. W. Norris in his admirable book* dealing with blood- 
pressure the response of a lowered systolic level to saline transfusions and 
epinephrin constitutes "a satisfactory criterion" of the amount required. 

Pneumonia. — The late Dr. Geo. Gibson of Edinboro first stated that a 
pressure persistently and decidedly below normal in pneumonia was "of evil 
omen," and that a decided drop "bodes disaster." He proposed the follow- 
ing formula: 

When the arterial pressure expressed in millimeters of mercury falls below 
the number of heart beats per minute the fact is of evil augury. 

This may be accepted as a rough clinical rule vitiated somewhat by the 
fact that high pressure may have existed before the attack of pneumonia; 
that cases showing absolute or relative high tension or a normal level not 
infrequently prove fatal; and that many factors affecting the pulse rate 
stand quite apart from blood-pressure variations. 

Howell states that a study of the four auscultatory phases is useful and 
believes that clear sounds and regularity of rhythm are of good augury, and 
that persistence of the relatively impermanent second phase is of especially 
good import. One must not overlook, however, the right heart and the car- 
dinal prognostic value of pulmonary accentuation and grade of cyanosis. 

Bronchial Asthma. — This condition is nearly always associated with de- 
cided hypertension, which in cardiorenal cases may be extreme. 

Hypertension occurring in the bronchial form doubtless is accounted for 

* "Blood Pressure. Its Clinical Applications." Lea and Febiger, 1916. 
3iJ 



Toxemic 
centers. 



May be a 
danger signal. 



A useful 
criterion. 



Fallible 
but useful. 



482 



MEDICAL DIAGNOSIS 



by the fright and distress attending the attack together with the asphyxial 
element. 

It is said to be low in the misleading cardiac form, but this has not been 
true of the few instances enountered by the author in which readings were 
obtained. 

Pneumothorax. — Conflicting reports only are available with relation to 
blood pressures in this condition. 

Obviously much depends upon the mode of onset, the degree of intra- 
thoracic pressure, the question of a preexistent tuberculosis and the stage 
of the process. 

Those of sudden onset are associated doubtless with an abrupt drop in 
arterial tension and those showing marked dyspnea and cyanosis should 
show a moderate psychic and asphyxial rise in pressure. 

Tuberculosis. — Active tuberculosis wherever seated is associated with 
moderate hypotension in most instances and one must extend this statement 
to cover many obsolete and inactive cases. 

Many, if not most of the latter, fall under the head of "chronic congenital 
asthenia" elsewhere described. 

Chronic Universal Congenital Asthenia. — This more or less visceroptotic 
functionally unstable, structurally deficient, and non-resistant group yields 
many instances of hypotension. 

The high percentage of obsolete or latent tuberculous foci revealed by 
the roentgen ray and tuberculin tests in these supersusceptible yet resistant 
individuals renders it difficult to determine whether or not they may be con- 
sidered as a group apart with relation to hypotension. 

Lowered Splanchnic Tonus. — In the hypotonias of congenital asthenia in 
its subnutritional form one assumes a loss of splanchnic tonus similar, but 
less in degree, to that present in shock. 

In many instances there appears to be a generalized lack of vascular tonus 
associated with the peculiar relative atonicity of the myocardium of the 
"drop"- or modified "drop "-heart characteristic of these cases. 

Syphi]is.-^-H ypotension is the rule probably in the more active earlier 
stages of syphilis, which, in its later phases, constitutes a not uncommon 
etiologic factor in hypertension. 

Pericardial Effusion. — The effect of a large exudate is to produce low 
tension and a small pulse pressure, and the degree of reduction, or better its 
persistent lowering, is one of the bad signs of this condition. 

Normally the pericardium tends to limit or prevent excessive dilatation 
and reenforce especially the weaker right heart and the left auricle. 

When the sac is excessively distended by an effusion the right auricle is 
compressed and cannot receive and pass on the proper amount of blood to 
the embarrassed ventricles. Deficient blood supply and insufficient activity 
of the heart as a whole contribute largely to the production of ypotension. 

Aortic Aneurysm. — No striking diagnostic points are elici table with refer- 
ence to this lesion. The associated conditions determine the pressure varia- 
tions for the most part. 



BLOOD PRESSURE 



483 



Dr. R. Edwin Morris reports, moreover, that decided unilateral pulse and 
blood pressure differences are common in individuals lacking any sign of 
aneurysm, marked arteriosclerosis or cervical rib. 

Chronic Alcoholism. — In delirium tremens hypotension is marked during 
the stage of active delirium. 

In cases of chronic alcoholism presenting vague symptoms, psychasthenic 
and otherwise, a curiously constant rise of systolic pressure (20-70 mm.) 
occurs and endures for several days. The systolic pressure remains relatively 
high. 

Raff has found the phenomenon of considerable differential value.* 

Morphinism. — The blood pressure in the morphin habitues of the better 
grades of society or those of any class who are relatively well nourished are 
said to show high pressures which are strikingly reduced by the free catharsis 
now universally used prior to withdrawal of the drug. 

Norris properly points out the fact, however, that the patients of this type 
admitted to the public clinics are usually in a state of semistarvation, pro- 
found cachexia and hypotension. 

Anesthesia. — Ether. — The primary sharp and oftentimes excessive in- 
crease in arterial tension due to excessive stimulation of the psychic sphere 
and the struggles of a resisting patient may be a source of great danger in 
cases of aortic aneurysm, antecedent hypertension and myocardial weakness 
of any type. 

During full anesthesia the blood pressure is maintained usually at 
about the normal level by stimulation of the respiratory centers, some- 
times so excessive as to cause temporary suspension of the breathing. 
Arrest of respiration in the stage of full anesthesia is the result of par- 
alysis of the centers. 

The combination of oxygen and ether produces a considerable rise in 
blood pressure throughout the anesthesia. 

Chloroform anesthesia is characterized by an early fall in pressure increas- 
ing pari passu wdth the deepening of the state of unconsciousness, and in 
fatal cases continuing its descent until death. 

It is asserted at present that this is wholly due to the persistent cardiac 
depression characteristic of the drug, but it would seem unlikely that this 
is the last word, and probable that peripheral vasodilatation plays a consider- 
able part. Not only progressive myocardial weakness, but also an increasing 
dilatation are present in lethal cases. 

The early temporary arrest of heart action often encountered is a respira- 
tory reflex inhibitory effect which may prove fatal in cases of myocardial 
degeneration or inflammation. 

Nitrous oxid slows the pulse and raises blood pressure. This anesthetic 
is somewhat dangerous in cases of decided chronic arterial hypertension. 

Ethyl chlorid exerts an effect wholly comparable to chloroform, but in a 
greatly lessened degree. 

Typhoid fever is characteristically a disease associated with persistent 

* Dr. Karl Raff, Deutsche Archiv. f. klinische Medizin, vol. cxii, p. 209. 



A suggestive 
finding. 



Public patients. 



Surgically ] 
important 



Caution. 



484 



MEDICAL DIAGNOSIS 



Low tension. 



Importantsign. 



Important data. 



and progressively increasing hypotension though this usually does not reach 
extreme figures (95 mm.). Sudden drops are ominous. 

The advantage of routine observations is especially marked in relation 
to hemorrhage and perforation where a sharp and sudden drop may indicate 
hemorrhage, and a decided secondary rise (within from two to four hours) 
point to developing peritonitis from perforation or to renal involvement. 

Malaria. — In malarial cachexia the blood pressure usually is low. 

Scarlet Fever. — Hypotension or normal pressure are usually present. A 
decided rise in blood pressure is of great importance as suggesting the coming of 
a complicating nephritis, for it may precede by several days the onset of 
frank signs or even the albuminuria. On the other hand, albuminuria 
may occur without such an ascent of pressure, and may be merely that of 
toxemia of the lesser grades. 

Norris emphasizes the following facts with relation to hypotension in 
acute infectious diseases. They may be summarized as follows: 

1. Hypotension occurs in practically all febrile infections, being especially 
marked in certain forms. 

2. In so-called sthenic fevers the fall of pressure is trifling. 

3. In asthenic fevers arterial hypotension is pronounced and death in 
many cases is attributable to vasomotor failure quite as much as to a failing 
myocardium. 

4. Toxemia rather than fever determines the degree of hypotension. 

5. Degeneration or disturbed function of the adrenal glands occurs in 
some febrile infectious conditions, notably in diphtheria. 

6. Decrease of pulse pressure usually represents a systolic fall and is a 
bad symptom; well sustained pulse pressure, a favorable sign. 

7. Practically any acute infection may produce cardiovascular damage. 

8. A convalescent patient should not be permitted to leave his bed so 
long as there is a marked difference between the pulse rates in the erect as 
compared with the recumbent posture. 

9. Minor degrees of physical exertion in unfit convalescents may cause 
a fall of 30 or 40 mm. Hg. systolic pressure. 

10. Arbitrary standards cannot be set forth in figures. The essential 
prognostic factors relate to the course of the blood pressure, diastolic and sys- 
tolic, upward or downward, and to the lability or stability of arterial tension. 

Hypotension Attending the Sudden Relief of Abdominal Pressure.— The 
danger from shock which is associated with the too rapid removal of preexist- 
ing abdominal pressure is well known. 

In the withdrawal of fluid from the abdominal cavity, a decided temporary 
hypotension is induced which is much less marked if the flow is gradual and 
constriction of the abdomen maintained throughout. 

Pleural Effusion. — A large pleural effusion whether transudate or exudate 
causes a rise in blood pressure; its removal, a fall coincident with its with- 
drawal, and to a degree measurably corresponding to the relief of intratho- 
racic pressure afforded, but dropping temporarily below the level of arterial 
tension normal or habitual for the individual. The dangers attending the 



BLOOD PRESSURE 



485 



A common 
error. 



withdrawal of exudates too rapidly or the yet greater one dependent upon 
undue irritation of the pleura are well known. 

The fall in blood pressure during thoracentesis (20 mm.+) is more rapid 
in the case of chronic than in recent or acute effusions and the only fatal a 
instance observed by the author occurred in the case of a patient suffering 
from a multiple serositis, whose chest had been aspirated again and again 
with impunity. Vertigo is a symptom to be regarded and shallow rapid 
inspiration may precede syncope. 

In the case of both paracentesis abdominalis and thoracentesis the lack of 
efficient preliminary local anesthesia, an unnecessary f ussiness, and the unwise 
assembling and parade of instruments, greatly intensifies the tendency to 
syncopal seizures. 

Both operations are ordinarily trifling in their nature and the patient 
should be spared mental perturbation so far as possible. 

Abdominal Colics. — Practically every form of severe abdominal pain of 
this character may be associated with moderate rise in pressure. An ex- 1 
cessive ascent in cases of preexisting arterial hypertension has been observed 
by the author several times in cases of angina pectoris with abdominal 
pain maxima, and this statement also applies to Pal's " splanchnic crises," 
possibly misnamed, certainly too often diagnosed. 

Blood-pressure Determinations in Pregnancy. — Significant and even 
critical arterial hypertension may precede the appearance of albumin in the 
urine. No pregnant woman should be allowed to go through delivery without 
receiving the benefit of repeated blood-pressure determinations especially More im- 

1 - 7 1 1 " 1 1 « i- • r • i • 1 1 Portant than 

during the later months, these being of infinitely greater importance than the urinalysis, 
examination of the urine. Any case which shows readings distinctly above I 
normal should be carefully watched and if the rise is progressive as well as 
persistent and reaches or exceeds 145 or 150 mm. it constitutes a danger 
signal. 

In cases of pregnancy associated with marked hypertension the rupture of 
the membranes is followed by a drop of from 60 to 90 mm. of mercury, a 
rebound of nearly as great an amplitude, a further and second recession 
following actual delivery, a second rebound, and then and thereafter a 
gradual return to normal occupying from three to seven days (Anders and 
Boston). 

Acute heart lesions, with profound weakness, show decided low pressure 
unless a marked asphyxia of the centers is present. 

Points of Importance. — A low systolic coexisting with a high diastolic pres- 
sure (100+) may prove of great significance in the early stages of an inter- 
stitial nephritis and is often present in the terminal stages of cardiorenal dis- 
ease when the myocardial reserve is near to exhaustion. 

A high systolic and normal diastolic pressure may result from purely 
temporary conditions such as emotional upsets or excessive exertion in an 
untrained individual. 

A high systolic and extremely low diastolic pressure almost invariably means 
aortic regurgitation even though the murmur be absent. If very marked it 



A curious 
sequence. 



486 MEDICAL DIAGNOSIS 



will be associated probably with Duroziez's sign in the femorals and a well- 
marked Corrigan pulse. If true aortic stenosis exists, this will be modified and 
the pulse pressure reduced, but usually retains its chief characteristics. Ac- 
cording to the author's limited observations, frank exophthalmic goiter usu- 
ally shows a similar but less marked pressure curve. 

A low systolic and diastolic pressure in ambulant patients usually repre- 
sents residual cardiovascular effects of past acute illness and in any event 
strongly suggests lack of cardiovascular reserve. 

Of late the value of this finding as an indication of cardiovascular depres- 
sion or actual myocardial weakness has been emphasized by the clinical 
experience of the author and the check afforded by the teleoroentgenogram, 
electrocardiogram and polygram. 

It is encountered with especial frequency in individuals of the congenital 
asthenic habitus carrying concealed septic foci. 

Its occurrence in terminal cases of heart disease and especially in post 
hypertension cases with failing hearts is well known and the author encounters 
a decided drop in blood pressure frequently in individuals who are experi- 
encing a definite impairment of what was previously an adequate com- 
pensatory reserve. 

In heart cases with a clear history of physical overstrain an initial low 
blood pressure may be seen to heighten daily under treatment. 

In cases of chronic arterial hypertension a pressure of 175-185 with a 
diastolic pressure above 100 appears to be well borne for years (author's 
personal observation), but pressures of 190-200+ convey a threat, and those 
of 220+ mean that the sword overhead is suspended by a hair. 

In this connection the author ventures to assert his utter disbelief in the 
widely accepted doctrine of the conservative effects of decidedly high blood pres- 
sure in cardiorenal cases. 

In nearly all of the non-terminal cases carrying a blood pressure of 200 
plus, in which, fortuitously or otherwise, a drop to 160-175 mm. Hg. has 
occurred, this event has been associated with immediate and decided better- 
ment, not only with respect to myocardial reserve, but also in a number of 
instances, decided shrinkage in the cardiac outline. This does not justify 
the use of an over-radical and depleting therapy, prove that a moderately 
increased blood pressure is never of good augury, or that excessive abrupt 
falls in pressure may not sometimes be ominous, but it suggests the danger 
inherent in the prevalent attitude. The point has been emphasized in a 
certain small group of cases in which by a happy chance the author found 
intermittent hypertension before any albumin appeared in the urine. 

In several of these individuals the adaptive changes in the heart itself 
were interrupted by hypertensive periods which definitely increased certain 
minor decompensatory phenomena. 

In cardiorenal cases high blood pressure would appear to be primarily 
and chiefly a toxemic manifestation. 

Those particularly affected were of the congenital asthenic type, but the 
same phenomena have been observed in others. 



THE RADIAL PULSE 487 



Chief Clinical Significance of High Diastolic Pressure. — As a matter of 
practical application a decided and persistent hypertension with a high or 
relatively high diastolic level means chronic nephritis, until another cause is 
proven or rendered a reasonable assumption. 

This statement holds good regardless of the absence of the classical 
urinary findings at the time that hypertension is become manifest. 

In other words, chronic Bright's disease with or without albumin and casts, 
but seldom without evidences of impaired renal permeability, is so commonly 
the cause as to place all other claimants among the "possibilities" only. 

In the group described in the preceding paragraphs periods of impermea- 
bility coincided with intervals of increased arterial tension. 

Blood-pressure Estimations in the Arrhythmias. — As stated previously, 
the difficulties encountered in taking 'the blood pressure when certain forms 
of irregularity are present may be insurmountable with respect to diastolic 
pressures. 

This is true of all arrhythmias in which inequality of force plays a part, 
i.e., auricular fibrillation, alternation, extrasystolic irregularities, etc. 
In such cases one can only determine the "highest" and "lowest" pressures 
at which the systolic sound is heard by the auscultatory method or, less 
accurately, record the levels by the palpatory method. 

With respect to the auscultatory method, this means merely the taking 
of the reading at the maximal pressure at which the first sound is heard 
and then slowly and carefully lowering and raising it until the sound of every 
systolic wave is heard. 

A count of the beats per minute then audible at the brachial should 
be made during several minutes and compared with a similar count made 
by direct auscultation over the heart. In both extrasystolic irregularity 
and fibrillation certain ventricular contractions may fail to open the aortic 
valves.* 

Pulse Deficit. — Such comparison of the number of beats reaching the 
radial or brachial artery with that of the heart itself as determined by auscul- 
tation direct is a matter of considerable interest and some importance. 

Venous Pressure. — The venous pressure may be roughly estimated by 
Oliver's method which consists in allowing the arm to hang downward so 
as to distend the veins, noting the height at which venous collapse occurs 
when the extended arm is raised. 

Normally the fulness is lost }^ inch above the level of the heart apex. 
Each additional inch represents a venous pressure equal to 2 mm. of mercury 
(1.985). Other methods of measuring venous pressure involve more trouble, 
time and apparatus than the information gained is worth to the clinician. 

* James and Hart obtain an "average" systolic pressure in such cases by making a 
systolic pressure record for each 10-mm. reduction of pressure, counting the systolic beats 
per minute for each level while an assistant counts the beats as heard over the heart itself 
during the same period. The systolic beats heard per minute over the artery at each 
level is multiplied by the reading obtained at that level and the sum of the products is 
divided by the number of apex-beats per minute. 



4 88 



MEDICAL DIAGNOSIS 



High figures are often present in marked systemic stasis such as occurs 
in right heart decompensation from whatever cause. 

THE RADIAL PULSE 

"TAKING" THE PULSE.— Relative Value of Methods.— In general 
clinical value, instrumental methods cannot compare with pulse-taking by 
the old method. The palpable beat of the radial pulse represents normally 
the sudden systolic increase of arterial tension and it is felt only when the 
artery is partially compressed against some rigid supporting tissue. 

Pulse Palpation. — Whenever possible the pulse should be taken casually, 
while talking of other matters, and due allowance made for the nervousness 
incident to examination and the effect of any antecedent physical exertion 
or excitement. In children, especially, accurate determination of the 
actual rate is often impossible unless the youngster is asleep. 

The Importance of Correct Technic— A correct technic is of the utmost 
importance and the patient's arms should be similarly placed, in a position 
free from restraint, flexion, or muscular compression of the vessels. The 
pulse should be taken simultaneously in the two radials, the pulp, not the ex- 
treme tip, of three fingers (mid-, fore- and ring-finger) being applied lightly 
over the artery at the wrist. (There is no better proof of bad training than 
the gingerly one-finger-tip approach sometimes observed.) 

Position of Arm. — Faulty position of the patient's arm and hand may 
greatly modify any pulse. 

The forearm should be slightly flexed, the wrist thrown slightly backward 
and a trifle supinated. 

Points to be Determined. — (i) The "size" of the artery. (2) Pulse rate 
or frequency. (3) Rhythm. (4) Uniformity of strength. (5) Synchronism 
and equality of the right and left radial pulses. (6) The force required to 
obliterate them (tension). (7) Abnormal thickening of the artery (arterio- 
sclerosis). (8) Correspondence of radial rate and rhythm to the auscultatory 
findings. (9) Peculiar variations in the character and quality of the beats. 

When the physician's fingers are applied to the artery the first four points 
("size" "rate," "rhythm" and "force") are determined almost unconsciously 
and instantaneously, the vessel being lightly rolled under the finger to get 
its size, which for the most part represents its "tonus" or state of contraction 
and not the force or efficiency of the beat. 

Pressure is then made with the upper finger until the pulse is lost to the 
lower, the force exerted being a rough and unreliable, yet extremely useful, 
measure of arterial tension. 

The artery, thus emptied, is rolled under the lower finger to detect any thick- 
ening of its walls (arteriosclerosis) and any vessel that can thus be felt as a 
distinct tube when collapsed is sclerotic and hence abnormal. 

Such vessels may be just palpable as a tube, definitely thickened, distinctly 
rigid, furrowed transversely and rigid, or carry multiple tiny plaques or beads 
of deposited lime salts. 



THE RADIAL PULSE 



489 



Determining the Rate. — It is ordinarily sufficient to count the pulse for 
thirty seconds and multiply by 2 to get the rate per minute, but in severe ail- 
ments or if any abnormalities in rhythm, quality, or force be present, it should 
be taken for at least one minute, and, if excessively rapid, it may be necessary 
to count each second or third beat only and apply the proper multiplier. 

Not infrequently, especially in myocardial degeneration, coronary sclerosis 
and certain valvular lesions, some systoles are premature and inefficient {extra- 
systoles), and though readily auscultated, may yield no pulse wave or a very 
feeble one. In such cases nurses' pulse records are often worthless with respect 
to actual cardiac beats. Nurses should be instructed with relation to the com- 
moner types of intermission and irregularity. 

The Recurrent Pulse. — This is one which cannot be cut off by the pressure 
of the upper ringer because of an unusually free communication and recurrent 
flow from the palmar arch. The difficulty may be surmounted by making 
obliterative pressure with the lower ringer and carrying out the usual pro- 
cedure above, or by compressing the ulnar artery. 

Unilateral Variations. — A student frequently jumps at faulty and far- 
fetched conclusions if he finds an unilateral weakening or absence of the 
pulse. Either finding may or may not indicate deficient heart strength, but 
is ordinarily due to an abnormal course of the radial artery, or, more rarely, 
to actual blocking of the vessel, to aortic aneurysm, cervical rib, or to pressure 
of new growths. The findings must be always checked by comparing the 
larger arteries, such as the brachials of the two sides. 

In aneurysm of the ascending portion of the arch involving the innominate, 
the right radial and carotid may be affected ; in aneurysm of the descending aorta, 
the left radial; or a delayed pulse may accompany aneurysm of the trans- 
verse portion. Direct sac pressure upon arteries abnormally constricted, 
deformed arterial openings, or the complete or partial conversion of inter- 
mittent into what may appear to be a continuous weakened pressure by the 
aneurysmal sac, make many variations possible, aside from those caused by 
adhesions due to associated perianeurysmal inflammation in certain cases. 
Too much reliance should not be placed upon this as a sign of aneurysm, as it is 
often lacking or without exact significance. 

In obscure chronic cases in which pain is present in the lower extremities 
upon exertion, whether cramp-like, rheumatoid or paroxysmal, the arterial 
pulse should be taken in the dorsalis pedis and posterior tibial arteries. 

Such pain is often due to obliterative arteriosclerosis and vasomotor spasm 
(intermittent claudication) or may be associated with Raynaud's disease and 
always demands a careful examination of the heart and kidneys. 

A full, bounding pulse is frequently mistaken for arterial hypertension 
because of faulty technic. Arterial hypertension may be detected by the 
finger in many instances, but correct determination requires the use of 
special instruments.* 

* No excuse remains at the present day for dependence upon the fingers for the estima- 
tion of blood pressure. Most humiliating errors are sure to occur if the unaided senses are 
employed 



Proper 
methods. 



Useful device. 



Lost beats. 



Vitiated 
records. 



Often trivial. 



Sometimes 
important. 



Important 
inferences. 



Importance 
great. 



A common 
error. 



49° 



MEDICAL DIAGNOSIS 



Fingers may 
fail one. 



Rate readily 
affected. 



Erect posture. 



Important 
sign. 



Danger 
signal. 



Persistent 
rapidity. 



Infancy. 

Childhood. 
Maturity. 



Tachycardia. 



Auscultation is of course often necessary to reveal the true rate and rhythm 
of the heart beat and in certain cases of paroxysmal tachycardia pulsus, alternans, 
or auricular flutter, instrumental determination alone yields strictly accurate 
results. 

PULSE FREQUENCY.— Exertion and Attitude.— Aside from mental 
excitement, the digestive process and bodily exertion, which latter includes 
even the changing of the posture in bed or evacuation of the bladder or 
bowels, the position of the body affects the pulse rate. 

In the erect posture the rate is from 10 to 15 beats faster than in recum- 
bency. (This variation was formerly believed to be due to rise in arterial 
tension, a theory exploded by the fact that the sphygmomanometer shows but 
trifling variations in systolic pressure and that often downward. Increased 
intra-abdominal pressure is undoubtedly a factor in many postural changes.) 

The significance of an abnormally great increase of rate upon slight, unusual 
exertion, unattended iy excitement, is very great inasmuch as it clearly indicates 
cardiac weakness and a limitation of the field of response (reserve). 

In cases of profound cardiac weakness such a maneuver frequently develops 
coincidently a suggestive subjective or objective dyspnea or substernal or epigas- 
tric distress. 

Congenitally asthenic individuals with their narrow hanging ("drop") 
hearts show a remarkably labile heart action during periods of nutritional 
depression especially if, as so often happens, the atonic myocardium is 
actually dilated. 

Alcohol, tobacco, the coal-tar products, arsenic and other toxic sub- 
stances used in excess, may occasion a persistent lability and increase in rate, 
and cachexias, hyperthyroidism and especially incipient tuberculosis should 
also receive attention in this connection. 

Age. — The average normal rates are for the first year of life from 130 to 
140; gradually dropping from the first to the fourth year to 105 or no, 
and so diminishing until at the fifteenth or sixteenth year it reaches from 75 
to 80 beats per minute. During middle age and up to sixty years frequency 
is slightly diminished, sometimes increasing somewhat beyond that age. 

Sex, — Women show a rate which averages 5 to 8 beats faster than men, 
and it is slightly slower in tall than in short persons. - 

Fever with Increased Pulse Rate.- — Any decided persistent increase in 
pulse rate, lacking obvious cause, demands the use of the clinical thermome- 
ter and we find that, as a rule, the rate increases from 8 to 10 beats per 
minute for each degree Fahrenheit above the normal, and further that the 
behavior of the pulse in fever is of both diagnostic and prognostic importance.* 
In general an increase in the rate out of correspondence with the rule given 
suggests profound toxemia or diminished resistance to the disease and 'con- 
stitutes a danger signal. In those few diseases in which the pulse rate should 
be lower than the rule, excessive rapidity has still greater significance. 

In fever a relatively rapid rate is of far less significance in the child than 
in the adult. 

* See "Fever." 



THE RADIAL PULSE 



4QI 



Slow Pulse. — High temperature and relatively slow pulse are observed espe- 
cially in tubercular meningitis, typhoid fever, and lobar pneumonia as well as 
in febrile ailments associated with some of tie organic causes of slow heart, such 
as coronary sclerosis, myocarditis, aortic stenosis and especially u heart block." 

Rapid Pulse. — A rapid pulse occurs in many non-febrile ailments, most 
markedly in exophthalmic goiter, and may be decided in the decompensatory 
stages of mitral stenosis and insufficiency, myocarditis, aortic insufficiency, 
acute endocarditis, pericarditis, and the pressure displacements of the heart. 
Paroxysmal tachycardia, alternation, auricular flutter and delirium cordis 
furnish striking examples of the special types of rapid pulse. 

An excessively weak, thready, rapid "running" pulse associated with 
marked evidence of cardiac weakness is a forerunner of death in certain 
diseases and may represent auricular flutter or alternation. 

Tachycardia. — {"Swift Heart"). — Mere excessive rapidity is known as 
tachycardia, and as used alone this term should be strictly limited to the 
pulse free from irregularity, intermittency, inequality or paroxysmal 
rapidity. 

Scarlatina and Tuberculosis. — In children an excessively accelerated 
pulse may suggest the onset of scarlatina before the appearance of the rash, and 
in incipient pulmonary tuberculosis a labile and persistently overrapid pulse 
is one of the most constant of the early signs. 

Various Factors. — In nearly all cachectic states weakness, acceleration 
and lability are present and it is an important confirmatory sign in severe 
shock and collapse. Aside from these must be considered sexual psychas- 
thenia, the overuse of snuff or tobacco (often associated with palpitation or 
sinus arrhythmia), physical and mental overstrain, and idiosyncrasy. 

Palpitation. — The term tachycardia covers most of the cases commonly 
described as " palpitation,' ' the heart action being in such cases quite normal 
save for a rapidity which seldom exceeds 170 beats per minute (Mackenzie), 
and showing no abnormalities of origin or transmission, when subjected to 
analysis with instruments of precision, unless it be an occasional extrasystole. 
In such cases the attack subsides gradually and excitement, radical 
changes of posture, and physical exercise markedly affect the rate. 

Bradycardia. — (Slow Heart). — Pulse below 60. A slow regular pulse 
may be congenital and physiologic, but most of those thus described have 
subsequently been proven to be due to heart block, chronic toxemia or or- 
ganic disease of the heart or brain, the latter being associated with increased 
intracranial pressures. Indeed any regular pulse under 50 usually indicates 
"heart block," i.e., blocking of certain of the impulses normally passing 
from auricle to ventricle through the "bundle of His" or in cases of extremely 
low rate, a complete block and dissociation of auricle and ventricle. 

The lesser degrees of slowing may be met with as toxic effects of various 
drugs, in aortic stenosis, chronic myocarditis, coronary disease, cerebral 
hemorrhage or tumor, meningitis, epilepsy, general paralysis of the insane, 
melancholia, mania, myxedema, pituitary disorders, jaundice, uremia, 
exhausting disease and sometimes in acute ailments, especially diphtheria 



Relative 
slowness. 



An ominous 
symptom. 



Seldom 
physiologic 

Significance of 

excessive 

slowness. 



Often partial 
"heart block-.' 



Many and 
varied con- 
ditions. 



492 



MEDICAL DIAGNOSIS 



Danger signal 



in which, no doubt, undeclared myocarditis and heart block are chiefly 
accountable. 

Abrupt Transition to Bradycardia. — As regards its occurrence in acute 
infections during either the active stage or convalescence, the rule may be laid 
down that any sudden and decided drop below the normal or usual rate, unless 
associated with crisis, is quite as much, if not more, suggestive of danger and need 
of special watchfulness and care as would be excessive rapidity. 

Toxemia, intracranial pressure and actual disease of the myocardium or 
bundle of His are therefore chiefly to be considered as its causes. 

Slowing of the heart may occur in connection with rapidly induced 
arterial hypertension. This fact is strikingly illustrated at times in cases of 
acute nephritis or the onset of uremia. 

Sinus Arrhythmias. — In sinus arrhythmia there is irregular spacing of 
the beats and by instrumental methods one discovers that this irregularity 
arises chiefly from a shortening of the diastole rather than of both the 
phases of the heart's cycle. With excessive increase of rate this irregularity 
disappears, with slowing it may reappear. 

Such sinus irregularity is recognized by a labile periodically shifting pulse 
rate, quickening with inspiration and slowing with expiration, but showing 
no inequalities of force in the individual beats. 

The variation in the diastolic periods is determined readily in many 
instances by auscultation, when difficult to recognize in the pulse 
(Mackenzie). 

As a matter of fact if one applies the finest and most careful measure- 
ments to electrocardiographic records some variation in the spacing between 
the diastolic periods can be detected in almost every record. 

By ordinary clinical methods these are not determinable nor is the matter 
one of importance. 

Syncopal attacks occur occasionally in this form o! tachycardial 
irregularity. The condition may persist for years but is rarely encountered 
after the age of 30. 

Quite recently in the case of a youth showing a frank myocardial decom- 
pensation with septic tonsils and an ethmoiditis, sinus arrhythmia alternated 
with short periods of fibrillation. 

It is usually of slight significance, but one cannot follow James Mackensie 
in regarding its (frequent) presence after an acute illness as evidence that the 
heart has escaped infection. 

It may be assumed, however, that the toxemia has affected the myo- 
ardium but slightly and may thus constitute indirect evidence of no serious 
amage. 

Either simple tachycardial "palpitation" or " sinus irregularity" may 
be the source of much discomfort and quite unnecessary alarm. 

Unfortunately the most serious forms of pulse irregularity may give rise 
to a similar condition and the reader should refer to " extrasystolic irregu- 
larity," " fibrillation, " "flutter," and "paroxysmal tachycardia" as de- 
scribed in the succeeding section. 



THE RADIAL PULSE 



493 



Serious error may result either from an overestimation of the gravity of a 
simple tachycardia or sinus irregularity, or careless disregard of the fact 
that "palpitation" arises also from some of the most serious cardiovascular 
conditions. 

In simple palpitation fear of death is readily excited by the curious sub- 
jective manifestations of precordial, "bumping," "thumping," and "turning 
over," of the heart, but the curious inward conviction of impending death 
sometimes experienced even in miniature replicas of angina pectoris is seldom 
present. 

IRREGULARITY AND INTERMITTENCY.— These conditions are de- 
scribed fully under the "arrhythmias." Irregularity includes variation in 
volume and strength as well as in wave intervals, though the former are 
better described by the term "unequal" 

By intermittency is meant the apparent or actual omission of beats. 
The stethoscope and more fully the polygraph or electrocardiograph show 
that intermittency may be due either to premature and inefficient extra- 
systoles or the " dropped," systoles of partial heart block (" pulsus deficiens "). 

" True pulse intermittency" therefore, would apply only to the phases of 
recurrence of inefficient or dropped beats, which result in the transient, 
persistent or irregularly recurrent actual elimination of pulse waves in the 
arteries. 




Fig. i 86. — Pulsus Irregularis Perpetuus. Two radial tracings taken during auricular 
fibrillation. Note extreme irregularity in time and force alike. (Drawn from the original 
tracing of Parsons-Smith.) 

If an extr asystole is of sufficient vigor to cause a lesser beat in the arteries 
there is established during the period of recurrence what might be termed a 
regular irregularity and inequality with respect to the phases in which it 
occurs. For the usual type of extrasystolic irregularity, as it is reflected in 
the pulse, the term "interrupted pulse" would apply more aptly. 

The fundamental cause (extrasystoles of the heart) may therefore be 
expressed by either an intermittent or irregular radial pulse. 

In the absence of definite clinical findings their significance is far more 
serious in middle-aged, or elderly people than in the young and both varia- 
tions admit of subdivisions. (See pp. 546 and 549.) 



"Pulsus 

deficiens. 



"Pulsus 

intermittens. 



Significance. 



--- 



:_z: :. -.: : :-.:-:■ ?:s 



::::: 



. — '"<:..':■ 
exc e ss iv e frequency [as in "delirium cordis" due to 
I mmj he transient, variable, persistent or periodic 

n:_ii i :r::i; :~ :::ei rr:i:r= lie in re: e en -leu ie~ :niiri:.e :y -_le 
polygraph, or, double or triple beats may occur with a prolonged pause be- 

i-eei lie Lis: :ei. ::' lie r::.:: Hi lie nei: 5_::ee:li.: :ei: ;:.'::.: 
una) {pulsus trigeminus), in extrasystolk hregularitv, or, the norma 
atkm due to deep inspiiation may be so exaggerated as to make the radial 
puke weak or imperceptible daring inspiiation {pulsus paradoxus)* 

"Tie ?irii:n: Pulse " — 1m .5 n :s: ilei-enl;. ::=.ervei n ei:eee:ve 
:i:iii: -Miizesi e = :e::ily : issiiii.ei —111 :!•= ::_: live irrssure = _:! is 

t :::::: : : ; : 7:.. if -ill nt :.:.:..: 

m. iiii-i: :: iii_:iii: :.:. : _.:i:. 7 zie iirii:.- :: lir.-re^ .mien 
:: '::::•'-'•' s:e-:>ii Tie eiiezi; . -;..;• nfe:ez:e :i ii; :i. : : ii 
litre ensii 



z:r 



:n :::.::i::::::.:::::. iir:_lii::- _:/ir i :e5i_-i::r. inr 
:: r:7i: ' 7.:.f :: z±'ii-iii: zzLiitz in i n lie :: res-en :e 
: inreniii. leir: iis-tis-e 

:ii- PuisiiS 7ni_s — Tne nit: in le::e: s: 

7i:.i:t5 lie ili-il-lle :: :i:::i: 7 = 7:: :: 1 ~i- :: 1 _iik 

.: ■: : : si:- rise mi ill Tie fzrner 

- - :: i:rii: Ins-imiieriry n: .i::e: 

: " 7 -_ .— :: i::e:. : f :.e: : .-.. ; .:: ^111 17:::.:.: iir:ii 



r ~i :: ti _i_i 



:e:i.e 

Mi- 



ll- 



:sis h; 1- 



THE RADIAL PUISE 495 



Monneret's Pulse. — The sieved, soft. Iz-zz^d pulse so often observed in the 

::ie~;i :: ;i_r.i::e is s:rie:iries river. '.iis sneni r ii:e :i : u: -.emir.:'.: r/ 

".'.- ?_.se - .-: r. -..-:,.-: : .:. v:.:::..:.: 

Puis is : r_s - - : .r \ "i::e:. ii -.er.s.:r. : .: r.:: srr.ii iii. ~iry 

Dicrotic Poise. — A re::ii ::'!:— :-* ±e bei: my zf.ei be :ei: rn:re :: 
iess iir.i- :ily --ir: r:::-e: ::rSS-:e iii iiiiii:es ::iiiiriy :-:-:- ei- 
iiisii:i :: ::rerri ei:iy -:ei ii :; — "r_ : i i fee: i~i lie ;yii:ii sii.e 
:u: :f:ei f:ni in ::ie: se e:e ::::::::.:: einiisiir. b.s-e.i.s.es :: i:.:-i 
sorts, and, very rarely, in apparent health after severe exercise. 

Tie iimiry 7 _i = r — .. : .' ; ':: ; •■'•■■ /•/;:.. :v :;/:.":-;. ;;,i ;.;',/*', 
It is a rhythmic blushing and paling which may be observed over iiinam- !| 
Hi::: i : : lie 1 ire :-:. 11 : r. ~ lining Izz: : :t: = ire : v: 

lies: eirs e:: by reiienbig lie siii :y ::.:- 

1:1 iir i ziiss siie :r eve- lie rir ::' i z : : i - : ni«:i lie 

riie ::* lie ib-s iis :iyiir :srllli:dr_z b:rier is reiiiiy 

:■: ... lie ;t ... ■'. ir:erie^ :y :-e s "jrri lien liy 

eiubei ii lie -•: ::' lie ::i:.ii.im 5 : :: - 

It is a valuable confirmatory sips, of aortic insufficiency but may also be 
:::{'■:■ i :-; -:::c : :.; ';:>::■; :::■:•:■'. :;; : ;.:";:i 1:;'; ; ; ;.>/;:/ :';■-■'.: :-:-:z:-. ::.-/: 
://>.:". ;-:•";: '::::...; :;:""-;:; :-:•; ;::,.;-: : ; :'"";;" ; ;:;f.;. 

Its associations are essentially those of the '"pulsus cder" and it is 
MMsiir-iiiy ::scr."ri in r t r 5 : r. s iiiireniy in r::i ieiin Tie lime: 
:•: de-bleb •liysiiiiri: iirilbiry : ■ -t instE seei :y lie iiii:: ms s:eiviiy 
iiziiiisiei since 115 iisiivery ::' lie fii: im: i sin: semi -:n: — iii 11 
irei ::' iibmry iirmei :: lie liiri iei: mersime rsiiiiy :eiresei:s 
miiiei: i::i: ieiiire 11: ::e:e:es :y i Linger :: simer re:::: lie 
appearance of a distinct diastolic aortic murmur. 

i: ::::.; .11:.::: irrireiiy ::; ; .i::.: lie me:. : m mry reiixi- 
1:1 : :t -i : :::e ::' ei: :.: y ::' rirrei: ie:essi:y : : r : : me e: : rr :r : 

r t:t:: ..:e ~: :: in :re ririiliriets ire linrrririe :: i mi5£ei iy;r:- 
* - ~ : : ir~. 

Tie Buirre in Pnise Terrnin:i:ry. — Tie :e:n is i :e- 

:: i:rr .nes "^ien men sniiri lie rnis-e mrre 

:it utt:: :in — e miens i: ~. iii li lit reniemeirs :: :r5ri::r ryui: 
i: : _r 5err:e 

I: ins i rinre ii lie :ini: ievenieie<i. ::: i: irrnri.eiy :tr::::e5 lie 
s-:::. emr:y ::zeiess r rise :::ei r::e: ::: 5:rne i:nr= ir:::e ieiii in reriiii 
iiriii: :.i.se5. Sis :_':iies riiinz iii : : Li i r s i n r :-y:rrri:.iiy _r:e: :re 
irre: — :nii ::ivey r::: lie -ir: sens.iii:n 

Tie m:is-e-:.=n' pnis-e ; : iess ie:s:rirrive :: iiy::..rr 

iiri : inirss i: ill-lies :: ::: 1 ise :: errrerneiy rriimi 
:e:rssi:i ii: ::i:n:::: :•: iisiiiniy ei::m:erei in r ire i::n: ::::.!.: 
: : :::: rri re 

Tie "• i:er-iinnrne: Piis-e— 7:i r.irr.e iT:::.:^ ':ei-i.:_iy :ie : / 
:-;,- ;:■> ::' r-re free i::::: :er_:rvn:i ~.:r. ::s surr = 
:.: :e: :.. ::: ::. :ie ±:.z-: 



496 



MEDICAL DIAGNOSIS 



Indurative 
mediastinitis 



Rare phe- 
nomenon 



Rare form. 



Instances might be multiplied if one were to quote from the works of the 
older clinicians and the aptness of many of the descriptive terms together 
with their multiplicity, is good evidence of the possibilities inherent in the 
tactus eruditus as applied to pulse-taking. 

VENOUS PULSATIONS 

"Diastolic Jugular Venous Collapse." — This is now regarded as a weak, 
unsustained, positive venous pulse, but the collapse is particularly marked 
in "adhesive mediastino-pericarditis" and is rendered more striking by the 
diastolic recovery of the chest wall, which has been dragged down by the 
ventricular systole of a greatly enlarged and adherent heart, associated with 
diastolic intrathoracic suction (Friedreich). 

Positive Penetrating Venous Pulse. — Very rarely and usually in associa- 
tion with the "capillary pulse'' a wave may be observed in the terminal 
venules. Compression causes central obliteration of this pulsation but does 
not affect the peripheral portion. 

Visible Respiratory Venous Phenomena. — The swelling of the veins of 
the neck during violent muscular straining or sustaining a musical note is 
common form, familar to every one and it is seen in all forms of severe dyspnea, whether 
temporary or permanent. In chronic conditions the overdistension may 
become permanent and, occasionally, the usual inspiratory diminution and 
expiratory fullness is reversed, in which case indurative mediastinitis, chronic 
pericarditis, aneurysm, or any form of mediastinal tumor is suggested. 

If forced expiratory movements, with the mouth and nose closed, show 
overfilling of the cervical veins upon one side as compared with the other, 
intrathoracic venous compression is suggested. 

Carotid vs. Jugular Pulsation. — Students often find difficulty in distinguish- 
ing between venous and carotid pulsation; the former covers a wider area, is 
undulatory and collapsing in character, and obliterative pressure upon the 
carotid does not affect it. 

Proper Posture. — The patient should be in the dorsal position with the 
head raised, supported by a pillow and turned well to the right, when in 
about 75 to So per cent, of all cases the pulse will be visible. 

If distention of the veins prevents visible venous pulsation the head and 
shoulders must be elevated until the pressure is modified sufficiently, if 
this be possible. 

Much maneuvering and many shifts of position may be necessary to 
secure results and these should be carried out with the least possible 
effort or psychic disturbance on the part of the patient. Very little 
exertion or excitement, for example, may suffice to remove an extrasystolic 
irregularity or other interesting subsidiary findings. 

INSTRUMENTAL METHODS 
The True Value of Instrumental Methods 
of genuine Facilitate Research. — The use of the fascinating and delicate instrument 

clinical value. . ...... .. . .. . ,. . , ,,ri 

of precision in the investigation ot cardiovascular disturbances has bee 



THE SPHYGMOGRAPH 



497 



of incalculable value in advancing our knowledge of cardiac physiology 
and in the clinical field the newer methods have clarified many obscure 
conditions and added much of real value to the resources of the clinician. 

The author feels strongly that with respect to the electrocardiograph we may 
hope that present achievement, remarkable as it is, represents but a part of its 
capabilities as an aid to clinical research. 

He now regards it as of very great value in detecting conditions of genuine 
importance with relation to both diagnosis and treatment such as cannot be 
demonstrated without its aid. 

Necessary Training. — It is proper and necessary that every earnest 
student of medicine should know the instruments and, so far as possible, the 
methods of modern cardiac research, fascinating alike to eye and mind. 
If possible he should be accustomed to their use so far as to enable him to 
translate readily the simpler forms of the graphic records which they yield, 
or, if time and opportunity offer, become sufficiently expert to take up 
research along this most fascinating and attractive line or even use them 
clinically to his advantage and that of his patients. 

Their value, especially in the early diagnosis of myocardial lesions, is 
extremely great and it is to be regretted that as yet neither the electro- 
cardiograph nor even that simpler instrument, the polygraph, can be utilized 
widely by the general practitioner. 

Simpler Methods Usually Adequate. — He should realize nevertheless that 
the major part of the clinically important circulatory phenomena registered by 
modern recording instruments may be recognized and interpreted by the simpler 
means of ordinary clinical technic, if this be founded upon an adequate 
knowledge of modern cardiac physiology and pathology. 



Useful but'not 
essential. 





Fig. 187. — Marey's sphygmograph. Now 
nearly obsolete, because of its slight value and 
the far greater usefulness of polygraphic 
tracings. It was never a satisfactory instru- 
ment. 



Fig. 188. — Ideal radial sphyg- 
mogram. b.c, percussion up- 
stroke; b.c.d., percussion wave; 
d.e.f., tidal wave; g., dicrotic 
wave. 



Without desiring to lead his readers to overvalue instrumental methods 
or to obscure the far more vital and practical aspects of clinical technic 
by a needless elaboration of graphic procedures, the author feels that a 
brief and simple reference to the chief of certain instrumental methods 
properly may be attempted. 

The Sphygmograph and Sphygmogram. — The sphygmograph, of itself 
and apart from its combination with other recording apparatus, is an instru- 
32 



49 8 



MEDICAL DIAGNOSIS 



Replaced by 
polygraph. 



ment of some slight value in connection with pulse-taking, yielding, in certain 
directions only, more important information than may be derived from touch 
and making, if desired, a permanent record, but the relation of time lost 
to information gained and the large elements of error inherent in the technic 
make impossible its general adoption in private practice. 

It has now been almost wholly superseded by the polygraph which has 
been elaborated to an extraordinary degree and has thrown a flood of light 
upon the genesis of cardiac irregularities and the pathologic phenomena 
of the heart cycle. 

The arterial pulse tracing represents the systolic and disastolic variations 
of intra-arterial pressure as registered by the expansion, retraction, short- 
ening and elongation of the elastic artery. 

In the case of rigid arteries the vessel itself may also move as a whole, 
as in the case of tortuous sclerosed temporals or brachials under high pressure 
or associated with aortic regurgitation. The rhythmic change of size and 
position of the artery itself is very slight normally, but sufficient to impart 
to the tambour of a delicate recording instrument the tidal wave of pressure 
generated by each systole which reflects to a remarkable degree certain 
important events of the cardiac cycle. 

The analysis of all sphygmo graphic tracings depends upon a thorough 
understanding of that oj the normal pulse. 

In this we recognize an anacrotic or ascending limb which at its summit 
or apex becomes the katacrotic or descending limb, the latter being divided 
into two chief waves, the higher being tidal or predicrotic, the lower the 
recoil or dicrotic wave. Between these two elevations on the descending 
limb is a hollow representing the aortic closure. The apex height shows the 
maximum excursion, the two secondary elevations on the descending limb the 
reactive contractions of the artery. 

These phases will be readily recognized in the ideal radial tracing shown 
on Fig. 188. 

THE POLYGRAPH. (Sphygmocardio graph) 

Principles Underlying Its Mechanism. — All of the simpler instruments 
depend upon the same general principles. 

A clockwork mechanism or small motor is employed, by means of which 
a roll of specially cut paper is passed at any required speed under a stylus 
or pen attached to a lever operated by delicate tambours, which, through 
rubber tube connection with the jugular and radial terminals (E and C), 
transmit and record the impulses. Some form of time marker graduated to 
two-fifths of a second should also be included, and several of the instruments 
are capable of registering three tracings of different origin simultaneously. 

The spring lever type of recorder may be used for the radial and a special 
receiver over the heart itself. 

The simultaneous records of greatest use and value are those of the venous 
and carotid pulse and to obtain these the patient is placed in the dorsal 



THE POLYGRAPH AND POLYGRAM 



499 



position, with the head slightly flexed, turned to the right* and resting 
upon a small pillow and should retain the posture for several minutes before 
record-taking is attempted. 

If the venous pulsations are not evident in the jugular fossa because of 
overdistension of the veins, it may be necessary for the patient to sit up before 
they can become manifest. In some cases of phlebosclerosis or extreme venous 
pressure no proper record is obtainable. 

Technic. — Ordinarily the venous pulse is evident and the proper receiver 
is placed over the jugular bulb in the interval between the two heads of the 



Jugular bulb. 




Fig. i 88. — Mackenzie ink polygraph. This instrument records two simultaneous 
tracings only, i.e., radial pulse and one other, such as carotid, jugular, apex beat, etc., the 
great advantage being the avoidance of smoked paper and the convenience and permanency 
of the ink tracings which may be continued almost to any length from the long roll of paper 
supplied with the instrument. The instrument need not be attached to the patient's wrist 
and by many is preferred because of this feature. The clock work operates at varied and 
controlled rates, permitting the taking of protracted records at different speeds. The 
original instrument was invaluable, but Dr. R. Edwin Morris has improved greatly the con- 
trol of the paper strip, increased the ease and accuracy of tambour attachment and adjust- 
ment, and, furthermore, has made possible a delicate, independent and accurate control of 
the pens, through various ingenious devices.* 

sterno-mastoid, just above the right clavicle, and such light pressure is 
permitted as is just sufficient to secure exact contact and exclude the air. 

The proper receiver is then placed firmly over the carotid which is easily 
palpable just at the inner edge of the sterno-mastoid when the head is in I 
proper position for the venous tracing, i.e., turned to the right. tracings!" 

The tracing of the venous pulse of course represents right auricle effects 
but tracings representing the left auricle may be taken by introducing into tracings. 



* See "Modification of Mackenzie Ink Polygraph." R. Edwin Morris, Teaching 
Fellow, Medical School, University of Minnesota. Jour. A. M. A., June 17, 19 16, vol. 
bxvi, p. 1922. 

f Almost all patients instinctively turn the head to the left unless watched and checked. 



5oo 



MEDICAL DIAGNOSIS 



the esophagus to the distance required, a stomach tube capped by a rubber 
bag and connected externally to a suitable tambour and writing lever. 
This method is ingenious but not of much practical use in clinical work by 
reason of the nausea and retching usually induced. 

Crehore registers both heart sounds and the events of the cardiac cycle 
by means of an ingenious apparatus termed the micrograph. It is valuable 
in cardiac research but too elaborate and time-consuming for clinical use. 




Fig. 190.— Portable polygraph, with continuous roll (20 meters) of smoked paper. 
This instrument consists of an accurate clock movement imparting two speeds to the paper, a 
time marker recording in one-fifth seconds and three recording tambours, each of which may 
receive impulses from three different parts of the body for simultaneous tracing. The in- 
strument thus answers the purpose of a kymograph and is valuable for many purposes 
because of its extreme portability. The same instrument is furnished with a mercurial 
syphgmomanometer indicating blood pressure and a cuff writing attachment. In this 
arrangement of the instrument one of the tambours must of necessity be used for recording 
the tracings of the brachial pulse under various pressures, while the other two tambours may 
be used to record any other two tracings such as the radial, jugular or carotid pulse, apex 
beat, respiratory movements, etc., under an accurately determinable blood pressure as read 
in a manometer. The pressure applied to the cuff is transmitted to the manometer and, 
at the same time, to the writing tambour by means of a rubber bulb enclosed within a glass 
bulb, or Erlanger capsule. {Courtesy A. H. Thomas Co.) 

There are many other special devices of extreme ingenuity and varying 
usefulness but none of them demand a full description here. 

The Interpretation of Venous Tracings. — A venous tracing remains a 
thing of mystery until the simple technic of correlating simultaneous records 
of different forms and sources is explained. 

Having fitted the receivers to the proper areas for receiving and recording 
simultaneously venous and carotid tracings, one first tries the excursions 
of the levers which should be at least 5 mm. for the venous tracings. 

The position of the two recording points initiating the record should then be 
distinctly indicated upon the paper by exaggerated sweeps of the pens and 
the record taken by running a series of short tracings. The measurements 



THE POLYGRAPH AND POLYGRAM 501 



accessary to the marking and interpretation are facilitated by the use of short 
runs. The longer the record the greater the opportunity for error. (See Figs. 
192 and 193.) 

The purpose of the venous tracing is chiefly to establish the presence and 
normal relation of the three chief oscillations, i.e., waves "a," "c," and "v." 

Their place in the tracing may be definitely established by comparison 
with the carotid tracing in the light of their known relationship to the ca- 
rotid curves and, of both, to the phenomena constituting the heart cycle. 





( 


• 


-k| 




>^H 


5r 


cK^jl 


r *i^JB ,--# am/a 








^jiBi 


SB s&i »i?ii 





Fig. 191. — Jaquet sphygmocardiograph. In this instrument one tracing must always 
be that from the radial artery, over which the instrument is fixed in place, either by means 
of a cuff as in the older forms, or by means of an arm rest. In the single tambour type, 
therefore, two simultaneous tracings are made in addition to the chronograph record, i.e., 
the radial pulse from the pelote attached to the instrument and one other tracing through 
the single tambour, which may be taken from the jugular, carotid, apex beat, respira- 
tory movements, etc. In the double tambour type two tracings may be made simulta- 
neously in addition to that from the radial pulse and the chronograph record. The double 
tambour type is the most widely used form of Jaquet instrument. Both types are pro- 
vided with two speeds so that tracings may be greatly magnified by the use of a high speed. 
The illustration shows the double tambour type with cardiograph attachment in position 
for recording apex beat and one receiving tambour free to take either jugular or carotid. 

Jaquet sphygmotonograph. By means of a tonograph attachment to the double tam- 
bour type of sphygmocardiograph, Prof. Jaquet has provided a means of recording the 
blood pressure from the brachial artery, under increasing and diminishing pressure, simul- 
taneously with the tracing from the radial pulse. The brachial pulse tracing may be read 
in millimeters of mercury by means of a calibrating table accompanying each instrument. 

By such a comparison of the more or less variable venous tracings, often 
obscured by wholly fortuitous notches or wavelets, with an arterial record 
of relative stability of character, one may readily locate its important 
events in most instances. 

It is necessary to establish the coincidence of the "c" wave of the 
venous tracing with the initial rise of the primary wave of the carotid 
tracing; for a vertical drawn f-rom this latter must intersect the venous "c" 



:o2 



MEDICAL DIAGX 



F: 



, 192. — Use of dividers in measuring up 
on the polygram. (-4 ) First step. 




ugulax patee. 



wave which in its own initial rise marks the onset of ventricular systole, but 
just precedes the actual systolic thrust in the large arte 

One has, therefore, only to measure on the carotid tracing the distance from 
the (previously 
marked) starting 
or finishing point 
oj the carotid lever 
to the starting 
point of a pri- 
mary carotid warn, 
and then lay off ex- 
actly that distance 

: the (previously marked) starting point of the venous 
pulse lever, and he will cut the li c' r wave of the venous trc 
which should commence its rise just before that of the former. 

The corresponding point on a radial tracing is attained 
by an additional allowance of one-tenth second on the an: 
tracing for transmission. 

Therefore' exactly the same initial procedure is adopted save 
that the distance from the starting point of the radial lever to 
the starting point of a radial wave is laid off and moved to the left one-tenth second of 
distance as per time marker. One has then attained the same point with relation 
to the venous "c" wave as in the former example. (See Figs. 192 and 193.) 

In the author's practice little use is made of the carotid tracing. 

The "a" wave summit of initial auricular systole precedes the 
s ::e summit by somewhat less than one-fifth of a second. 
The "v" wave of protodiastole normally is about two-fifths 
of a second later than : . 

THE AURICULAR VENOUS PULSE.— The instru- 
mental study of the cardiac venous pulse, as distinct 
from the respirator)- oscillations, which occur in active 
breathing, has added greatly to precision in clinical 
diagnosis and the so-called "jugular wave" gives most 
valuable information as to the action of the auricles with 
relation to the other events of the cardiac cycle. 

General Sig- 
nificance. — The 
carotid and the 
venc us pulsations 
are quite distinct 
in form and char- 
acteristic 5 One 
; reflects primarily 

i the systolic contraction of the left inferior, or pumping chamber, the other 
chiefly represents the effect of presystolic contraction of the automatic 
pumping reservoir of the right heart (right auricle). 




-Use : : fividas in measuring up on the polygram. 
E St: :nd step. 



THE POLYGRAPH AND POLYGRAM 



503 



Of the two, the venous pulsation is infinitely the more valuable in instru- 
mental readings. 

One most easily recognizes the former by its thrust; the latter, by its collapse. 

The venous pulse when normal and visible over or near the jugular 
fossa appears to be a phantom double wave; the first element ("a" wave Presystolic 

* *3," W8. VC 

of the polygram) is presystolic as timed by the heart sounds or apex-beat 
and its collapse immediately precedes the commencement of the carotid pulse. 




Fig. 194. — Site of election for the application of the receiver used for jugular tracings 
is indicated by the circle, and overlies the jugular bulb. It will be noted that the veins 
are shown in black wherever accessible. {After Keith, modified.) 



The second element, "c" wave, or secondary rise, immediately follows The systoi 
it, just preceding the thrust of the carotid beat. 

Events of the Venous Pulse Cycle. — This double pulsation so often visible, 
in the jugular fossa, higher along the course of the vein, or, in the supracla- 
vicular fossa over the external jugular, is found to be triple actually, when 
recorded by the polygraph. 

The first ("a" auricular) {atrial) wave is, as stated, unquestionably the 
result or the auricular presystolic contraction, being due either to a return 
wave to the jugular bulb or to the sudden check interposed by the auricular 
systole to the venous current. It is absent, therefore, in auricular fibrilla- 
tion, or auricular paralysis from excessive persistent distention. 

Nodal extrasystoles occur when the impulse to contraction arises 
(probably) in the auriculo-ventricular node, not in the sino-auricular node, 
its proper normal point of origin. 



A triple pulsa- 
tion. 



Genesis of 
"a" wave. 



Presphygmic 
wave. 



:: - 



1LEDICAL DIAGN 




APEX 
TRACING 



CAROTID 
TRACING 



RADIAL 

PULSE 

TRACING 



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^rreri :e :. 



THE POLYGRAPH AND POLYGRAM 



.">^0 



As a result the ventricular contraction may 
practically coincide with or actually precede that 
of the auricles and in consequence a large wave 
embracing both "a" and "c" may result. 

Such concurrent or fused waves, a-c, merely 
show on a tracing as interruptions and variants of 
the dominant rhythms followed by the '"'com- 
pensatory pause." 

The second wave u c" is now known to be a Presphygmic 
venous wave independent of the carotid beat, 
starting probably early in the presphygmic 
period.* present even though the carotid be ligated 
and aorta held away, and instrumentalb demon- 
strable in both esophageal and hepatic venous 
tracings. Indeed its form in the tracing, as 
obtained with sufficiently light pressure, is entirely 
diflerent from that of the arterial wave. 

Its beginning probably represents the time of Genesis of 
the closure of the tricuspid valve and it precedes 
the actual carotid pulse by the presphygmic inter- 
val, i.e., the time elapsing between such tricuspid 
closure and the forcible systolic opening of the 
pulmonary valve. t 

A studv of this wave in extrasvstolic frustrated The wave of 

. ' . , , * , valvular 

contractions, i.e., such nasty, weak, and prema- closure, 
ture contractions as are incapable of opening the 
Diagram drawn aortic and pulmonary valves though the tricuspid 




close, shows the truth of this 



Fig. 196 
from actual tracings showing anc j m i tra l mav 
the variations in records of . 

the auricular type of venous hypothesis. 

pulse._ The upper phlebo- -phe third or "v" wave is practicallv svnchro- 

gram is normal. The lowest . , , ' . " 

shows the effect of free tri- nous with the second sound 01 the heart, i.e., with 

cuspid regurgitation. _ Xote closure of the pulmonarvand aortic valves, opening 

the gradual increase ot wave . . .. %■»■*_•• 

u v" at expense of the de- oi the tricuspid and mitral and the beginning ot 

pression "x." (1) The be- diastole.! 

ginning of auricular svstole. .. .. . 

(3) The appearance of the Between the "a and the "v waves is. ot 

pulse in the carotid. (5) The course, a drop in the tracing due to the emptv- 
closure ol the semilunar. . . . . * 

valves. (6) The opening of mg ot the veins which accompanies auricular 

the tricuspid valves. (After diastole which mav be denominated the "x" 
John Hay. . 

depression. 

After the height of auricular systole is attained a drop in jugular venous 

* It is probable, however, as von Jagic says, that in practice, the carotid pulse is often 
included in the tracing of this second wave through technical error. 

t Minute interval of time (0.07 to 0.085 sec.) elapsing between the closure of the mitral 
and tricuspid valves and the opening of the aortic and pulmonary exits in systole. It is 
more properly termed the ventricular isometric period. 

t A second "v" wave (v") is recognizable in polygraphic tracings, but as yet has been 
assigned no clinical significance. 



Proto -diastolic 
"v" wave. 



506 MEDICAL DIAGNOSIS 



pressure results which is reflected on the polygram by the "x" depression 
interrupted by the "c" wave. 

Any encroachment upon the "x" depression by the "v" wave indicates a 
tendency to venous stasis and more rapid and perhaps excessive filling of 
the auricles. 

Any of the various pulmonary and cardiac conditions embarrassing the 
right heart and resulting in venous stasis would tend to cause a widening 
of the "v" wave at the expense of the "x" depression or " phase." 

Summary. — The "a" element of the jugular wave corresponds to the beginning 
of auricular systole in its rise; to the close of auricular systole in its fall and 
immediately precedes the first heart sound. 

The "c" element of the jugular wave in its beginning marks the closure of 
the tricuspid valve and the initiation of ventricular systole. It coincides with 
the first sound of the heart and just anticipates the carotid thrust. 

The "v" wave crest very nearly marks the beginning of diastole and coincides 
with the opening of the tricuspid and mitral valves, the closure of the pulmonary 
and aortic and the second sound of the heart. See Fig. 194. 

Registration of the Venous Waves. — It is evident that if the venous 
pulse events and those of the carotid or radial are registered simultaneously 
in graphic form, one may draw conclusions of great value with regard to 
irregularities and conduction, as well as heart strength. Lack of balance 
between the venous and arterial circulations and variations in heart strength 
are often clearly shown. 

Scope of Methods. — Such registration is now readily obtained by means 
of any one of several polygraphs and, in fact, the heart sounds and the direct 
action of the auricle as well as the electric "action currents" of the heart, 
can also be graphically represented by means of special instruments of 
precision. 

Decided Limitations. — Special training is necessary to accurate results 
with such instruments and this fact and the time consumed in the necessary 
procedures will confine such work largely to the research laboratory, teaching 
hospital and, possibly, the consulting room of the specialist. 

MARKING AND INTERPRETATION OF THE POLYGRAM 

Systematic Procedure Indispensable. — It is absolutely necessary to 
proceed in a systematic and orderly manner in the marking and interpreta- 
tion of a polygram. (See Figs. 192, 193, p. 502.) 

Technic of Marking. — The only instrument necessary to the marking is 
a pair of needle-pointed dividers. Inasmuch as these are permanent records, 
mark the name, date, and special circumstances surrounding the taking of 
the record, i.e., whether following exercise, special medication, accident or 
injury, association with painful seizures, syncopal attacks, etc. Also mark 
the radial and jugular tracings, indicating the side used. 

It matters little what particular system is adopted. The one in use in 
the author's clinic is outlined below and has proven fairly satisfactory. 



MARKING AND INTERPRETATION OF THE POLYGRAM 



507 



i. Determine the " c" wave from the radial record by measuring the 
distance from the beginning point to the first point of rise of any radial thrust. 
Lay off this same distance on the venous record from its beginning point. 
That wave occurring J-fo of a second earlier is the venous "c" wave of that 
corresponding heart cycle. Mark the "c" wave in at least six consecutive 
heart cycles, in the same manner. (See page 502 for details.) 

2. Determine the "a" wave. This is the definite wave preceding the 
"c" wave normally by ^ of a second or less. 

3. Determine the "v" waves. These are normally the only remaining 
waves of importance and lie approximately midway between the "c" 
wave and the "a" wave of the following heart cycle. 

4. Determine the nature of extrasystoles if they occur. (Detailed descrip- 
tion to be given later.) 

5. If the "a" wave is absent look first for the presence of fibrillation and, 
if found, label the fibrillatory waves "f," "f," "1" 

6. Determine the rhythm. With the presence of extrasystoles or fibrilla- 
tion the arrhythmia itself is apparent at a glance. To determine sinus 
arrhythmia measure the distance between the tops of any two radial thrusts 
and make comparison with several other similar intervals. A variation in 
these intervals, in a record otherwise normal, indicates sinus arrhythmia in 
its varying degrees. The pulse rate is markedly affected by respiration, 
being increased by full inspiration, and decreased by full expiration. It is 
wholly abolished by vigorous exercise. 




Fig. 197. — This record shows an extrasystole of auricular origin at a'-c'. There is no 
compensatory pause. In this patient the conduction of the premature stimulus is unduly 
delayed, the a'-c' interval being almost two-fifths of a second. The diagram shows the 
relative incidence of the systoles of the auricles and ventricles. {After John Hay.) 

7. Determine the "a-c" interval. Lay off the distance from the 
beginning of the "a" wave to the beginning of the "c" wave. Compare 
this with the time-record. The normal does not exceed 0.20 sec. 

8. Determine the rate. The time is recorded by the " marker" in fifths 
of^a second. Fifteen spaces on the time-record is equivalent therefore to 
3 seconds. From the top of one of the radial thrusts lay off a 3-second 
interval (15 spaces on the time-record) and count the radial thrusts during 
that period; then lay off another consecutive distance of 3 seconds and 
continue the count. The result is the number of heart cycles in a 6-second 



;o8 



MEDICAL DIAGNOSIS 



interval as recorded by the time-marker. Multiplying this by 10 gives the 
rate per minute. 

Special Conditions. — Extrasystoles. — Extrasystoles may be (i) auricular, 
(2) ventricular, or (3) nodal. Sinus arrhythmia has already been dealt with. 




7M. 



Fig. 19S. — In this record an extrasystole. originating in the ventricle has occurred 
before the normal systole of the auricle a\. Xote that in this case there is no ventricular 
systole resulting from the auricular systole «i, the a-v bundle apparently refused to con- 
duct the stimulus. Xote absence of K v" wave immediately after extrasystole. 

The downstrokes in the upper space "As" of the diagram indicate auricular waves "a" 
in the jugular pulse: the downstrokes in the lower space w vs" indicate the carotid waves 
• - c" in the jugular tracing, the slanting lines connecting them give the "a-c* 1 interval. 
{After John Hay.) 

1. Auricular extrasystoles show a premature contraction of the li'hole 
heart indicated on the record by an abnormally early occurrence in diastole 




As 



<1-C 



V* 



T 



s 



i; 



v^: 



Fig. 199. — Simultaneous records of radial and jugular pulses. Three extrasystoles 
are recorded at "o." "p" and "o" in the radial tracing. The rhythm of the auricle is 

regular but the ventricle contracts prematurely as is obvious from the radial tracing. The 
post-extrasystolic pause is fully compensatory and lasts three and-a-half fifths of a second. 
"a" = auricular wave, "'a:" = the auricular wave associated with the extrasystole. 
The diagram represents the events in the latter two-thirds of the above record. (After 
John Haw) 



of the "a" and "c" waves, with a corresponding early appearance of the 
radial thrust. This is followed by a lengthened diastolic interval represent- 
ing less than two heart cycles in duration as measured on the radial record. 



MARKING AND INTERPRETATION" OF THE POLYGRAM 



509 



j. Ventricular extrasystoles are premature contractions originating in the 
ventricle and show (a) unaltered auricular rhythm, (b) a premature systole 




S 



To7 



V4 



Fig. 200. — Simultaneous records of the jugular and radial pulses. Shows four nodal 
extrasystoles. The diagram gives the sequence of events as shown in the jugular tracing. 
Note (1) that both auricle and ventricle contract prematurely; (2) that there is a full com- 
pensatory pause: (3) that the wave "v" is greatlv diminished after the extrasvstoles. 
r John Hay.) 

of the ventricles either preceding that of the auricles or simultaneous with 
it, and (c) complete compensatory pause, i.e., equal to two heart cycles. 




T? a ^ 



Fig. 201. — Shows three irregular periods due to extrasystoles. At "A ,J a nodal extra 
systole; during "B" a ventricular extrasystole; and at "C" an auricular extrasysto le 
(After Mackenzie.) 

A record in this case would show the regular occurrence of "a" wanes 
and an abnormally early "c" wave appearing either before or coincidently 




Fig. 202. — Radial and jugular tracing from a patient suffering from auricular fibrilla- 
tion. Xote 1 the absence of ""a " waves in jugular tracing; (2) the presence of fibrillatory 
waves ('fff : 3 the lack of rhvthm of radial thrusts. The slow radial rate is due to digitalis. 
(After John Hay.) 

with the "a" wave. In the latter case the "c" wave cannot be differentiated 
from the "a" but its location is determined bv the usual method. 



5io 



MEDICAL DIAGNOSIS 



It is to be noted that in ventricular extrasystoles the "a" waves do not 
occur prematurely and the so-called " compensatory pause" following is 
equal to two complete heart cycles. 

Note. — Extrasystoles of ventricular origin in rare instances occur as 
interpolated beats between two normally spaced ventricular contractions 
each of which represents a response to normal auricular stimulation. 

3. Nodal extr asystole is indicated by the premature and simultaneous 
contraction of both auricles and ventricles. This is followed by a com- 
pensatory pause equal to two full heart cycles (called complete compensatory 
pause). This is indicated on the venous record by an exaggerated wave 
resulting from and in time measurement representing the simultaneous 
occurrence and merging of the "a" and "c" waves. 



C v" 



ev £r 



<~ v c~ V ^ V 



RJ 



TtR. 



Rafc= 63 



9ZZI Mt.fl.H. 




Fig. 203. — Mr. A. H. 

(A) Polygraphic record taken in case of fibrillation in a young adult at beginning of 
hospital regime. 

(B) Record in same case 54 days later showing practically normal rhythm at radial, 
marked improvement in myocardial tone and strength as indicated by the height of the 
radial. The general absence of "a" waves in the jugular record shows that fibrillation 
still exists, but an occasional wave in the normal position of the "a" wave is found. R.R. 
= right radial. R.J. = right jugular. 

Fibrillation. — Fibrillation is characterized by a total irregularity in rate, 
force and rhythm of the radial pulse, the absence of "a" waves in the venous 
tracings, and the occurrence of multiple coarse or fine undulations (fibrillatory 
waves). Label fibrillatory waves "f," "f," etc. 

In this condition many impulses are so weak as not to be registered on 



MARKING AND INTERPRETATION OF THE POLYGRAM 



5" 



the radial record and even less would be detected by palpation of pulse. 
The more rapid the heart the greater the "pulse deficit." (See page 551.) 

Block. — Block may be (1) complete or (2) partial. In complete block 
there is complete dissociation between the "a" and "c" waves together 
with a slow rate in the radial record. 







Os 






1 














jZ-v\ 


y > 


k \ 


V3 











Fig. 204. — Increased depression of conductivity producing an arrhythmia. The "a" 
wave occurs perfectly regularly. Note that the "a-v" bundle requires the whole time of 
two auricular systoles to recover its conducting power. When this length of time is cur- 
tailed as in the middle of the record the "a-c" interval A 1 is at once lengthened. 

The diagram represents the condition present in the above record. The downstrokes 
in the upper compartment As representing auricular systoles, occur with perfect regularity, 
with one exception every other systole is blocked. Note the lengthening of the "a-c" 
interval when two consecutive stimuli pass down the "a-v" bundle. The downstrokes in 
the compartment Vs represent systoles of the ventircles. (After John Hay.) 

In this condition the complete block existing in the conducting fibres 
compels the ventricles to adopt their own slow, deliberate rhythm, causing 
the occurrence in the venous record of correspondingly few "c" waves. The 
conduction through the auricles being unimpeded, they respond freely to the 



4 J"u«» * 



Qs 



Vs 



H3 



Fig. 205. — The record above shows a sudden halving of the pulse frequency. There 
is no depression of conductivity. The "a-c" interval is normal throughout. Depression 
of excitability is shown by the refusal of the ventricle to respond to a stimulus normally 
conducted. The diagram represents the events shown in the jugular record. (After John 
Hay.) 

stimuli arising in the pacemaker (sino-auricular node). The result is a 
preponderance of "a" waves over "c" waves in the venous record varying 
in degree with the ventricular rate. An auricular rate of 70 might accom- 
pany a ventricular rate of 40, for example. The lowest ventricular rate 



12 



MEDICAL DIAGNOSIS 



reported to date is one beat every 57 seconds, observed shortly before 
death. 

In partial block some of the auricular contractions cause corresponding 
ventricular contractions. There is found a predominance of "a" waves 
again, but every so often at definite intervals, there is found an "a" wave 
which has its normal position in relation to the "c" wave. For example, 
in 2:1 block every other "a" wave is in its proper relation to the "c" wave 
with the extra "a" wave midwav between these two. Here the auricles are 



»■ t f >->• r 



£da 4 a a & c § 



4 q a.a a a_<. a< 2 «. 




Fig. 206. — Tracing showing auricular flutter ' 
Auricular rate = 24c. Ventricular rate = 60. 



As 



ave due to systole of auricle. 
itr :: 4 : 1. [After John Hay.) 



1 block there are two extra 
waves, all of the "a" waves 



beating twice as fast as the ventricles. In 
•"a" waves between two normally placed '"a 
being the same distance apart. 

Auricular Flutter. — This is a condition of extremely rapid, rhythmic 
auricular contractions associated usually with a partial block, and occasion- 
ally with alternation of the pulse. An associated block may give rise to a 
2:1. 5:1. 4:1. or in rare instances, even 6:1 ratio between the recorded auricular 



*p^Jtyj& 







*»«.-.* 



Fig. 207. — Polygraphic curve showing a sinus irregularity during a period of suspended 
respiration. The arterial curve resembles those found in partial A—V block; the venous 
curse shows that the auricle participates in the irregularity. The diagram shows the 
events of the heart upon the hypo thesis of " sino-auricular" block. See Sir:o-auricular 
Block " — in Electrocardiographic S e : :i o. {After Thomas Ltj. is . 

and ventricular waves. This condition is accurately determinable only by 
instrumental methods. (See page 555. 

Paroxysmal Tachycardia. — This is a condition characterized by a sudden 
outburst of rapid action of the whole heart and its abrupt termination 
after a duration of minutes, hours or days. It is usually, if not always, 
initiated by extrasystoles of auricular origin. Rarely, it is said that these 
cases are ventricular in origin, v^ee page 559.) 



MARKING AND INTERPRETATION OF THE POLYGRAM 






Rhythm. — A record is either rhythmic or arrhythmic. Arrhythmic 
records are by far the more common and the larger per cent, of these are 
due to the simple, and relatively unimportant, sinus arrhythmia. Of the 
arrhythmias due to extrasystoles. the ventricular type constitute the largest 
per cent. 

The Venous Record. — The examination and interpretation of the venous 
record is very important for it reveals some of the earliest signs of myocardial 
insufficiency. 

■n and Character. — Normally the venous record is small and 
narrow, with its various components small but clear-cut and distinct. A 
wide exaggerated record with large, disproportioned components is significant 
of an abnormal condition of the cardiovascular system. In order to deter- 
mine the condition present, the 'a." "c" and "v" waves must each be 
examined as to form. size, and general characteristics. 

—Normally the •"a"' wave is a small rounded wave, smaller 
than the **c" wave and just preceding it. Its absence suggests fibrillation. 
Note whether the "a" wave is larger than the "c" wave. If not larger all 
the time, is it larger than the "c" wave part of the time? Is it a wide, 
broad w:- 




■^aJ>al 



Fig. :: ; — S imultaneous records of the jugular and radial pulses. In the jugular 
pulse there is a marked lengthening in r. interval. The distance between the 

downstrokes i and 3 represents more than two-fifths of a second. This indicates delay 
in the passage of the stimulus from the right auricle to the ventricle. {After Eerrirgham.) 

-'_-" Interval. — Normally the "a-c" interval is 0.20 sec. as 
measured by the polygraph. Any interval greater than 0.20 sec. indicates 
delayed conduction. Among the conditions found to be associated with 
delayed conduction are the following: acute and chronic myocarditis, myo- 
cardial degeneration, decided or profound toxemia, myocardial insiiinciencies 
resulting from overexertion, acute infectious diseases, etc. 

The determination of the u a-c" interval is important at all times 
but especially so when digitalis is being administered, for the sudden develop- 
ment of delayed conduction under this circumstance usually means over- 
digitalization. 

The author's experience with the polygraph and electrocardiograph 
during the past two years have served to convince him that too little 
stress is laid upon the importance of minor degrees of delayed conduction 
such as. do not reach the grade of even partial block, and believes that it 
constitutes a finding of definite clinical significance and one that demands 
33 



514 MEDICAL DIAGNOSIS 



in many instances the most careful and discriminating therapeutic 
management. This is particularly true of the cases arising in the chronic 
heart lesions as contrasted with those in which some active and potent 
infection is demonstrable. 

In cases of actual heart block, contrary to the usual belief, digitalis may 
act most favorably in ameliorating the condition provided that other signs 
of myocardial insufficiency are present in the case. 

In administering digitalis, however, the author exercises the greatest 
care not to produce the so-called full physiologic effect, finding that in many 
instances when this is done a definite weakening of the myocardium becomes 
manifest. In cases of block especial care is needed, but in his opinion the 
rule applies to nearly all decompensated cases. The object of digitalis 
administration in such cases is to aid in removing whatever insufficiency 
may be present inasmuch as this seems to be a decided factor both in per- 
sisting delayed conduction, partial block, and complete block alike. 

"c" Wave. — The "c" wave is usually called the carotid wave. It is a 
venous wave however quite independent of the carotid heat which it pre- 
cedes by the "presphygmic interval" (see page 505). Normally it is larger 
than the "a" wave and is followed by a fairly sharp drop and then by the 



<<-.>> 



v" Wave. — There is usually one, and sometimes there are two, "v" 
waves. An exaggerated "v"-i suggests a tricuspid insufficiency. 

The Radial Record. — In general the height of the radial thrusts indicates 
the condition of the myocardium. A good myocardium gives a good radial 
thrust. Before the interpretation of the height of the radial thrust can be 
made, however, one must know that the instrument was working properly 
and that the adjustment to the radial artery was accurately made. This is 
especially important in cases of weak myocardial strength which frequently 
give a practically flat radial record. 

One exception to the above statement is in the case of the "drop" type 
of heart, for, even with a good myocardium, this heart gives a relatively 
small radial thrust. 

Normal tracings show a nearly vertical upstroke of moderate amplitude, 
moderately sharp apex and a gradual descent, the tidal wave being small, 
the dicrotic wave low but well marked. 

Abnormal Tracings. — (a) Broad Apex. This indicates sustained tension 
and a strongly acting deliberate heart, as in interstitial nephritis, aortic 
stenosis and aneurysm, or, merely too great pressure on the artery by the 
pad. 

(b) An unduly long sharp apex indicates low or unsustained tension^and 
is especially marked in aortic regurgitation. 

(c) A short upstroke indicates small volume, as in mitral regurgitation, 
aneurysm, aortic stenosis, and arteriosclerosis. 

(d) A long upstroke means free peripheral circulation, sharp systole, or, 
in general, unsustained pressure. Aortic regurgitation furnishes a typical 
example. 



MARKING AND INTERPRETATION OF THE POLYGRAM 



515 



(e) Excessive obliquity of the upstrokes points to slow filling of the artery 
and is especially noticed in aortic stenosis, mitral stenosis or regurgitation, 
arteriosclerosis, aneurysm or a weakened myocardium. 

(J) A vertical upstroke indicates large blood volumes and quick systole 
whether strong or weak and is exemplified by aortic regurgitation. 

(g) A marked tidal wave suggests high tension or actual obstruction as in 
aortic stenosis or in arteriosclerosis with a strong cardiac impulse. 

Qt) A diminished tidal wave indicates cardiac weakness, or strength with 
relaxed peripheral circulation, as in mitral or aortic regurgitation. 

(i) A marked dicrotic wave points to low tension or to high tension with 
cardiac weakness. It is best marked in the pulse of typhoid fever. 



Mr. M*D . 
• • ■ "V 



a* 



~ y GZZ 



#$££ 



,Zh«. 




Jw« Jay* 



R«t*^ 4° 



F?a<i«A/ 



S^JssvfrS^ 



\\-~L-L- -*s\ 



ac*v- a 




Fig. 209. — Mr. M. D. 

A. Case of extreme terminal decompensation of sudden onset. Note flattening of 
radial record. 

B. Record made 3 days before death and just before onset of terminal coma. Flatten- 
ing of radial tracing still greater than in A. Undulations barely perceptible. 

(J) Lessened dicrotic wave. Aside from aortic regurgitation this points 
to an obstructed circulation with a strong systole, i.e., aneurysm, arterio- 
sclerosis and aortic stenosis. Aside from these points, irregularities in the 
line of descent are noted in mitral lesions; irregularities of the base line corre- 
sponding to respiration, in dyspnea or any form of irregular forcible breath- 
ing, and any inter mittency or irregularity which can be reflected in the pulse is 
usually made clearly evident by the tracings. 

In the pulsus celer type the radial has a rapid rise and fall which usually 
goes below the base line. This type of pulse is due to a weakening of the 
aortic ring and quickly expanding and relaxing vessels. 

The ''compensated mitral type" of pulse is a wide, low, flat-topped 



5i6 



MEDICAL DIAGNOSIS 



type of radial thrust. This is the result of the powerful deliberate action 
of the left ventricle which has greatly increased its muscle mass. The radial 
thrust is relatively low and flat-topped for, because of the regurgitation, it 
can attain only a certain height, but it maintains this height longer than 
usual as the increase in the muscle mass gives the left ventricle a longer 
sustained action than it has normally. 

The pulsus alternans is the type of record in which we find high radial 
thrusts alternating with lower ones. This is a very important prognostic 
sign. (See page 561.) 



Valuable 
information 
from use of 
polygraph. 



ZZ2-Z 

^^ RJ Mr.G.Mc. 



m***** 





Rod. 



UUlL^^ |U 



Fig. 210. — Mr. G. McC. Poly-graphic record in a case of typical, definitely insufficient, 
"drop" heart of a 36-year old man. The high, unsustained radial (pulsus celer type), a 
common rinding in this type of heart, is shown in the record. See x-iay, Fig. 000, page ooo, 
and Electrocardiographic record, Fig. 234, page 540. 

By vagus hypertonus (not hypertension ) we mean a radial record with a 
radial thrust in which the fall is more gradual than usual. It is sup- 
posedly due to increased resistance in the vessels as a result of overaction 
of the vagus. This is not hypertension. 

It must be evident that the polygraph gives much very valuable informa- 
tion about the heart and the circulation. Much of this information can- 
not be obtained by other than instrumental methods. When used routinely 
in the first examination of a patient, side by side with the ordinary clinical 



■^ f r »^y-*r">^*y<r 



■vv— w— v^> v 



Fig. 211. 



-Pulsus Alternans. Every alternate wave is small, each pulse'period is of full 
duration. (After John Hay.) 



methods, it is a great aid in diagnosis. Its value does not stop here, how- 
ever, for if employed frequently thereafter it gives much valuable infor- 
mation as to the progress of the case and the results of medication. It can 
be of inestimable value in hospital and house cases where the elaborate and 
efficient office instruments are not available. When used in this way it very 
frequently gives the first hint that the patient is not doing as well as he is 
believed to be doing and gives the opportunity of changing the existing 
regime of the patient before any real harm is done, hours or even days before 
the ordinary clinical methods reveal the threatening trouble. 



THE ELECTROCARDIOGRAPH 



517 



THE ELECTROCARDIOGRAPH 

Basic Principles. — Whenever a portion of muscular tissue takes on activ- 
ity it becomes electrically negative with relation to the resting portion. 

The differences of electric potential thus created (electromotive force) 
can be measured by the "string galvanometer" when one electrode overlies 
the active portion and the other the passive area. 



Plate/LAdjustabieSlit 
w ^Cylindrical Lens 



Time Marker 



Water Bath 

Condenser 



-800 
Fig. 212 




Arc 



HO _*<_80-— 



-Essential parts of electrocardiograph, as shown below. 




Fig. 213. — Cambridge electrocardiograph. Simpler and less expensive instruments are 
much to be desired and those shown are undoubtedly satisfactory. {Courtesy of the Taylor 
Instrument Co., Rochester, N. Y.) 

In the heart we deal with an aggregation of muscular units which become 
intermittently active, not as a whole, but in a coordinated sequence which 
especially sets apart in greater or less degree its different chambers and the 
threshold formed by the junctional tissues of primary conduction. 






MEDICAL DIAGNOSIS 



There is created a recurrent flow and ebb of electric potential from one 
portion to another, each beat of the heart representing a tidal cycle of "meas- 
urable action current"' which is described technically as a "diphasic" current. 

Waller first obtained registrations of such human heart currents in 1887, 
using a capillar)- electrometer and in 1903 Einthoven devised the string 
galvanometer which forms the basis of the modern electrocardiograph. 

Essential Features. — As now made, the electrocardiograph is merely 
a galvanometer to which a photomicrographic projection apparatus with an 
arc lamp is attached, which registers the deflection shadows of an inter- 



^^^r^ ^^^L. 2 "^^yp- 






' M^Bl S ■ ^m. m 


% 


1 


9 



Fie 2 ;_. — New s:~plined and relatively inexpensive electrocardiograph manufactured 
by C. F. Hi n die. New York City. This is the instrument used by the author and is 
most satisfactory. Mr. Hindle now puts out a still simpler and less expensive 

instrument . 

; : sed current-conducting filament, of platinum or of silvered quartz, upon 
a screen opposed to a photographic film moving at any required rate. 

Sensitivity and Responsiveness. — To secure sensitivity and quickness 
of movement the filament which conducts the action currents of the heart 
must be extremely fine (0.002 to 0.003 trim.) and the strength of the magnetic 
field in which it lies must be maximal. 

Any electric current generates a magnetic field acting at right angles 
to the course of the current and exerting attraction and repulsion upon any 
second adjacent magnetic field. If. there: ere. a : inducting filament is inter- 
p : sed as in this instance and made to conduct a current it will move at 
right angles to itself and to the magnetic field, reversing its direction with 
reversed now of current. 

The movements of the conducting filament are directly proportional to 



THE ELECTRO CARDIOGRAPH 



519 



the strength of the magnetic field and the current passing through the string 
itself, and, inversely, to the tension of the latter. 

Extracardial Sources of Deflection.— One must obtain the heart-action 
current separate and apart from any others, such as skeletal muscle move- 
ments and the skin current, generated in the body of the patient who, there- 
fore, must be absolutely still, muscularly relaxed, and breathing quietly. 




Fig. 215. — New simplified electrocardiograph. (.4. H. TJwmas Co.. Phila.) 

The rest "current" representing the difference in potential between the 
two parts of the body in contact with the electrodes, and quite distinct from 
the "action current" of the heart, is neutralized by passing through the 
galvanometer, in an opposite direction, a current derived from an accessory 
batter>-. 

Skeletal muscle movements create a slow deflection easily recognized 
as distinct from that of the heart action and, in the case of mere muscular 
tension, one meets with a characteristic rapid vibration. 



: : 



MEDICAL DI 



Accidental Vibrations, — Irregular rapid vibrations may arise from the 
passage of electric cars, defective insulation, improperly applied electrodes, 
loose connections, wireless waves and the induction due to an imperfect 
arc lamp, but are easily identified. 




7::- 



Fig. 2i7.^LeadIL 




Fig = ::_ ;:- ;:: — \ :r~~.' ^~i r~::: 
Lead II shows largest deflections in all phases. (Some or all R summits touched up with 
widte for contrast throughout section. AH are oleqnal height in original of "lead Q 



R R = jR R R 




m ' 2 L *'■ ' 



Fig. ::;.—] 



Metasof 



All non-muscular vibrations persist even when contact with the patient is 
absent. The coarse slow waves of active muscle movement are distinctive and 
the finer ones, though simulating auricular fibrillation, lack the distinctive absence 
of the "P" wave. 

The Electrocardiographic Leads. — The action of the heart produces 



THE ELECTROCARDIOGRAM 



521 



changes of electric potential throughout the entire body and for convenience 
one use? the extremities for making the connections necessary to tap the 
cardiac action currents. 

touring the records three so-called ''leads" are usually adopted: 

1. Right arm and left arm. 

:. The right arm and left leg, the most important lead, but all three are 
:ry to accurate differentiation and interpretation. 

3. Left arm and left leg. 

The electrocardiogram obtained varies slightly with the lead, one often 
yielding information not given by the others (see plates). The second lead 
is the one most generally useful, but in many instances the other leads are of 
especial value. 



Choice of 
leads. 




Fig. 220. — A diagram representing the .relationship of the heart to the three Leads. 
Lead II approximates most closely the long axis of the heart, and is the lead most commonly 
used. After John Hay. Modified.) 

The Auricular Complex. — In interpreting the electrocardiogram one must 
remember that it normally represents practically the current generated by a 
contraction starting in the auricle at or near the sino-auricular node (junc- 
tion of right auricle with the superior vena cava). 

This auricular contraction is registered by the electrocardiogram as the 
summit " P " representing a base negative effect. This is followed by a short 
"no-current" (isoelectric) phase which may be represented by a horizontal 
line, or by a slight (base positive) downward dip. 

The "P" wave probably represents the phase of sinus activity and the spread 
of the wave of contraction through the auricle. 

The Ventricular Complex. — The ventricular complex immediately follows 
and is characterized: 



Starting point 
of contraction. 



522 



MEDICAL DIAGNOSIS 



i. By the sharp base-negative upstroke instantly followed by a base-positive 
downstroke, these together forming "spiked" summit "R," which probably 
corresponds practically to the contraction of the papillary muscles, as it just 
precedes the heart sound. 

2. By a rapidly succeeding descent ("5") which may dip below the line 
and finally by a slower phase ("T") which presumably represents the terminal 
phase of ventricular contraction and ends just before the second sound of the heart. 

Thus it appears that auricular contraction is represented by the summit 
"P," and that ventricular contraction is expressed by the phases represented 
by "R" and "T" or to be more exact by "Q," "R," "S" and "T." 




Fig. 2 2i. — The normal and typical electrocardiogram. Showing nomenclature of Ein- 
thoven, in common use. {After Mutter.) 

VARIOUS INTERPRETATIONS OF THE ELECTROCARDIOGRAM. 

— Among the many conflicting interpretations of the electrocardiogram that 
of Hoffman is the simplest and clearest, and best lends itself to the student's 
memory and comprehension of the complicated and obscure phenomena. 
His hypothesis assumes that the electrocardiogram represents merely the 
variations in electric potential accompanying impulse conduction rather than 
the act of contraction. 

The "P" wave represents auricular conduction; the "P-R" interval covers 
the crossing of the auriculo-ventricular bridge ("His bundle"); depression of the 
intervening ("Q") wave marks the phase at which the papillary muscles first 



CARDIAC ARRHYTHMIAS 



523 





a.l!i cl$ cl2_ a,4 (1C. 1L Q,i 


J'\ \J' L U* j l/* 1 U* J »> *7 M' / 




*±., 


:~::;=::;zi::^~::==:=== 


"7 *" 


1 / \ n *■-.- 


EEEEEE^FEzEE^i^EEEEEEEEEEEEEEEE 


^ 2 5 ■ 2 \ 






« = ^ )ex - kCa= Hiari^^v^is 





Fig. 222. — Time relationship of the apex and carotid beats, heart sounds, and events of 
the electrocardiogram. (Miiller, slightly modified.) 









t 






fl T' 


D tt I D 


-X tt -=.-? ^«- P 


4* \ tt -.2 5 t ^=V 


, ^ v-azt *-,^ 5___2 5 


12* 


T^ 


■X U 


2 „2„ tt 


£ n - 


3 _J tt 




M -■■■■■■■■■■■■■*." 




HE E£ U2 B5 HE" US OX 







Fig. 223. — Time relationships of the electrocardiographic phases. 1. Electrocardio- 
gram. 2. Heart tones at apex of heart. 3. Heart tones at base of heart. 4. Ventricular 
pressure. (Miiller. slightly modified.) 



524 



MEDICAL DIAGNOSIS 



receive the excitation; the rise of the " R" peak denotes excitation of the bases of 
the ventricles; the "T" wave denotes the initiation of muscular relaxation after 
contraction. 

Wiggers thus summarizes with admirable brevity the various views now 
held with respect to the matter.* 

SUMMARY. — The following summary expresses the different interpre- 
tations that have been given to the different waves: 

The "P" wave accompanies (a) contraction of auricle, (b) conduction 
through auricle, (c) activity of sinus region plus conduction through auricle. 

The "R" wave (rise) accompanies (a) 
predominant contraction of right ventricle, 
(b) contraction of basal portions of both ven- 
tricles, (c) impulse conduction from base to 
apex of ventricles. 

The "R" wave (drop) accompanies (a) 
predominant contraction of left ventricle, (b) 
contraction of apical portion, (c) conduction 
from apex to base. 

The "S-T" interval results from (a) a 
balance of potential between left and right 
hearts, (b) a balance of potential between 
base and apex, (c) a balance between differ- 
ent layers of the heart, (d) an absence of further 
conduction because all muscle is already ex- 
cited and contracting. 

The "T" wave is due to (a) a change in 
the position of the heart (Uskoff), (b) a return 
of the contraction wave to fibers around the 
aortfr(Gotch, Nicolai), (c) a continued nega- 
tivity of base outlasting that of apex (Bayliss 
and Starling, and Einthoven), (d) the contrac- 
tion of no particular part but the entire expression of the electrical wave accom- 
panying the contraction of the ventricle (Samojlojf, Straub, Hoffman), (e) a 
diminution of the intracardial short-circuiting at the end of systole when the 
ventricle is empty. 

The "U" wave (not lettered) is a diastolic event, due to (a) the last relaxation 
of the fibers of the ventricle (Einthoven), (b) the electrical variation of the arteries 
(Hering). 

The Phonocardiograph.— By a relatively simple combination of a second 
galvanometer, microphone, stethoscope, rheostat, accumulator, and a trans- 
former, simultaneous electrocardiograms and phonocardiograms are obtain- 
able which are capable of showing both the volume and pitch of the murmur 
together with its exact place in the cardiac cycle and relation to the events 
of the electrocardiogram. 

* "Modern Aspects of the Circulation in Health and Disease," Carl J. Wiggers, 1915. 
An admirable exposition of the most recent work in this field. 



Registers time 
pitch and vol- 
ume of 
murmurs. 




Fig. 224. — Simple apparatus for 
registration of heart sounds and 
murmurs when attached to the 
electrocardiograph. It consists 
merely in the bringing of a micro- 
phone into circuit with the string 
galvanometer. 



ELECTROCARDIOGRAPHIC RECORDS 525 



MARKING AND INTERPRETATION OF ELECTROCARDIO- 
GRAPHIC RECORDS 

Systematic Procedure Indispensable. — The absolute necessity for 
proceeding in a systematic and orderly manner in the marking and inter- 
pretation of the polygram was emphasized in that chapter. 

While it is important there, it is even more important in regard to the 
marking and interpretation of electrocardiographic records. 

Time Record. — In all instruments the time is indicated in hundredths of a 
second. In the Hindle instrument, used by the author, it is indicated by 
main divisions of 0.20 seconds with sub-divisions of 0.04 seconds. 

General Description of Waves. — The important deflections in the electro- 
cardiographic record have been arbitrarily designated as P, Q, R, S, and T, 
waves as shown on page 522. Usually the P-wave is the first upward deflec- 
tion of the heart cycle. The Q-wave, which is frequently absent, is the 
first downward deflection immediately following the P-wave and occurring 
just before the tall R-wave, which is the second upward and the most promi- 
nent deflection. The S-wave is the second downward deflection and occurs 
immediately after the R-wave. The T-wave is the third upward deflection, 
occurs after the S-wave and indicates the end of the cardiac cycle. Follow- 
ing this is the diastolic period of rest, indicated on the record by a flat line 
extending to the P-wave of the next heart cycle. (See pages 522-524 
inclusive and accompanying illustrations.) The P-wave normally is a 
small wave 1.5 to 3.5 mm. in height. 

The R-wave is the tall narrow peak 5 to 25 mm. high. The width of the 
R-wave or the Q-R-S- interval is about 0.03 sec. 

The T-wave is normally a low broad wave 2 to 4 mm. high occurring from 
0.30 to 0.40 sec. after the Srwave. 

The length of the diastolic period of the heart following the T-wave is 
inversely proportional to the rapidity of the heart beat. 

Technic of Marking. — The only instrument necessary to the marking is a 
pair of needle-pointed dividers. 

1. Indicate the first lead by the numeral I, and follow this by the date, 
the patient's name, and any special circumstances surrounding the taking 
of the record, inasmuch as these are permanent records. Designate also by 
numerals Leads II and III. 

2. Identify and label in capitals the P, R and T waves, and the Q and S 
waves if they be present. Label the positive waves above the line and the 
negative waves below. (A positive wave is directed upward and a negative 
wave downward.) In this manner label three or four heart cycles in each 
lead. 

3. Determine the P-R interval. This observation is made first on Lead 
II and later, if necessary, on Leads I and III merely to corroborate the first 
finding. To determine the P-R interval place one point of the dividers on 
the base line at the first point of rise of the P-wave. The other divider 
point is placed on the first point of rise of the R-wave. The distance between 



S26 



MEDICAL DIAGNOSIS 






Fig. 



225. — Mr. J. B. Electrocardiographic record showing right branch block and an 
auricular extrasvstole. The extrasvstole occurs in Lead III. 



ELECTROCARDIOGRAPHIC RECORDS 527 



the two is the P-R interval of that heart cycle. This distance laid off on 
the time record will give its equivalent in hundredths of a second. The 
normal P-R interval is 0.12-0. 18 sec. Indicate the time length on the 
record in the proper heart cycle just below the base line. 

In a like manner determine the P-R interval of the remaining heart 
cycles of Lead II and label those showing a variation from the first reading 
if any be present. It is important to measure many P-R intervals, for a 
record may show considerable variation in them. This variability of the 
P-R interval in a record is of distinct clinical significance. 

4. Determine the rate of .the record. With the dividers lay off on the 
time record a distance equal to 3 seconds (15 main divisions on time records. 
Along the tops of the R-waves lay off a 3-second interval from the exact 
top of any one and count the R-waves occurring in that period. Then lay 
off another consecutive distance of ? seconds and continue the count. The 
result is the number of heart cycles in a 6-second interval as recorded by the 
time-marker. Multiplying the figure obtained by 10 gives the rate per 
minute. 

5. Determine the rhythm. With the presence of extrasystoles or fibrilla- 
tion, the arrhythmia is readily apparent. To determine sinus arrhythmia 
measure the distance between the tops of any two R-waves- and make com- 
parison with several other similar intervals. The variation in these intervals 
in a record otherwise normal indicates sinus arrhythmia in its varying 
degrees. 

Extrasystoles. — Extrasystoles may be auricular, ventricular, or nodal. 

1. Auricular extrasystoles show a premature contraction of the whole 
heart indicated on the record by a heart cycle occurring abnormally early in 
diastole, the only abnormality evident in the appearance of this heart cycle 
being some change in the P-wave, which is usually of the inverted type. On 
the other hand the P-wave may be upright and show a narrowing or flatten- 
ing, or may be diphasic; that is. showing both an upward and a downward 
deflection. 

The diastolic period of rest following the abnormally early heart cycle is 
lengthened, but is less than two heart cycles in duration (incomplete com- 
pensatory pause). 

2. The ventricular type of extrasy stole is characterized on the record by an 
abnormally appearing exaggerated diphasic wave; that is. extending both 
above and below the base fine. It stands out in striking contrast to the 
rest of the record. Bearing no relation to the stimulation or contraction of 
the auricles, the ventricular extrasystole occurs with no relation to the P- 
wave of auricular contraction. It is a premature heart cycle in which the 
impulse to contraction originates in the ventricles, not in the auricle. This 
ectopic impulse causes a contraction of (1st) the ventricle in which it origi- 
nates, and (2nd) a contraction of the opposite ventricle. This asynchronism 
of the ventricles, while very slight is sufficient to cause an absolutely character- 
istic electrocardiographic picture, and determine the ventricle, right or left, 
in which the aberrant impulse originates. One is able, therefore, by means 



528 



MEDICAL DIAGNOSIS 






Fig. 226. — Mr. G. D. Electrocardiographic record showing right ventricular extra- 
systoles and overaction of the ventricles in a slowly beating heart. Left ventricular pre- 
ponderance indicated in high R in Lead I and deep S in Lead III. Conduction time nor- 
mal. Slowing of heart due to digitalis. Exaggeration of T-wave shows overaction of 
ventricles. 



ELECTROCARDIOGRAPHIC RECORDS 529 



of the electrocardiograph to differentiate the side in which the ventricular 
extrasystole occurs, by the following characteristics. 

In Lead II a right ventricular extrasystole is indicated by an initial 
upward deflection, while the direction of the T-wave following is downward. 
A left ventricular extrasystole is indicated in Lead II by an initial downward 
deflection, while the direction of the T-wave following is upward. In 
other words the one is a mirror image of the other. The direction of all 
waves of the extrasystole occurring in Lead I may be opposite in direction to 
those occurring in Leads II and III. For example, a right ventricular extra- 
systole in Leads II and III would, in Lead I have the appearance of a left 
ventricular extrasystole and vice versa. 

The auricular contraction being unaffected as has been said before, the 
P-wave may be evident after the extrasystole or occur during the extra- 
systole, malforming its contour. 




Fig. 227. — Lead III. Three examples of right ventricular extrasystole as shown by the 

electrocardiograph. 

The pause following the ventricular extrasystole before the occurrence 
of the next heart cycle is equivalent to two heart cycles, spoken of as a com- 
plete compensatory pause. 

3. Nodal extr asystoles are premature heart cycles in which the impulse 
for contraction is supposed to arise in the auriculo-ventricular node instead 
of in the pacemaker, (sino-auricular node). These are indicated on the 
record by an abnormally early heart cycle normal in appearance with the 
exception that the P-wave is absent or merely suggested. The compen- 
satory pause following is equivalent to two heart cycles. 

A short run of nodal extrasystoles is spoken of as nodal rhythm. 

Fibrillation is characterized in the electrocardiographic record by the 
absence of P-waves, the occurrence of multiple coarse or fine undulations 
(fibrillatory waves), and an utterly disorderly rhythm in the occurrence of 
the R-waves. The latter show also considerable variation in height. 

Fine fibrillation is usually associated with the rapid rates while with 
coarse fibrillation we have usually a slower rate. The P-wave being absent, 
of course there is no P-R interval. 

34 



53° 



MEDICAL DIAGNOSIS 




Y ■'UZJHL liL 





'-IPillllll^ 




1 1 i ! A - ! is ! 1 



7T (IMZtZ 

MkJM 



E*Sj3. 









f « r 

"T^--*- -•-— -At ■ 



riY.rri irr 7/262/2 



Fig. 228. — Mr. I. H. Electrocardiograph record showing a right ventricular extra- 
systole in each Lead. The direction of the deflections of ventricular extrasystoles in Lead 
I is opposite to that of the deflections in the other two leads. 



ELECTROCARDIOGRAPHIC RECORDS 



531 



Block. — Heart block may be either complete or partial. In complete 
block there is an entire dissociation between the P-waves and the R (or S) 
waves, together with a slow ventricular rate, as indicated by the number of 
R- waves occurring in the 6-second interval. 

In this condition the complete block existing in the conducting fibres 
compels the ventricles to adopt their own, inherent, slow deliberate rhythm 
causing an occurrence of correspondingly few R (or S) waves. The con- 




Fig. 229. — Lead II. A short paroxysm of six beats shown electrocardiographically 
to be of A-V nodal origin. P-wave is inverted during the progress of the paroxysm, and 
the P-R intervals are shortened. Time in one-fifth of a second. (After John Parkinson.) 

duction through the auricles being unimpeded, they respond freely to the 
stimulation arising in the pacemaker (sino-auricular node). The result is a 
preponderance of P-waves over R-waves varying in degree with the ventricu- 
lar rate. An auricular rate of 75 may accompany a ventricular rate of 40 
to 20 or much less, for example. 



tiiitzti 



mmmm 



Fig. 230. — Mr. H. F. M. Lead III in a case of auricular fibrillation with a rapid 
ventricular rate. Left ventricular extrasystole is present. Note absence of P-waves, and 
inversion of T-wave. 

In partial block some of the auricular contractions get through and cause 
corresponding ventricular contractions. There is found a preponderance 
of the P-waves again but at definite intervals there is found a P-wave which 
has its normal relation to the R-wave. For example in 2 :i block every other 
P-wave is in its proper relation to the R-wave with an extra P-wave midway 
between these two. Here the auricles are beating twice as fast as the 
ventricles. In 3:1 block there are two extra P-waves between two normally 
placed P-waves, all of them being the same distance apart. 






MEDICAL DIAGNOSIS 





zfife,MfeE 

if I2.12.J4_ €*_? - ^«/e 




Fig. 231. — Mr. A. H. Electrocardiographic record of auricular fibrillation under the 
influence of digitalis. Xote the complete absence of P-waves and the presence of coarse 
tibrillatory waves (fff). The slow rate of 66 is due to the administration of digitalis. 
Arborization defect is indicated by the notching and widening of the R-waves. 



ELECTROCARDIOGRAPHIC RECORDS 










Block 







5 B S55 BS mSS ^RS ■ ■■ ■ ■ SB Bi TBTTTTRI i S?S ma£255 




. — M: 



Electrocardiographic records on a 16 



Id bov with mitral and 



aortic insufficiency and decided decompensation. 

A Shows a dropped ventricular systole. The conduction time before the period of 
block is 0.44 and 0.42 sec. and immediately after the rest-period of the Bundle of His is 
c. and then immediately lengthens to 0.2S sec. This shows the presence of extreme 
toxemia and the marked fatigability of the bundle. 

B Taken 6 days later still shows a markedly delayed conduction ('0.40 sec. > and sino- 
auricular block. This is simply an arrest of the whole heart and comparison with A wtD 
show "that the "period of rest is not preceded by a "lone " P-wave. as occurs in partial block. 

C Taken 4 months later after hospital regime, showing absence of all forms of block 
and reduction of conduction time to 0.22 sec. 



5 54 MEDICAL DIAGN 



In the less severe grades fewer and fewer ventricular contractions are 
missed until there may be a ventricular beat dropped only rarely. 

Sino-auricular block is indicated on the record by a temporarily arrested 
action, that is. the diastolic period is unusually long but the heart cycles 
preceding and following are both absolutely normal. 

It is customary to indicate the occurrence of events such as described 
above on the face of the record in the following manner: Right ventricular 
extrasystole — R.V.Ex.. left ventricular extrasystole — L.V.Ex., total block — 
T.B.. partial block— P. B.. fibrillation— f. f. f. sino-auricular block— S. A. B., 
etc. 

The reader will recall that the Bundle of His 'Conducting bundle) divides 
into two main branches, one for each ventricle, and that each of these in 
turn subdivides into many smaller branches, ending finally in specialized 
cells, called the Purkinje cells which are situated in the outermost portion 
of the ventricular musculature. Block may occur in any branch or sub- 
division, and is determinable by the electrocardiograph alone. 

In branch block the conduction of the impulse to contraction is inter- 
fered with in one of the main branches of the bundle of His. The electro- 
cardiograph indicates this condition by the following findings. 

i. An accentuation of the first and third leads; that is the deflections are 
wider here than in the second lead. 

2. The R-wave is widened (normally it is 0.03 sec). 

j. There is a notching of the R or S waves. 

4. The T-wave in the first and third leads is opposite in direction to 
that of the dominant wave of those leads. 

5. The general appearance of the second lead is that of a continuous 
ventricular extrasystole of the side opposite to that on which the block 
occurs. This has been taken by some as indicative of the side on which 
the block occurs, but this finding has been found not to be constant. The 
branch blocked is now more accurately indicated by the following finding 

In a block of the right branch, the first lead shows a high R-wave. with an 
inverted T-wave, while the third lead shows a deep S-wave with the follow- 
ing T-wave upright. 

In a block of the left branch. Lead I shows a deep S-wave. followed by an 
upright T-wave. while lead three shows a high R-wave with the T-wave 
following being inverted. 

In arborization block, one of the lesser branches is affected. The electro- 
cardiographic picture has the same essential features as that of branch block, 
but all are exaggerated. The difference is one of degree only. 

Arborization defect is a condition in which the terminal fibers of the 
"His" conduction system are affected. It is a much less important condi- 
tion than either branch block or arborization block, and is indicated on the 
records by a notching of the R- waves or the 5-waves. the rest being un- 
affected. It is usually interpreted as indicative of some impairment of the 
intrinsic circulation of the heart. Some writers believe it is due to local 
pathology. Robinson in a recent article assumes that it is due to the 



ELECTROCARDIOGRAPHIC RECORDS 










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Fig. 253. — Mr. J. K. Electrocardiographic record of right branch block. Right 
branch block is indicated 1 by a vertical accentuation of Leads I and III; (2) by a widen- 
ing of the V-R-S interval; and 3 by the inversion oi T-i. its direction being opposite to 
that of the dominant R-i; and T-iii upright in direction and opposite to the dominant 
S Hi . 



536 



MEDICAL DIAGNOSIS 



presence of acid metabolites which are the result of anything that inter- 
feres with nutrition of these tissues, be it fatigue, over-strain, sclerosed 
coronaries, or what not. 

Abnormalities in the P-wave. — Normally the P-wave is a small rounded 
wave, 1.5 to 3.5 mm. high. A P-wave higher than this is spoken of as an 
exaggerated P-wave. A wide and exaggerated P-wave is usually interpreted 
as indicating auricular hypertrophy, while a tall narrow one means usuallv, 
over-acting auricles. A definite notching of the P-wave is taken to indicate 
an asynchronism of the action of the auricles, This is a common finding 
in mitral stenosis. 

Immediately after the P-wave and before the R-wave, is an isoelectric 
(no-action) flat line. Frequently there is found here, however, fine oscilla- 
tions. These may stop just before the R-wave, or they may continue on 
past the R-wave and be evident up to the T-wave. This condition is 
spoken of as continued action of the auricle. 

Auricular disturbance is a term applied to the finding of indefinite 
undulations in the diastolic period of rest on the electrocardiogram, between 
the T and the following P-wave. 




Fig. 234. — Mr. A. M. Lead III of electrocardiographic record showing arborization 
defect as indicated by the notching and widening of the S-waves. 

The P-R Interval. — As has been said before, the normal P-R interval is 
0.12 to 0.18 sec. A lengthening of the P-R interval is spoken of as delayed 
conduction and this finding is of great clinical significance. The usual 
delayed conduction finding is 0.19 to 0.24 sec. The longest conduction 
period noted by the author is 0.42 sec. without actual block. 

Frequently there is found variation of the conduction period within the 
normal limits. This means that the impulse to contraction does not always 
start from exactly the same point. 

The T-wave. — This is the last wave of the heart cycle and usually is a 
positive wave, from 2 to 4 mm. high. The inversion of the T-wave in the 
first lead, the first and second, or the first second and third leads is very 
important from the standpoint of prognosis, and is thought to indicate the 
presence of one of the graver heart conditions, making the prognosis less 
favorable. Inversion of the T-wave in the third lead alone is of no practical 



ELECTROCARDIOGRAPHIC RECORDS 



537 




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Fig. 235— Miss L. H. Atypical electrocardiographic record in a 14-year old girl with 
mitral stenosis. P-ii is exaggerated and wide showing the auricular hypertrophy. The 
typical notched P-wave of mitral stenosis is flat-topped. Slight notching of the P-wave, 
indicative of asynchronism of the auricles, can be made out here and there. The conduc- 
tion time is delayed, being 0.18-0.20 sec. Right ventricular preponderance is indicated 
by the deep S-i and the high R-iii. The deep S-ii shows the asynchronism of the ven- 
tricles. 



538 



MEDICAL DIAGNOSIS 



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Ftg. 236. — Mr. T. C. Electrocardiographic record of over-digitalization. This con-, 
dition is characterized by an inversion of the T-wave in all Leads together with a delayed 
conduction. 



ELECTROCARDIOGRAPHIC RECORDS 



539 



significance. The inversion of the T-waves due to digitalis must not be 
lost sight of however, and it is usually readily distinguishable from the other 
types. It follows the administration of digitalis, and besides the inversion of 
the T-wave in all leads, there is also a delayed conduction. The sudden 
development of this picture in an electrocardiogram, should call for immediate 
cessation of all digitalis administration. 

Inverted T-waves are of two types, (i) That type which is the mirror 
image of an upright T-wave, and (2) that type in which there is a negative 
wave which begins earlier than the rise of the usual upright T-wave. This 
negative phase then rises, and becomes actually a positive phase, small but 
definite, ending at the usual time for termination of the T-wave. 

Ventricular Preponderance. — In ventricular preponderance, there is 
increased muscle mass, in one or the other ventricle, over that normally 
found. This increases the conduction time through the affected side, the 
result being the loss of the normal unison of action of the two ventricles 
and a characteristic electrocardiographic picture, depending upon the side 
involved. In preponderance of the right ventricle, there is found a deep 
S-wave in the first lead, while the third lead shows a dominant R-wave. 
In preponderance of the left ventricle, the picture is the mirror image of 
this and shows a dominant R-wave in the first lead with a deep S-wave in 
the third lead. 

Asynchronism of the ventricles is indicated by an S-wave in the second 
lead. 

Auricular Flutter. — This is a condition of extremely rapid, rhythmic 
auricular contractions associated with a partial block and occasionally 
with alternation (alternately higher . and lower R-waves) . An associated 
block may give rise to a 2:1, 3:1, 4:1, or in rare instances even 6:1 ratio 
between the recorded auricular and ventricular waves (auricular = P, 
ventricular = R and T, or S and T-waves). This condition is accurately 
determinable only by instrumental methods. (See page 555 and 556.) 

Paroxysmal Tachycardia.— This condition is characterized by a sudden 
outburst of rapid action of the whole heart and its abrupt termination after a 
period of minutes, hours or days duration. It is usually, if not always, 
initiated by extrasystoles of auricular origin. Rarely it is said to be ven- 
tricular in origin. (See page 559.) 

Special Conditions. — The infantile type of heart is a centrally placed, 
low-lying heart. The electrocardiographic record in these cases is said to be 
characterized by a minute first lead, the other two leads being of the usual 
height. 

Hearts having a congenital defect are said to give characteristic electro- 
cardiographic records, and the unusually wide R-waves, together with evi- 
dences of hypertrophy in one of the chambers are taken as the indications 
of this condition. 

Conditions of hypotonus of the myocardium are indicated on the electro- 
cardiographic record by unusually low P and T-waves throughout the 
entire record. 



Over- 
digitalization. 



54Q 



MEDICAL DIAGNOSIS 



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Fig. 237. — Mr. G. Mc. Electrocardiographic record 'showing left ventricular pre- 
ponderance in a typical "drop" heart of a 36-year old rrale. The preponderance of the 
left ventrical is indicated by the high R-i and the deep S-iii. 



ELECTROCARDIOGRAPHIC RECORDS 



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Fig. 238. — Mr. H. L. Electrocardiographic record in a case of typical "soldier's 
heart" 'exhausted insufficient •"drop" heart) occurring in a 16-year old male. V-wave in 
Leads II and III shows marked continued action of the auricle. Conduction time is nor- 
mal (0.15 sec. j. Right ventricular preponderance is indicated by a deep S-i and a high 
R-iii. 



542 



MEDICAL DIAGNOSIS 



An arching of the T-P interval, which is usually flat, is said to indicate a 
hyperthyroid condition. It is spoken of as the hyperthyroid type of record. 

Myocarditis is said to be indicated by an abnormally low lead II, 
the first and third leads being normal in height. 

































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Fig. 239. — Mr. F. F. Electrocardiographic record showing hypotonus. This is indicated 
by the marked flattening of both the P- and T-waves throughout the entire record. 

Alternation, a condition very important from the standpoint of prog- 
nosis, may be indicated in the electrocardiographic record, by alternating 
inequality in the height of the R-waves. This rinding is not constant, the 
polygram being much more dependable, but when it is shown, it is clearly 
shown. (See pages 516 and 561.) 



CARDIAC ARRHYTHMIAS 



543 



CARDIAC ARRHYTHMIAS 



-The simplest is that of von Tabora, who 



retained fundamental rhythm 
(premature contractions) . (b) 



Occasiona 
great value. 



A common 
arrhythmia. 



Classification of Arrhythmias, 
divides them as follows: 

i. Arrhythmias usually associated with 
(par arrhythmias), viz.: (a) Extrasystoles 
Impaired conduction (heart block). 

2. Arrhythmias resulting from causes which abolish the fundamental 
rhythm [true arrhythmias), viz.: (a) Extracardial (sinus) arrhythmias (char- 
acterized chiefly by equality of force co-existing with variations in the length 
of the diastolic periods), (b) Intracardial arrhythmia, viz. : auricular fibrilla- 
tion ("arrhythmia perpetua," "delirium cordis"). 

Paroxysmal tachycardia and alternation are not properly arrhythmias 
but represents respectively: the one, abnormal acceleration; the other, 
rhythmic variations in the force of the contraction. 

ANALYSIS OF THE ARRHYTHMIAS.— Clinical Importance.— In most 
cases the direct clinical information afforded is not great save in the case of 
auricular fibrillation, yet certain important deductions may be drawn and 
at times accurate and more timely diagnosis or prognosis made possible, if 
one can readily differentiate the arrhythmias, with the various ingenious 
instruments now available for research and teaching. 

EXTRASYSTOLIC ARRHYTHMIA (Premature Contraction).— The extra- 
systole is an abnormally hasty, inefficient contraction initiated by misplaced 
stimuli which may be generated at any point in the heart muscle or its conduction 
system. It introduces not an additional beat, but merely a premature one without 
vitally altering the fundamental rhythm, as may be determined instrumentally 
or, usually, by auscultation of the heart. . " 

The extrasystole may or may not carry its wave into the radial artery. 
The untimely precocious beat is not an extrasystole actually for it merely 
replaces the one which should come at the normal time and is followed 
usually by a long pause which is practically equivalent to the displaced full Compensatory 
cycle plus the shortened diastole of the premature systole. If the latter I pau 
does not carry to the radial the pulse intermission equals two complete 
cycles. 

Frequency of Extrasystolic Contractions and Their Direct Cause. — These 
and the auricular fibrillations are the commonest irregularities associated 
with cardiac disease and result from irritability or an extreme stimulation 
of the whole, or some portion of the myocardium or conduction system 
which releases the hasty aberrant and ineffectual contractions before 
the proper filling of the heart chambers is completed and causes an elision of 
the normal systoles which these premature contractions anticipate and 
replace. 

One encounters extrasystoles originating in the sinus, auricle, auriculo- 
ventricular node, ventricle, or bundle of His. Each may be differentiated 
as to its point of origin by modern instrumental methods and the com- 
monest (ventricular form) at times, by the unaided sight. 



Abnormal loci. 



Points of 
origin. 



■ — 



MEDICAL DIAGN 



Extrasystoles may be rhythmic and persistent in their appearance or 

come at longer or shorter intervals between which the heart maintains a 

normal rhythm- 
Means of Recognition. — They may be palpable at the wrist, absent at 

the wrist and present in a tracing, or detected only by the stethoscope, poly- 

zzizl :: ele::r: ;i:i:;z:'-z ~. 




Frustrated Contraction. — In most instances the first- and second sounds 
1=5: ::i:e : ~ izz iz± pre— i:-r ::z.-zi:. : . z. :-.:z : ::ji iui:;.r :_: in — my :-e 
extrasystole is too weak to open the aortic and pulmonary valves and only 
the first element of such a "frustrated" heart contraction is heard. In 
such cases the pulse intermits and the single sound audible may usually be 
identified by the ear alone as a frustrated premature contraction. Only in 




"2 Z _ I Z. . .-"':"" _ ■-. '"_ : ." .". .' r 



tone is a similar sound 



xal stenosis with a protodiastolic third he 
lible at the apex. 
It is obvious that in certain instances of valvular insufiiciencv or stenosis 



CARDIAC ARRHYTHMIAS 



545 



sound may be lacking over its area oi normal maximal audibility even 
though contractions are registered graphically.* 

Intermittent Pulse. — It is evident that dropped pulse beats due to extra- 
systoles constitute a form of intermittent pulse. 

Ventricular Extrasystolic Intermittent Pulse. — When occurring regu- 
larly after each full beat and followed by a full compensatory pause (paired 
beats with pause' 1 and when strong enough to raise the aortic valve and be- 
come palpable at the wrist, they cause the full pulsus trigeminus. Extrasys- 
toles of auricular origin show a pause slightly less than that of ventricular 



Bigeminal 
pulse. 



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Fig. 242. — Extrasystole P. R. originating in left ventricle (lead III). In ventricular 
extrasystolic "premature." "ectopic." •"heterogenous", contraction, the wave of contrac- 
tion spreads from the abnormal point of initial stimulus production to the other chambers 
of the heart, not from the sinus node and auricles. This results in a wide departure from 
the normal electrocardiographic complex representing the heart cycle or cycles affected. 
Obviously (.a) the entire diphasic wave will be large and protracted, as compared 
with the normal and (b) the anticipated, rhythmically recurrent "P" wave of auricular 
activation is submerged or buried. As between extrasystoles of right and left ventricular 
origin respectively it is known thai an initial asct>:: :;' the "JR M wave represents initial right 
ventricular stimulation; an initial descent, left ventricular initial stimulation. In both 
instances the diphasic "R" wave is of exaggerated dimensions. The characteristic fea- 
tures then are: 1 The absence of the "P M wave from its normal position. [2 An exag- 
gerated broad based "R" summit. 5 An " R ward deflection) in right ventric- 
ular extrasystoles: an -- R" downward deflection in left ventricular extrasystoles. 
(4) A pause equal to two complete normal heart cycles, by reason of the substitution of the 
extrasystole for one normal heart cycle and its interruption of the rest period of the preced- 
ing cycle. There are many variants in the form of double consecutive extras; 5:: 
very rarely two such successive premature contractions may arise in the right and left ven- 
tricles respectively as shown in one of the electrocardiograms taken by Dr. R. Edwin Moms 
(Figure 243). If ventricular extrasystoles are double, or if a premature contraction is 
auricular in origin, the compensatory pause is less than two full heart cycles. 



form. It is obvious that the beat following the prolonged pause will be often- 
times of unusual amplitude because of the prolonged resting period. 

Underlying Factors. — Aside from experimental stimulation, the extra- 
systole is a common event in cardiac disease, when the walls are dilated or 
the heart is working against high pressure. 

A dilated and usually degenerated ventricle, in the presence of an excess 
of residual blood (imperfect emptying, overdistention \ failing reserve power, 
arid, perhaps, a coincident increased peripheral resistance, may become highly 
excitable and generate its own impulses independent of the pacemaker. 

* In a case of combined congenital and acquired heart disease examined by the author 
just before writing this note both the pulmonary and aortic tones were wholly lacking 
35 



Effect of 

overload. 



Toxemia. 



546 



MEDICAL DIAGNOSIS 





" So also with an auricle overdistended by reason of an obstructed or insuf- 
ficient mitral or tricuspid valve. 

Yet again, toxic influences may similarly affect temporarily even the 
otherwise normal heart (digitalis, gastrointestinal subinfections, the causa- 
tive agents of acute infectious disease and their toxins). It is also said to 
occur in the wholly normal heart, but unless it be due to excessive distention 
of the stomach or colon or in advanced pregnancy such a statement would 
seem at least debatable. 

Clinical Significance of Extrasystoles. — That these not infrequently occur in 
persons in whom no heart lesion can be demonstrated at the time admits of no 
doubt, nor can their presence and persistence be considered a grave symptom in the 
absence of other signs of serious cardiac impairment. They may exist for years 














































































































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Characteristic 
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merpolated 
extrasystoles. 


Fig. 244. — "Interpolated" right ventricular extrasystole. Compare with left ven- 
tricular systole (Fig. 242). The "P" of the perverted cycle is submerged in the 
exaggerated "R" wave in both instances. Note that the extrasystolic contraction of 
abnormal origin happens to fall in with the rhythm of the normal cycles. Hence, the ab- 
sence of the usual compensatory pause. {After Thos. Lewis. Lines of original deepened.) 

unattended by demonstrable gross myocardial disease, but so may the commonest 
forms of myocardial degeneration. 

Miniature Murmurs. — If lesions of the valves exist and the strength of 
the extrasystoles is sufficient, murmurs in miniature may occur with prema- 
ture contractions, save in the case of mitral stenosis. 

Extrasystoles of Ventricular Origin. — These are most common and are 
characterized (a) by a remarkably constant time interval representing the 
period between the beat just preceding the substituted premature contrac- 
tion and that regularly following the one which the extrasystole has antici- 
pated, (b) by a large, single, jerky, venous wave which is the auricular wave 
of the anticipated systole acting against auriculo-ventricular valves closed 
by the extrasystolic contraction. This when present sweeps from the 
jugular fossa over the sterno-mastoid muscle. 

Exception. — In bradycardia (slow pulse) if the premature contraction 
is very early the compensatory pause may be absent because the regular 
beat escapes full elision and takes its proper place in the cycle, time enough 
having elapsed between the ventricular extrasystole and the period of normal 



CARDIAC ARRHYTHMIAS 



547 



auricular excitation of the true contraction to enable the muscle fibers to 
partially recover from the " refractory stage." Such imperfect normally 
timed contractions are called ''interpolated" extrasystoles but the term 
"interpolated ventricular contractions" is preferable as they are not prema- 
ture but correctly timed. 

Electrocardiographic Differentiation of Extrasystoles. — The electro- 
cardiogram is characteristically altered in event of the presence of premature 




Fig. 245. — Extrasystolic tachycardia. Remarkable occurrence of one right and one left 
ventricular extrasystole in direct succession. (R. Edwin Morris.) 



^^^^^^^^^^^^ 



Fig. 246. — Right ventricular extrasystoles (ex). "R" summit high; sharp drop down- 
ward. Giant "peak." Lead II. 

contractions and shows decided differences not only as to their auricular ! Eiectro- 

... . cardiogram _ 

or ventricular origin, but also as between those originating in the right and and polygram, 
left ventricle respectively. 

Thus with lead II right ventricular extrasystoles are indicated by an 
extremely high "R" summit followed by a deep "S" descent. 

Left ventricular extrasystoles are indicated by an extreme dip "Q" 
preceding "R" which is also decidedly higher than normal. In lead I the 



548 



MEDICAL DI 



characteristic deflections, with rare exceptions, are reversed, i.e., they are 
mirror images of the deflections encountered in leads II and III. 
Electrocardiographic section for further discussk : 

The Auricular Extrasystoles. — These invariably produce ventricular 
response in the form of a premature contraction and show usually " shortened 
bigemini" in the pulse waves if the extrasystoles are carried through to the 
wrist, inasmuch as the so-called '"compensatory" pause rarely or never is 




n n n 




X X 



Fig. 247. — A beautiful example of ventricular extrasystolic arrhythmia showing pulsus 
bigeminus (z) and trige m ir.u: g :: aether with the typical corresponding jugular tracing. 
Right jugular above; right radial belo-v. u n" indicates the normal radial beats. 
R. Ed:: in Morris.) 

quite complete.* If they originate in the neighborhood of the great veins or 
sinus node, the pause is that of the normal rhythm. They are associated 
with a double jugular wave in the polygraphic tracing and the electrocardio- 
gram shows an inverted imperfect or superimposed auricular complex 
"P" wave . the last being due to so premature an impulse as meets and 
coincides with the B T" of ventricular systole in the electrocardiogram. 



M MP5 Js 



Fig. 248. — Inverted K T M in an apparently normal heart. {R. Ed^in Morris.) 

It is obvious that extrasystoles of shortened pause are of auricular origin 
and that a pause reduced to that of the normal rhythm indicates the sinus 
region as the point of origin. 

Extrasystoles from Bundle of His. — In this type the auricular and ven- 
tricular systoles may or may not fall absolutely together. These are recog- 

* Lewis believes that they are in some instances fully compensator)' but he says that 
"if in the case of any premature contraction the pause fails to be compensatory then such 
a (premature) beat has arisen in the auricle" adding in a footnote that the interpolation 

cases are excepted. 



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CARDIAC 




ARRHYTHMIAS 




















549 


d with difficulty in polygraphic tracings by their prematurity and the 
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undisturbed ventricular complex and a buried auricular complex. The 
cal electrocardiogram is by no means constant. 




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Fig. 249. — Normal electrocardiogram inserted here for contrast and comparison. 

Clinical Significance of the Auricular and Ventricular Extrasystole. — 
Premature auricular contractions are most frequently encountered in primary 
myocardial degeneration and in mitral stenosis. 

Premature ventricular contractions also occur most frequently in myo- 
cardial degeneration alone or as associated with aortic and mitral lesions. 


























































































































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associations. 



55° 



MEDICAL DIAGNOSIS 



Proper " 
viewpoint. 



Sign of 
overstrain. 



Prognostic 
value. 



As previously stated, persistent extrasystolic irregularities may occur in 
persons apparently healthy, but the student should not lose sight of the fact that 
Thomas Lewis has reported but three such instances out of a group of ninety-seven 
cases investigated, and furthermore, that of the remainder seventy-one cases were 
definitely those of cardiovascular disease. 

Extra-systoles are probably to be regarded precisely as one should view heart 
lesions in general, viz., as conditions not of themselves and of necessity proving 
the presence of a dangerous or threatening condition but as morbid phenomena 
strongly suggesting toxemia or structural deterioration and overload and as such 
always demanding a thorough and painstaking investigation of conditions.* 

Certainly premature contractions do not often occur persistently in a 
heart which is sound, fully competent, and well nourished, and the author 




Fig. 251. — Auriculo-ventricular (junctional) extra systole; originating in junctional 
tissues. A long pause follows, then a normal cycle, then a right ventricular extrasystole. 
Mitral stenosis is indicated by the "P" summits (truncate or split) and the effect of 
digitalis administration by the constantly inverted T. 

has rarely encountered it save in decided toxemias and intoxications, frank 
cardiac or renal disease, or the overstrained, undersized, flabby, and in- 
sidiously dilating hearts of congenitally asthenic and nutritionally depressed 
or unstable individuals. 

Furthermore, the onset of marked extrasystolic irregularity in known 
cardiopaths, formerly free from it, may be an ominous symptom and its 
disappearance under treatment a favorable sign. 

Useful Maneuvers. — It should be remembered that holding the breath, 
manual or postural increase of intra-abdominal pressure, and the erect posture 
will often bring out any latent tendency to extrasystolic beats. On the 
other hand, the abrupt assumption of the erect posture, exercise and even 
excitement or fear may temporarily abolish such an arrhythmia even if 
present primarily. 

A pulsus alternans is occasionally present in connection with them, and 
irregular extrasystolic beats, or in fact any of the extrasystolic phenomena 

* The author has seen many cases of long-enduring extrasystolic irregularity, but rarely 
or never in persons presenting a perfectly clean bill of health. It is quite possible that in 
Great Britain toxic cases, of gouty origin, are especially frequent, which assumption may 
account for the optimism of so distinguished an authority as Mackenzie. 



CARDIAC ARRHYTHMIAS 



551 



are usually associated with a relatively slow or bigeminal radial pulse by 
reason of the frustrated beats. 

Their abrupt disappearance when instrumental recording is attempted 
is one of the trials often encountered by the medical investigator. 

AURICULAR FIBRILLATION {Delirium Cordis).— In this important 
condition there is a veritable riot of abnormal futile and abortive contraction 




Fig. 252. — An extremely well-marked case of auricular fibrillation. The normal "a" 
wave of auricular systole is wholly lacking, and replaced by small diastolic undulations 
(fff). 

waves in the auricle, the result being a continual fibrillary flickering of the 
muscle and an entire loss both of effective rhythmic transmission and coor- 
dinated muscular contraction. 

Myriad impulses of the most feeble, irregular, hasty, and imperfect sort, 
crowd upon the ventricles at a rate far exceeding the possibilities of complete 
transmission, and such as can achieve transmission excite these chambers to 









































































































































































































































































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Fig. 253. — Auricular fibrillation. Note very decided oscillations (f f f) due to fibrilla 
tion; evidence of absolute irregularity and inequality shown in the varying height of "R' 
summits and spacing of cycles; absence of "P" in every cycle, indicating lack of efficient 
auricular impulses to contraction. Pulsus irregularis perpetuus or delirium cordis evident. 
Record taken over auricles. (After Thos. Lewis.) 

rapid, irregular and unequal contractions which are nevertheless, in toto, 
sufficient in many instances to maintain a circulation of some effectiveness 
over long periods. 

The auricle itself is meanwhile dilated in the diastolic position and is as 
utterly unable to maintain an efficient contraction of its own musculature, as it 
would be in a state of actual paralysis. 



Fibrillary 
flickering. 



Delirium 
cordis. 



Blocking and 

unregulated 

escape. 



552 



MEDICAL DIAGNOSIS 



Polygram and 
electro- 
cardiogram. 



As a result the normal presystolic venous pulse (represented by the 
"a" wave of the polygram or "P" wave of the normal electrocardiogram) is 
faint, lacking, or substituted by a systolic wave in the jugulars, the feeble 
auricular nickering may be revealed as an undulating line in the polygraph] c 
tracing, and in the electrocardiogram by a complex in which the auricular 




Fig. 254. — Auricular fibrillation; right ventricular extrasystoles. Auricular fibril- 
lation (f). Right ventricular extrasystoles (Ex). Pulsus bigeminus was evident in 
the rhythmic pairing of a normal beat with an extrasystole. Lead I. Time Y^ sec. 
(R. Edwin Morris.) 

(presystolic) "P" wave is absent and represented only by this rippling un- 
dulation and a hurried, irregularly spaced and unequal ventricular complex 
("QRS").* 

If in a case of auricular fibrillation the bundle of His {atrioventricular 
conduction bundle) be normal, the heart rate is doubled or trebled, though the 
ventricular contractions are haphazard, the pauses of varying length and 






s ff$ 



#**f f f ,:--f 



Fig. 255. — Auricular fibrillation. (R. Edwin Morris.) 

the beats unequal. If, however, the conduction bundle is diseased, a block 
may be evident and the pulse may drop to 40 or less per minute. 

In- all pulses of less than double the 'normal rate and showing the other 
characteristics of fibrillation, pronounced digitalis effect being excluded, heart 
block from other causes may be assumed as a factor. 

The commoner pulse rate in auricular fibrillation is about 120 to 140, 
and nearly all markedly irregular pulses of this rate result from this condition. 

* Unless heart block is present. 



CARDIAC ARRHYTHMIAS 



553 



The efficacy of digitalis is peculiarly marked in most but not all such 
cases in which the pulse rate equals or exceeds 120. 

A careless observer may overlook fibrillation with slowed pulse; indeed, 
in some cases its presence cannot be positively affirmed without instru- 
mental aid. 




Fig. 256. 



-Normal electrocardiogram inserted here for purposes of contrast and 
comparison. 




Fig. 257. — Lead I. 




Fig. 258.— Lead III. 

Figs. 257 and 258. — Auricular fibrillation with left ventricular : extrasystoles. Left 
ventricular hypertrophy is indicated by large "R" and absent or small "S" in lead I, 
and small "R" and large "S" in lead III. Fibrillation is evident (f f f); "P" (of auricular 
contraction) is absent; T is inverted from digitalis effect. 

It has been said that angina pectoris and fibrillation cannot coexist 
and the onset of the former condition and its persistence completely 
removes the tendency to anginal attacks. 



554 



MEDICAL DIAGNOSIS 



Importanrfact. 



Frequency of 
occurrence. 



In the light afforded by recently reported cases, one must assume at 
least this rule is subject to exceptions. 

Any considerable exertion or even quick change of posture such as so 
often suffice to temporarily remove or to bring out extrasystolic irregularity 
represent maneuvers which are not without risk in severe incompensation, 
and this is especially true of cases showing the delirium cordis* of auricular 
fibrillation. 




Fig. 259.— Auricular fibrillation. The absence of all evidence of auricular contraction is 
manifest. Fibrillary wavelets are shown (f f f +). 

Cases of auricular fibrillation constitute over 40 per cent, of the total 
arrhythmias encountered in a general hospital and it is most commonly as- 
sociated (50 per cent, of cases) with mitral stenosis. It is common in 
other conditions in which myocardial degeneration, cardiac decompensation 
and prolonged chronic overstrain are marked features, i.e., advanced myo- 
cardial degeneration alone (20 per cent.), aortic lesions, chronic diffuse 
nephritis with arterial hypertension or arteriosclerosis. 




R.R 



Fig. 260. — Arrhythmia, pulsus bigeminus of extrasystolic type; fibrillation, n, Nor- 
mal beat; Ex, l.v. extrasystole producing bigeminal pulse; f, fibrillation waves from auricu- 
lar fibrillation; RJ, jugular pulse; R, radial. Time % sec. 

In all of these the myocardial change is doubtless the chief factor and in a 
public clinic nearly three-fourths of those specifically cardiovascular indoor 
cases admitted who show severe incompensation and associated arrhythmia will 

* The secondary slowing of the pulse which follows the primary acceleration induced 
by exertion is usually lacking in this condition but, if present, decreases fibrillation, though 
it usually increases other arrhythmias (Lewis). 



CARDIAC ARRHYTHMIAS 



555 



show auricular fibrillation. (In the author's clinic at the University Hospitals 
nearly 90 per cent, were of this type.) * 

Unquestionably a great number of unrecognized temporary and even 
fleeting attacks of fibrillation occur and, no doubt, there is a tendency to 
more frequent recurrence and longer persistence of the individual attacks 
prior to its appearance in an established form. 

Once fully developed, it tends to persist throughout the after-lifetime 
of the victim but this rule also is subject to exceptions. 

As in the case of auricular flutter, embolic manifestations occasionally 
follow the resumption of normal rhythm. 




Fig. 261. — Electrocardiogram. Same case as Fig. 254. R, normal "R" wave; Ex, 
extrasystole, ventricular type; f, fibrillation; time 3^o sec. showing exact nature of extra- 
systole in Fig. 254 and absence of "P" wave and presence of fibrillation "f". 

AURICULAR FLUTTER. — This term is of recent introduction and covers 
cases of suddenly initiated i excessively rapid auricular contraction exceeding 
200 to the minute and reported as high as 420. 

It may continue for months or years only to cease as abruptly as it came 
or occur in brief attacks lasting for a few hours. The pulse rate is usually 
one-half that of the auricular contractions but various degrees of block are 




^wl/uJ 



Fig. 262. — Auricular arrhythmia due to auricular fibrillation. The cause of the 
greater proportion of cardiac arrhythmias, "f f " indicates auricular waves of fibrillation. 
Upper line jugular, lower line radial. Time 3^ sec. The "Pulsus irregularis perpetuus" 
and "delirium cordis" are beautifully shown in the radial. 

manifest and the ventricle may respond to only the third, fifth or eighth 
auricular contraction. 

It not infrequently passes into auricular fibrillation spontaneously or as a 
result of digitalis administration (Lewis) under which the existing block is 

*The most responsive cases of fibrillation from the therapeutic standpoint seem to 
be those in which it is initiated by unusual effort or acute toxemia. (R. E. Morris.) 



Duration. 



556 



MEDICAL DIAGNOSIS 



Digitalis 
phases. 



Suggestive 
resemblances. 



Relatively un- 
common. 



heightened purposely, the ventricular rate falling first with irregularity, 
then into a regular rhythm of lower rate; then into fibrillation. At this 
point the drug is discontinued and in "a large proportion of cases" the 
regular heart action returns and any preexisting cyanosis, engorgement or 
dropsy "vanish quickly" (Lewis I.* 

The occasional occurrence of embolic manifestations following the resump- 
tion of a normal rhythm is a fact of clinical interest and importance. 

Apparently it is closely allied to paroxysmal tachycardia. It is frequently 
associated with alternation. It is next neighbor to auricular fibrillation 
and may pass into that condition spontaneously, but nevertheless is still 
dealt with as a distinct clinical phenomenon. 









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Fig. 263. — Case of auricular nutter. Auricular contractions were 310 per minute; ven- 
tricular rate, 120. 

Frequency and Causation. — It is a relatively uncommon condition! and 
its causes are essentially those described under auricular fibrillation save 
that it more distinctly affects the middle-aged or elderly and seems especially 
common in cardiosclerotic degeneration. 

Diagnosis of Auricular Flutter. — The electrocardiograph alone furnishes 
constant and positive diagnostic results, yet one may in some instances make a 
correct diagnosis by other means. 



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Fig. 264. — Auricular nutter. The ventricle is responding only to alternate auricular 
stimuli. Auricular rate, 324 per minute. (After Thos. Lewis.) 



The Venous Pulse in Auricular Flutter. — In some cases the condition 
is clearly indicated by visible excessive rapidity of the venous pulsations 
or the multiplicity and rapidity of "a" waves in the polygraph. The auricu- 

* The frequency of failure of such medication to produce this result would seem to have 
been somewhat underestimated. Certainly many cases are wholly unaffected. 

f Thos. Lewis and Mackenize find it common, but in the author's clinic it was encoun- 
tered very rarely unless one followed Satterthwaite's dictum, which declares all countable 
auricular contraction rates above 200 to be ,; flutter." 



CARDIAC ARRHYTHMIAS 



557 






RJ. 



^aaJWjwJV^ 



/CLajuJ^ 



J 10 ". 26 5 - — Passa S e fr° m flutter and state of general arterial anemia and venous stasis or 
fibrillation. Profound cardiac decompensation. (RJ. = right jugular. R.R. = right 
radial. 

i. "Running" pulse barely palpable; rate 168 per minute; jugular waves enormous. 

2. After 24 hours treatment with digitalis by Eggleston's method. Radial now pre- 
sents a definite pulse of 156 beats per minute. Jugular less intense but lacking "a" waves. 

3. Twenty-four hours later. Radial shows clearly the characteristics of fibrillation 
(' pulsus irregularis perpetuus")', "a" waves wholly absent from venous tracing. Pulse 
rate 132. 

4. Twenty-four hours later. Pulse rate 108; less arrhythmic; fibrillationclearly shown 
by minute waves (f f +) in jugular tracing. 



^8 



:>:> 



MEDICAL DIAGNOSIS 



Functional 
block. 



lar pulsations are so rapid as to surpass the conduction capacity of the His 
bundle or the possibilities of recovery and response on the part of the ventri- 
cles, and, therefore, save in the rarest instances, such cases show a relatively 
low pulse rate; 240 or even 400 aurciular contractions to but 60 or even 30 
ventricular beats being present. If the block, or as one might say, the 
inadequacy of the conducting bundle, is less marked, the rhythm may be 
and usually is definitely 2-1, in which case, of course, a rapid radial pulse is 
present. 

The polygraphic tracing may show clearly the excessively rapid produc- 
tion of distinct or even large "a" waves occurring in the various auricular- 
ventricular ratios common to the "block" usually present in this condition. 

This statement applies chiefly to cases in which the arterial pulse 
is distinctly slow, and the veins of the neck are yielding good auricular 
pulsations. 




Fig. 266. — Same case three months before. Electrocardiogram shows fibrillation and 
right ventricular extra.svstoles. 



Occasional 
excessive 
ventricular 
rapidity. 



Paroxysmal 
tachycardia 
and alter- 
nation. 



Distinguished 

from 

fibrillation. 



If, as occasionally happens, the auricular rate is under 300 and the 
ventricle responds to every auricular contraction, an uncountable, excessively 
weak radial pulse results, together with symptoms of profound incom- 
pensation, syncopal attacks, or coma and death. 

The electrodiagrams show the same characteristics and it is usually clearly 
distinguished from auricular fibrillation by its lack of the extreme erratic 
variability both in the pauses and in the heights of the "R" summits 
characteristic of its congener. 

The equality in time, large and uniform size and regular occurrence of the 
'•flutter" waves are points of importance in differentiation. 

Under such conditions the pulse characteristics of paroxysmal tachycardia 
are actually present and, very frequently, the excessively rapid beat often slims 
distinctly an alternating strength and weakness (pulsus alternans) if instrumen- 
t-ally recorded. 

Symptoms. — It will be noted that the extreme irregularity of interval 
so marked in fibrillation is ordinarily absent in these cases, the ventricular 
response being usually, but by no means always, rhythmic. As in paroxysmal 
tachycardia these cases may show arterial anemia and venous stasis. 

Recurring periods of high pulse rate of which the patient is conscious, 



CARDIAC ARRHYTHMIAS 



559 



lasting for days or weeks, attended by distinct evidences of cardiac decom- 
pensation, yet unlike the wholly delirious arrhythmia of fibrillation, vertigo 
or actual unconsciousness attending the onset and the frequent initiation of 
the attacks by slight exertion, are among the clinical evidences of the condi- 
tion given by Thomas Lewis and Mackenzie. 

It is obvious that they are merely suggestive, and unfortunately true 
that pulsus alternans and irregularity may render the pulse most puzzling. 

The cases of regular 2-1 block would be the ones most likely to be guessed 
correctly, but rational non-instrumental diagnosis would seem to be depend- 
ent chiefly upon the pulse phases induced by digitalis therapy as previously 
described. 

Duration. — Auricular flutter like auricular fibrillation may occur in short 
paroxysms or endure for months, but during any decided seizure, marked and 
progressive symptoms of decompensation become manifest. 




Fig. 267. — Mere febrile tachycardia. Normal cycle throughout in venous tracing. 

Rapidity only. 

Physiologic Heart Block. — Inasmuch as the normal conduction time is 
nearly one-fifth of a second (0.12-0. 18 sec), it is evident, as previously 
suggested, that a certain degree of functional heart block must occur in this 
lesion when the auricular flutterings exceed 360 although it has no such sig- 
nificance as has the heart block due to organically impaired conduction. 
\ PAROXYSMAL TACHYCARDIA.— This curious speeding up of the 
whole heart apparently represents the sudden appearance of a few auricular 
extrasystoles initiating excessively rapid rhythmic, but inefficient heart 
beats of auricular origin in place of the slower rhythmic stimuli normally 
arising from the pacemaker (sino-auricular node).* 

In rare instances the impulse to contraction seems to arise in the ventricles. 

The rate is usually about double that of the normal heart. 

Essential Features. — It consists clinically of the abrupt onset of a series of 
excessively rapid beats, their equally abrupt cessation after a period varying 

* Paroxysmal trachycardia of ventricular origin is extremely rare. In some instances 
it would appear unlikely that any extrasystolic phenomena initiate the attacks. 



Decompensa- 
tion produced. 



Excessive 
rapidity and 
weakness. 

Arise in 
auricles. 



5 6 ° 



MEDICAL DIAGNOSIS 



Abrupt onset 
and ending. 



Vagus inhibi- 
tion lost. 



Sometimes 

beyond 

counting 



Electrocardio- 
gram. 



from a few seconds to several hours or weeks, a somewhat prolonged pause, 
and the resumption of a normal rate. 

The subjective cardiac distress is primarily slight though curiously alarming 
to the patient. Weakness or oftener a sense of profound exhaustion adds to 
his apprehension. 

In a case observed with especial minuteness by the author the attack 
is not initiated by obtrusive or subjective recognizable extrasystoles although 
the onset is sudden and definite. An immediate limitation of effort is 
obligatory. If this cannot be secured anginal pain of moderate or even 
somewhat severe grade results. 

This is manifested first in the precordium, then the left arm, and finally 
by radiation to the left side of the neck and jaw. 

Until habituated through the frequent recurrence of attacks a "sense of 
impending death" was experienced in the painful seizures. 

The patient feels convinced that the heart would dilate rapidly under 
any decided physical exertion, i.e., he " senses" the extreme overload present 
as a result of the quickened rate. 

The tendency to attacks may pass into auricular flutter or fibrillation, 
wholly cease for long periods or occur persistently several times a day or 
at any other interval. 

In many cases an acute cardiac insufficiency is developed in a few days 
or even hours. The heart dilates widely, general edema appears, orthopnea 
is present, the liver enlarges and decided passive congestion of the kidneys 
is manifest. 

Vagus control is almost or quite removed throughout the period of tachy- 
cardia. (Vagus pressure slows the ventricular beat in these cases by creating 
a partial vagus block, but without affecting the abnormal auricular contrac- 
tions in the slightest degree.) 

The beats may show decided inequality and the rate varies from 120 to 
200, the average rate being somewhat more than double the normal. 




/1/U- — \%^-\ 



RR 



Fig. 268. — Paroxysmal tachycardia. The abrupt onset and cessation of the brief par- 
oxysm and its equally sudden relapse into extrasystolic irregularity (Ex) and "pulsus 
bigeminus" are clearly shown. In the full-sized tracing, alternation seems to be present 
during the paroxysm. (R. Edwin Morris.) 

The lack of the subjective sense of violent palpitation and the fact that 
exercise during the attack does not increase the rate (Mackenzie-Lewis) 
stand in sharp contrast to the symptoms of simple acceleration (palpitation) 
or a simple tachycardia of exertion or excitement. 

The electrocardiogram demonstrates clearly in most instances the 
auricular origin of the aberrant impulses, the "P" wave of the paroxysmal 



CARDIAC ARRHYTHMIAS 



56: 



„Tic-tac' 
rhythm. 



cycles and that of the introductory auricular extrasystoles being identical 
in form. Rarely it is initiated by a ventricular extrasystole. 

In cases of excessive rapidity the "P" wave may be merged in the 
"T" wave or wholly obscured by it. 

It occurs at any age save the first decade but with significant frequency 
between the ages of twenty and forty, the selective rheumatic period, and Age groups, 
even more frequently between forty and sixty, the preferential period of 
the myocardial degenerations. 

It is most common in myocardial degeneration, is often present in mitral 
stenosis, and has a decided pathologic significance though occasionally 
present without other distinct signs of cardiac disease. In severe cases the 
rhythm is essentially fetal (the "tic tac" rhythm). 

To the author it would seem wiser to consider this condition clinically 
as one standing wholly apart from "flutter and fibrillation." 

ALTERNATING PULSE.— This represents usually very rapid rhythmic 
alternation of stronger with weaker beats, the variation and force being 
often imperceptible to the finger. It is best shown by the radial and 
carotid tracings, and is sometimes beautifully clear in the electrocardiogram. 

It will be noted that the beats fall at regular intervals, the abnormality 
being one of force only. 

It is especially common in cardiosclerosis, the terminal cardiac insuffi- 
ciency of interstitial nephritis and coronary sclerosis, and is frequently asso- 
ciated with paroxysmal tachycardia and with auricular flutter. 

In practice its immediate seriousness is largely dependent upon the 
question of attendant pulse rate. 



Impaired 
contractility 



R.J. 




Fig. 269. 



■Pulsus alternans. Rhythmic pulse, a.c.v. waves present in jugular tracing. 
Upper tracing jugular, lower tracing radial; time }/$ sec. 



Significance of Associations. — If the alternation occurs in mere rapid 
heart (simple tachycardia) such as may arise temporarily from trivial causes 
and subside upon their removal, it may or may not indicate myocardial dis- 
ease or overstrain. If associated with paroxysmal tachycardia the signifi- 
cance and associations of that form of pulse acceleration, w T hich is probably a 
manifestation of "auricular flutter" dominate the clinical picture. 

// it occurs in a heart beating at, or but slightly above, the normal rate, and 
especially in persons of middle or advanced age, or in connection with known 
cardiac disease, it is of serious significance. 
36 



Prognostic 
factor. 



Rapid hearts. 



Moderate rate. 



562 



MEDICAL DIAGNOSIS 



Induced by 
exercise. 



A "herald of 
rfeath." 



The same is true of cases in which alternation occurs under exercise or 
sudden changes in position with but moderate resulting acceleration of the 
heart beat. 




Fig. 270. — Pulse resembling pulsus alternans, though smaller pulsations are due to 
extrasystoles. Auricular fibrillation shown by waves ff. Upper tracing jugular, lower 
tracing radial. Time % sec. (R. Edwin Morris.) 

It may be confined to but a few cycles, especially in the presence of 
occasional extrasystoles. 




Fig. 271. — Auricular fibrillation. Pulse simulates alternans on this half of original 
tracing, although the spacing is markedly irregular when instrumentally demonstrated. 
Left one-fifth of tracing, not reproduced here, showed a bigeminal pulse due to extrasystolic 
arrhythmia. Fibrillation was manifest in both phases, (f f++). (R. Edwin Morris.) 

Prognostic Significance. — Occurring either under the conditions of moderate 
rate, on the one hand, or excessive paroxysmal rapidity, on the other, as the 




Fig. 272. — Sinus arrhythmia. Electrocardiogram and respiratory curve. (After Thos. 

Lewis.) 

result of exercise, or in connection with extrasystoles, the alternating pulse is 
a serious condition representing extreme exhaustion of reserve and impaired 
effective response, and ranking, as Lewis says, with u risus sardonicus, ,} " sub- 
sultus tendinum^ and optic neuritis as heralds of a death at best not many 



CARDIAC ARRHYTHMIAS 



563 



months distant. In fact it is often actually associated with such urgent and 
ill-omened conditions as "Cheyne-Stokes breathing," cardiac asthma, and 
severe angina pectoris, though as in these conditions the possessor may sometimes 
live many months or even years. 

SINUS IRREGULARITIES.— The vagus nerve controls the "pacemaker" 
of the heart (sino- auricular node), normally reduces by over one-half the 
rate of the unrestrained-heart stimuli, and probably determines their point 
of departure from the sinus area. 

Partial inhibition of the vagus influence is evident in the quickened heart 
(tachycardia) associated with fear, joy, pain and a host of other emotions, no 
less than from the action of many well-known drugs. The more unstable 
the nervous system or psyche of the individual, the more readily are trivial 
sights, sounds, odors, aches and trials magnified and made effective inhibi- 
tors of vagus control. So also may the inspiratory quickening of rate be 
exaggerated under conditions or toxemia, poor nutrition or psychasthenia. 

The known independence and automatic irresponsibility and lawlessness 
of the heart muscle under certain conditions of overstrain and valvular and 
myocardial disease largely vitiates the vagus control. 

Characteristic Features of Sinus Irregularities. — These are characterized 
by a varying length of cardiac cycle represented by a diastolic variation but unasso- 
ciated with dropped beats, alternation, delirium cordis or extr asystoles, though 
peculiarly unstable in rhythm and often responsive to and modified by, the phases 
of respiration. Merely taking one's pulse during forced inspiration, a long 
pause and forced expiration demonstrates this common " juvenile type of 
irregularity." The rate of the beats tends to wax and wane, to speed up and 
gradually slow down in series. 

In many the respiratory response is absent but all show the tendency to 
complete orderly systole, varying diastole, equality of force in the beats, 
and the serial waxing and waning of the rate. 

Significance. — Sinus irregularities are usually of slight significance and 
in the respiratory form constitute the great majority of the arrhythmias 
of childhood and youth and of neurotic, congenitally asthenic, unstable, 
undernourished or mildly toxic individuals. 

Furthermore, if the pulse is sufficiently quickened by exercise, excitement, 
or more radically, by full doses of atro pin, which usually lifts the vagus influence 
to a marked degree within an hour, arrhythmia is often modified or wholly set aside. 

Instrumental methods at once define them clearly for, whatever the rate 
of any series, the graphic auricular and ventricular complexes are wholly 
normal and the variable diastolic phases are obvious. 

It is an arrhythmia of perfect physiological complexes occurring in normal 
sequence, abnormal only in the spacing of the rest periods. 

It is obviously a sinus ejfect in every instance for it is space only that is 
affected save in the dropped beat type of "sinus block" and here the defect 
lies in the failure of the sinus to release its stimulus. 

Simple Bradycardia. — If, on the other hand, vagus inhibition be exces- 
sive, a slow pulse develops (50 to 55 beats per minute) which in itself lacks 



Vagus 

influence. 



A juvenile 
type. 



A simple 
demonstration. 



Tests of 
exercise and 
atropin. 



Always a sinus 
effect. 



Import ant 
possibilities. 



564 



MEDICAL DIAGNOSIS 



serious significance though it may occur in paralysis of the sympathetic, 
direct vagus pressure from any cause, from poisoning by adrenalin, digitalis, 
or lead, or in association with intracranial pressure, acute infections, asphyxia, 
icterus, convalescence from acute infections, profound toxemias, arterial 



















































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Fig. 273. — Complete heart block. Note regularity of auricular and ventricular com- 
plexes and wholly independent rhythm. P 6 has fallen accurately upon a ventricular T. 
(After Thos. Lewis.) 






Lead II. 



Fig. 274.— Digitalis heart block (partial). Inverted "T" and lengthened "P-R" 
interval (delayed conduction characteristic of digitalis block). "P-R" normally (conduc- 
tion time) is 0.12-0. 18 sec. In this case 0.32 sec. Split "P" of mitral stenosis was present 
in lead I. In this case left ventricular hypertrophy was indicated b>- prominent "R" and 
absent "S" in lead I, contrasted with its opposite, a submerged "R" and relatively 
prominent "S" in lead III. Only lead II illustrating the block is shown here. (R. Edwin 
Morris.) 




"Vagus 
heart-block. 



Fig. 275. — Digitalis heart- 2 : 1 block. Pulse 60; auricular contractions 120 per minute. 
Inverted T throughout all three leads (digitalis). Lead II here shown. Dissociation does 
not exist here, but one-half of the auricular contractions fail to cross the Bridge of 
Gaskell' ("Bundle of His") 

hypertensions and the like, in connection with which heart block is found to 
be very common if tested by instrumental methods. 

In sino-auricular heart block the complexes are normal but certain 
entire beats may be wholly absent or the heart may slow down and beat at 



CARDIAC ARRHYTHMIAS 



565 



about one-half the original rate, whether or not this is always a vagus effect 
is not determined, but it is frequently seen in digitalis toxemia. 

HEART BLOCK. — As previously stated, true heart block results from 
an impaired conduction of stimuli to contraction passing from auricle to ventricle 
through the bundle of His ("GaskelVs bridge"). 

The normal conduction time is one-fifth of a second and the " block" 
may represent a mere lengthening of this interval (the a-c interval of the 
polygram or "P-R" of the electrocardiogram) or there may be complete dis- 
sociation, in which case the auricle beats independently at about the normal 
rate while the ventricle originates its own contractions and beats at a rate 
approximately one-half the normal. 

Acute Cerebral Anemia. — If the ventricular contractions become too slow 
and feeble to supply the brain, syncopal attacks, convulsive seizures, vertigo, 
or headache may occur which with the evidence of auriculo-ventricular block 
constitute the Adams-Stokes syndrome. 




Fig. 276. — Heart block. Dissociation of auricle and ventricle is shown. Ventricle has 
adopted its independent intrinsic rhythm and the auricle is responding faithfully to the 
impulses from the pace maker. 

Death may occur in these attacks or recovery may take place despite a 
complete cessation of ventricular systoles extending over a brief period. 
The radial pulse may drop to 5 or 6 beats to the minute just before such an 
attack, and in one such case of the author's in which recovery from the 
attack occurred the ventricular beat was wholly inaudible for a period of 
over twenty seconds.* 

Age Periods. — Heart block is far more frequent in the male (75 per cent.) 
than in the female, may occur at any age and will fall into two general groups, 
i.e., those of the younger ages (ten to forty) in which past rheumatism, chorea 
and acute infections generally play a chief part, and the older group in which 
the primary cardiovascular degenerations, aortic lesions and syphilis are the 
main factors. 

* One of Mackenzie's cases had 50 attacks of syncope and 15 slight epileptiform 
seizures during a period of ninety minutes, these attacks recurring every few moments 
for ten days. 

Odriozola recently reported a case showing shortly before death intervals of from 
50 to 58 seconds between the heart beats (practically one to the minute). 



Partial block. 



Complete 
block. 



Adams-Stokes 
syndrome. 



Asystole. 



Apparent 
death. 



Rheumatic. 



Luetic and 
degenerative. 



5 66 



MEDICAL DIAGNOSIS 



Acute Infections. — The heart block so frequently present in the acute 
infections though occasionally complete is usually partial and apparently 
transient, being indicated by a mere increase of the a-c or "P-R" interval, 
detected by the polygraph or electrocardiograph. 




Fig. 277. — Heart block and dissociation in child aged twelve years. Auricular waves 
are marked "a," carotid waves, "c." Auricular rate 38 per minute. Ventricular rate 
88 per minute (almost a 2 : 1 block. 




Fig. 278. — Same case recovering from pneumonia. Auriculo-ventricular dissociation . 
Upper tracing, jugular. Lower tracing, radial. The auricle beats at the rate of 108 per 
minute (a.a.a., etc.). The ventricle takes its own rhythm from the junctional tissue and 
beats at a rate of 41 per minute. Auricular rate has increased one-fifth; ventricular rhythm 
remains practically unchanged). 



tftT»tft»»*TtT 



»»»»»»» 




R.R. 



Fig 279. — Carotid and radial tracing of same case. Carotid tracing shows slight emi- 
nences indirectly due to the auricular contractions. See beats marked+. 

Heart block of this type is especially common as a sequence of or in direct 
association with, acute rheumatism, secondary syphilis, influenza, diphtheria, 
pneumonia, typhoid fever and profound sepsis. 

As in the case of the extr asystoles, its practical value in this connection lies 
chiefly in the fact that it emphasizes the importance of myocardial toxemia in 
the commonest of acute infections, which are doubtless the starting point of 
chronic degenerative processes far more often than has been believed hitherto. 



CARDIAC ARRHYTHMIAS 



;67 



Changes in the Bundle of His. — Aside from the transient acute infectious 
types of which little is known, these are of the most varied description, viz. 
— acute myocarditis, ulceration, chronic myocarditis, gummata, fibrosis. 




[ ::-. ; So. — Lead I. 




Fig. 281.— Lead II. 




Fig. 2S2. — Lead III. 
Figs. 2S0. 2S1 and 2S2. — Intraventricular heart block. Impaired conduction in right 
branch of "Bundle of His.*' The "R"' "S" >; T' ; complex is characteristically broadened 
and split. The appearance of the electrocardiogram resembling broadly extrasystolic 
deflections of the opposite (unaffected j ventricle. If left branch were affected the picture 
would be reversed. R. Edwin Morris. 



tumors, etc. Cryptogenetic focal sepsis and syphilis probably play a promi- 
nent part in the heart block of the older-age group. 

Recognition of Heart Block by Simple Means. — The lesser grades as- 
sociated only with a lengthened auriculo-ventricular conduction-interval 



568 



MEDICAL DIAGNOSIS 



Suspicious 
bradycardia. 



Suggestive 
conditions. 



Auricular 
"ticking." 



(a-c of the polygram, "P-R" of the electrocardiogram) cannot be detected 
by mere observation. 

One should suspect block (a) when the pulse is below 50; (b) whenever the 
presystolic murmur and, thrill of mitral stenosis is maximal in early or mid- 
diastole of the ventricles; (c) in cases of fibrillation with a pulse rate less than 



R 






Fig. 283. — Lead I. 




Fig. 284. — Lead II. Xote fibrillation in all leads. 




Fig. 285.— Lead III. 
Figs. 283, 284 and 285. — Same case three weeks later. 

twice the normal; or (d) in cases of any kind associated with clearly redupli- 
cated first or seconds at the apex. 

Turning the patient on the right side one rarely may hear over the 
auricles tiny clicks which resemble the ticking of a watch and represent 



CARDIAC ARRHYTHMIAS 



569 



auricular contractions made audible by their distinct separation from the 
ventricular systole. This, of course, only in cases of complete dissociation or 
very decided block. 

Furthermore, the normal visible jugular pulse may be increased and, per- 
haps, additional undulations single or multiple which are suggestive of a 
lack of orderly sequence in the auriculo- ventricular events. 

Single systoles may be dropped even when others pass through the conducting 
bundle and these elisions may be regular or irregular in occurrence. The 
silent pause with pulse intermission thus induced is in sharp contrast to ex- 
trasystolic dropped radial beats in which case the frustrated or abortive 
ventricular systole is audible either as to one or both its elements. Such 
silent intermissions if unaffected by deep respiration indicate a blocked 
impulse. 









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Fig. 286. — Nodal rhythm. Auricle and ventricle contract simultaneously. Auricular 
complex wholly lost. Note absence of " P," normal "R" and " T;" and absolute regularity 
equality of "R"s. Rate 48 per sec. When the ventricle is wholly dissociated from its 
auricle it adopts a rhythm of its own representing usually in rate about one-half the normal 
frequency. ^ If impulses to contraction arising in the sinus are blocked at the junctional 
tissues ("His bundle") the auricles respond, but the ventricle follows its own steady slow 
(30-48) rate receiving its impulses to contraction from stimuli arising in the auriculo- 
ventricular bundle itself. Contrast this Electrocardiogram with the figure showing true 
heart block complete (Fig. 269). In this present instance both auricle and ventricle are con- 
tracting from the same junctional center in exact coincidence and the auricular complex is 
wholly submerged in the normal ventricular phases. The ordinary auriculo-ventricular 
heart block does not exist, but the sinus node, the normal "pacemaker" is inert. By the 
pulse it could not be distinguished from simple bradycardia or active auriculo-ventricular 
complete block (dissociation). (After Thos. Lewis.) 

Lewis states that in a 2-1 heart block of mitral stenosis, in which ailment 
block of various degrees is common, one occasionally encounters two distinct 
murmurs of stenosis each with its thrill to each radial or carotid beat. This 
because of two distinct auricular contractions, each competent to force blood 
through the narrowed mitral orifice but only one capable of exciting a ven- 
tricular response. Such ventricular silences and dropped pulsations are 
well appreciated if palpation of the carotid and auscultation of the apex of 
the heart are practised simultaneously. 

General Rule. — Complete block is almost invariably present if the ventricular 
rate is under 40 and in such cases the rhythm is usually regular and peculiarly 
sedate though, as stated previously, faint echo-like ticks or muffled diastolic 
sounds over the auricles may indicate the blocked auricular contractions. 

Simultaneous Auricular and Ventricular Systoles. — It must happen at 
times in heart block with complete dissociation as in ventricular extrasystoles 



Large positive 

jugular putee. 



Dropped 
systoles. 



Silent pauses. 



570 



MEDICAL DIAGNOSIS 



Alternating 
jugular pulse, 



Important 
distinction. 



Unmasking 
heart block. 



Serious when 
persistent and 
severe. 



May die in an 
attack. 



that one auricular contraction accidentally "falls in" exactly with that of 
the ventricle. 

In such cases, the first sound is usually loud and an extremely pronounced 
systolic jugular wave is present of the character described in connection with 
ventricular extrasy stoles. 

It is evident that this condition, if regularly repeated, as occasionally 
happens, would yield alternate large and small jugular waves as timed by 
the apex, one being ventricular-systolic made up of the accidentally systolic 
auricular contraction acting against auriculo-ventricular obstruction (from 
the premature valvular closure), reinforced by ventricular contraction itself; 
the other due to auricular contraction alone, the lagging, dissociated ven- 
tricle being at the time of the latter in its prolonged diastole. 

Adams-Stokes Syndrome. — Any drop in the ventricular rate below 20 
renders the patient unconscious precisely as in temporary complete cessation. 

Temporary attacks, strongly suggesting and often mistaken for the status 
epilepticus, occur in such cases when actual periods of asystole ensue, 
though convulsive movements are oftenest limited to twitching of the face 
and extremities and even severe attacks are unaccompanied by tongue- 
biting or the involuntary passage of urine. The author has observed but 
one proven case in which the latter event occurred. 

Latent Heart Block. — It was believed formerly that a latent block might 
be unmasked by administration of digitalis to the point of toxic effect. In 
such cases atropin betters the condition to some extent or even removes it 
probably because the supposedly latent block is actually an active vagus 
effect produced by the toxic action of the digitalis itself. 

The older belief in an actual persistent, pure, "vagus block" is neverthe- 
less, practically abandoned. 

Prognosis in Heart Block. — The existence of any pure, primary and severe 
heart block without involvement of other structures is dubious, or at least very 
rare, and a genuine and decided block, if persistent, means a serious condition, 
a shortened after -lifetime and almost invariably indicates an extensive myocardial 
degeneration of which the changes in the bundle of His constitute but a part. 

Nevertheless, it is often extremely chronic and, of itself, and in the presence 
oj an otherwise slightly affected myocardium, need not produce death for long 
periods. 

Exitus usually occurs through the same mechanism as in other forms of 
cardiac disease or through an intercurrent ailment though it may occur during a 
severe attack of the A dams-Stokes type. 



HEART ROENTGENOGRAPHY 



ROENTGEN DIAGNOSIS OF CARDIAC LESIONS 



57i 



Frank S. Bissell, M. D. 

Minneapolis 

While an elaborate discussion of technic does, not properly lie within the 
province of a work of this character, a few points bearing thereon must be 
emphasized by way of preface to this chapter. 

1. To determine approximately the size of the heart one may resort to: 
(a) teleroentgenography; (b) teleroentgenoscopy ; (c) orthodiagraphy. 

Procedures (a) and (b) require only that the tube be 2 meters distant from 
the plate or screen, the patient being closely approximated to the latter. 
Orthodiagraphy requires a special apparatus to the employment of which 
attaches considerable danger to the operator. 

2. Simple roentgenography, with glass over the screen upon which 
may be traced various sections of the heart outline, offers much valuable 
information bearing upon the diagnosis and prognosis of heart lesions. 
One advantage of this method is that in the right oblique position the 
posterior mediastinum may be studied. This space may be found markedly 
encroached upon in pericardial effusion, hypertrophy of the right ventricle, 
dilatation of the left auricle, or aneurysm of the aorta. The usual measure- 
ments, however, are made in the postero-anterior position, the patient stand- 
ing with his back toward the tube and chest against screen or plate. 

Principle of Orthodiagraphy. — Since the X-rays take a divergent course 
from the focal point on the antikathode, any shadow resulting from their 
obstruction must of necessity be larger than the object causing the 
obstruction. 

This distortion is greater in proportion to the distance of the object from 
the screen and the proximity of the object to the antikathode. Since the 
distance of the heart from the outer chest wall is a variable one, we would 
obtain variable measurements of hearts of a given size if we employed these 
divergent rays. 

Modified Orthodiagraphy. — By means of a very small lead diaphragm, 
however, one may eliminate all but those rays which pass in a straight line 
from the antikathode to a given spot on the fluoroscopic screen. 

If the tube is now carried around the heart so that this spot of light 
describes its borders, the latter may be traced accurately upon the glass 
covering the screen, which is disconnected from the tube box and held 
firmly against the chest wall. Tracings are also made of the lateral chest 
walls in order to determine the cardio-thoracic ratio, and of the diaphragm 
in expiration and inspiration. 

The median line is drawn through the shadows of the dorsal spinous 
processes. The most distant outer margins of the cardiac silhouette are 
then indicated upon the orthodiagram and lines are drawn from these points 
to meet the median line. The sum of these two transverse lines represents 
the greater transverse diameter and they may be compared to ascertain the 
relative distance of the right and left cardiac borders. 



Technic of 
heart-study. 



572 



MEDICAL DIAGNOSIS 



Safer and 
better. 



This orthodiagraphic tracing may now be transferred to a transparent 
sheet of tracing paper laid over the glass. 

Teleroentgenography. — Alban Kohler (Deutsch. med. Wochenschr., 
1908), first described this method by which it is possible to avoid the more 
distorting effect of the divergent rays. He placed the roentgen tube at a 




Fig. 287. — "Drop" heart. Extreme type. (Author's series.) 

distance of 2 meters (about 6 feet 7 inches) from the patient's back; the pro- 
jected shadow is then only a millimeter or two larger than the heart, and is 
recorded upon a photographic plate. This method is both safer and more 
convenient than the orthodiagraphic method and, probably, quite as accurate. 
Transverse and longitudinal measurements may be traced upon the tele- 
roentgenogram exactly as on the orthodiagram. 

The "Drop" or Pendulum Heart. — The typical "drop" heart is long, 
narrow and on the screen appears to hang suspended from the great vessels 
above. Its right border, when visible beyond the vertebral shadow, is 



1 1 1 ART ROENTGENOGRAPHY 



573 



formed by the right ventricle rather than the auricle as in the normal. These 
characteristics are the result of a low position of the diaphragm and a small 
atonic heart. Such hearts are extremely frequent in those of an asthenic 




Fig. 288. — A modified form of "drop" heart. Mitral stenosis (Duroziez's type). 

structural configuration but modified types of the small heart are also 
occasionally seen in individuals with broad chests. 

As the author of this book has shown us, such hearts are readily dilatable 
and easily overstrained when the general nutrition of their possessors is 
impaired or an acute prostrating infection is present and even when greatly 
enlarged, from whatever cause, may most misleadingly present what appears 
to be a normal total transverse measurement. 



574 



MEDICAL DIAGNOSIS 



Heart profile. 



Important 
divisions. 



Left border 
notches. 



Important 
exception. 



Hence it is of great importance for the roentgenologist to be able to 
recognize the type even when hypertrophy or dilatation has increased the 
transverse cardiac measurements to normal or above normal. He may 
find some assistance in the following points of differentiation from the 
normal. 

i. The contractions are sharp, the excursions appearing greater than 
normal as though one could actually see the heart rotate upon its long 
axis. 

2. The right border is seen to contract synchronously with the left, 
indicating that the former is the right ventricle. This characteristic is 
observed, however, only in the typical "drop" heart. 

3. The distance from the arch of the aorta to the sternoclavicular articu- 
lation is increased. 

4. If one suspects dilated or hypertrophied drop heart, it is of some 
confirmatory value to examine the stomach when filled, thus perchance to 
demonstrate another sign of congenital asthenia — the ptosed stomach. 

THE NORMAL HEART.— The right and left borders of the heart appear 
sharply outlined in bold contrast to the air-filled lung on either side. 

The lower border is concealed by the dense shadows of the diaphragm and 
abdominal organs, unless it is brought into relief by inflation of the stomach 
with gas. 

The base is fused with the equally dense shadow of the large blood vessels. 
The latter should be considered a part of the cardiac silhouette, so closely 
are they associated both anatomically and pathologically. 

The Left Border. — A careful study of the left border of the cardiac profile 
or silhouette makes it possible to separate it into three, sometimes four distinct 
sections. These sections are convexities separated by slight indentations in the 
silhouette. 

The uppermost one, marked and abrupt, represents the transverse and 
descending portions of the arch of the aorta. Below this, more perpendicular, 
and only slightly convex, is the section representing the pulmonary artery and 
the left auricle, frequently indistinguishable from each other in the normal 
heart. The third section, longer, more diagonal and tending toward the 
elliptical outline, is the left ventricle. 

Right Border. — On the right side the shadows of the ascending aorta and 
the vena cava are usually overridden by that of the spinal column and ster- 
num. Below, the border of the right auricle appears as a rather sharp con- 
vexity. The right ventricle is not determinable marginally, for it is the 
right auricle which forms the right border of the cardiac silhouette, save in the 
case of u drop " heart in which the right ventricle forms it. Either the aorta or 
vena cava may be visible above without pathological significance; the former 
as a convex shadow, the latter as a straight perpendicular line. With this 
description of the normal heart outline one may proceed logically to a con- 
sideration of valvular disease. ■ 

Valvular Disease. — In our present state of knowledge it is more scientific 
perhaps to speak of a mitral, or aortic heart configuration than to attempt a 



hear: 



ROENTGENOGRAPHY 



575 



more accurate roentgen differentiation of various types. However, each 
lesion tends to modify the cardiac outline and the orthodiagraphic measure- 
ments in a somewhat characteristic manner. 




Fig. 289. — Advanced endocarditic mitral insufficiency. Note prominence of both 
convexities and elliptic, contour of left ventricle. Lung shadow opposite left ventricle ! 
probably due to past embolic process. {Dr. Frank S . Bissell.) 

Mitral Insufficiency. — If the mitral valve becomes freely incompetent a 
tendency to stasis and overload in the left auricle is at once evident. Both 
the pulmonary artery and the auricle thus become overdistended and a 
resultant alteration may be noted in the contour of the left cardiac border. 

The section intermediate between the aortic convexity above and that of j change in left 
the left ventricle below becomes rounded out so greatly as to equal or even to 



576 



MEDICAL DIAGNOSIS 



exceed the former in prominence, the result being an obliteration of the 
normal concavity and the formation of a relatively or absolutely straight 
line from the aortic convexity above, obliquely downward to the apex. 
As the left ventricle increases in size through dilatation or hypertrophy its 
silhouette assumes a more rounded or elliptical contour and this, with the 
alterations noted above, gives the left heart border a semi-circular shape. 
If the right ventricle enlarges, it tends to force the already prominent right 
auricle into greater prominence, thus completing the circle. Here we have 
the typical mitral configuration. A triangle may be constructed around 



L.Veni 




orax 



Fig. 290. — Fluoroscopically demonstrable pulsation of cardiac rhythm in aortic in- 
sufficiency with hypertrophy and dilatation of the left ventricle, transmitted to surface of 
gastric contents. (After Holzknecht.) 

the circle by dropping lines from an interclavicular point (the apex of the 
triangle) along the right and left cardiac borders to the diaphragm to form 
the base. 

The hypertrophied right ventricle may itself become visible as a per- 
pendicular pulsating border immediately above the diaphragm and to the 
right of the sternum. 

The orthodiagraphic measurements are modified by a marked increase 
in the total transverse diameter and less marked increase in the longitudinal 
diameter. 



HEART — ROENTGENOGRAPHY 



577 



Mitral Stenosis. — In mitral stenosis, the enlargement of the left auricle 
is the most distinguishing feature, and this is best demonstrated in the 
left anterior oblique position, the patient being rotated to an angle of 50 
degrees. The dilated left auricle is noted as a marked salient into the lower 
retro-cardial clear space, encroaching upon or merging into the shadow of 
the vertebral column. The right auricle may also be markedly enlarged 
while the left ventricle remains small. 

Since pure mitral stenosis is extremely rare,* the outline usually encoun- 
tered is that of the double lesion. The enlargement of the right ventricle 
and the auricles may be so predominant that the left ventricle is completely 
overshadowed, the entire silhouette being right ventricular and auricular. 
This is possible only in pure or stenotically dominant cases in which left 
ventricular hypertrophy is slight, absent or possibly replaced by atrophy. 
The left ventricle may be wholly forced away from the wall of the chest by 
its fellow or one may discern sometimes a division of the left ventricular 
silhouette into upper and lower curves, that above representing the/border 
of the right ventricle, that below, the left. In both valvular stenosis and 
regurgitation, but especially in the former, or in the combined lesion; enlarge- 
ment of the left auricle is inevitable and may assume enormous proportions. 
Any such increase may be rightly determined by oblique illumination which 
may reveal an enlargement equal to or much greater than the size of the fist 
and show clearly and definitely its presystolic pulsations, or its immobility 
if paralysis or fibrillation is present. The diastolic-presystolic pulsation in 
cases of very marked stenosis may assume the form of a laborious deliberate 
vermicular contraction representing the extra effort required to force the 
blood from the narrowed mitral orifice. 

In cases of extraordinary dilatation of the auricle, symptoms of pressure 
upon the left recurrent laryngeal nerve may be present, precisely as in certain 
cases of aortic aneurysms involving the first or second portions of the arch, 
or in certain massive pericardial effusions. In like manner decided pressure 
may be exerted upon the esophagus and the left primary bronchus. The 
former may be" demonstrated readily by having the patient take and attempt 
to swallow large capsules of bismuth when these will be found to be checked 
or actually arrested for considerable periods at the point of esophageal ob- 
struction. Curiously enough the patient is conscious of little trouble from 

* According to the author's experience, cases of "pure" stenosis in the light afforded by 
modern technic are limited almost wholly to those classified under "Duroziez's disease," 
elsewhere described, and represent a "drop" heart in a congenitally asthenic, visceroptotic 
individual who has suffered from active tuberculosis in the past or shows, rather more 
clearly than the average, roentgenographic evidences of past infection. Several of the 
author's cases had carried for many years an active, but slow-burning and retarded, pul- 
monary tuberculosis. In mitral stenosis occurring in individuals of robust build, even 
when no murmur of regurgitation was demonstrable, the author cannot recall any typical 
of pure stenosis, and but few small hearts. On the contrary, some left ventricular en- 
largement has been manifest to some degree even in cases in which, doubtless, the 
regurgitant element was slight, and, in nearly all instances, a systolic bruit has become 
audible., ultimately, at some time or in some posture. (C. L. G.) 
37 



"Pure" 
stenosis rare. 



Vermicular 
contraction. 



Pressure symp- 
toms possible. 



578 



MEDICAL DIAGNOSIS 



this phenomenon. If a bismuth suspension is taken swallow by swallow, 
transmitted rhythmic undulation of the esophageal content may be 
observed. 




Fig. 291. — Aortic insufficiency with wide dilatation of descending aorta. 
{Dr. Frank S. Bissell.) 

Aortic Insufficiency. — In this lesion, the predominant feature is left 
ventricular hypertrophy with little or no dilatation of the auricle. The 
orthodiagram therefore shows an elongated, elliptical or oval left ventricular 
border, a marked intermediate concavity, an increased longitudinal diameter 
and a relatively short horizontal diameter. The right heart border remains 
unchanged except when there is marked functional disturbance. The 



HEART — ROENTGENOGRAPHY 



579 



right cavities may then be dilated. The radiological demonstration of a 
distended left auricle (previously described) is distinctive evidence of a 
concomitant mitral stenosis. In the case of such enormous hearts as result 
from the combined aortic and mitral lesions or from the aortic lesions alone 
(cor-bovis) the compression of the left lung and the resulting atelectasis may 




Fig. 292. — Aortic stenosis type of cardiac outline. Note contour of left ventricle "like 
an egg on its side." Dorso-ventral aspect. (Dr. Frank S. Bissell.) 

cause so dense a shadow in the left phrenic-costal angle as actually to simulate 
a pleural exudate or make difficult the delimitation of the true left ventricular 
border unless the clarifying effect of deep forced inspiration is evoked. 
In such hearts the diaphragmatic movements are restricted and that struc- 



A misleading 
shadow. 



5 8o 



MEDICAL DIAGNOSIS 



Epigastric 
oppression. 



ture itself may be pressed down 2, 3 or even 4 cm. on the left side. Cohn 
has reported rhythmic transmittent pulsation of the stomach contents in 
cases of this kind. Jiirgensen believes that the instances of oppression 




Fig. 293. — Pericarditis with effusion (typical). Note "stubby" neck above. 

after meals experienced by many sufferers from heart diseases is due to left 
ventricular enlargement.* 

* This doutless serves as one means of explanation for the extraordinary frequency of 
epigastric localization of the pain, distress or discomfort of cardiac origin in connection with 
heart lesions. In many instances, however, it seems to be due largely to heightened irri- 
tability of the muscle of an overtaxed or actually overstrained heart or one whose intrinsic 



HEART — ROENTGENOGRAPHY 






Arterial Changes in Aortic Insufficiency. — It is important from the stand- 
point of prognosis, to be able to differentiate an insufficiency of the endo- 
carditic type from one of arterial origin. In the latter, the aortic shadow 
appears widened, either from its point of origin to the arch or throughout its 
visible extent. It usually pulsates more forcibly than normal and shows 
in the quality and extent of each excursion the water-hammer quali* 
characteristically manifested in the peripheral arteries. In the endocarditic 
type (rheumatic type changes are limited to the left ventricle, the aortic 
arch and right heart border remaining unmodified. The orthodiagram 
shows an increase in the long diameter and a relative^ decrease in the trans- 

x diameter. 

Combined Aortic and Mitral Regurgitation. — When the aortic and mitral 
valves both are diseased, the heart body appears more diagonally placed, 
the left border and the right alike are greatly extended and the apex yet more 
markedly displaced outward and downward, the exaggerated mid-section of 
the left silhouette border present in pure aortic lesions becoming filled out to 
approach or meet the widened areas above and below. 

Aortic Stenosis. — Early in pure stenosis the changes in the cardiac outline 
are wholly absent or very slight and in the case of a ''drop"'' heart especially or 
in any of small size, the dimensions of the organ may be less than the normal 
maximum even in the presence of an established lesion, for the ventricular 
changes are extremely slow and the hypertrophy induced is to a large degree, 
though not wholly, concentric. The radiographic picture of aortic stenosis 
closely resembles that of insufficiency, the enlargement tending to convert 
the normal parabolic curse of the ventricular border into an ellipse and in 
contrast to mitral configuration, to intensify the delimiting notches of the 
mid-curve of the left border. The apex may appear more blunt and rounded 
than in aortic insufficiency. In aneurysm, especially of the ascending aorta, 
and in cases of arterial hypertension, as in other conditions which tend to over- 
load the left ventricle, one may see sometimes the same elliptic type of heart. 

Pericarditis Exudativa. — .4 large exudate into the pericardial sac forms a 
very striking and characteristic roentgen picture. The transverse measurements 
of the cardiac shadow may be extreme, reaching to the left almost to the lateral 
thoracic wall, and to the right for 8 or even 9 cm. beyond the sternum into the 
-.eld. Its shape is distinctly that of a squat oval with left lateral predomi- 
nance surmounted by the short plugAike shadow of the distended sheaths of the 
greater vessels above, and suggests a similarity to a poorly moulded decant: 
a stubby broken neck. 

A point of differential diagnosis between this configuration and that of chronic 
general cardiac ins 1 with wide dilatation is that the latter inclines to the 

triangular in outline. In such cases a slight, low-lying, small pericardial 
accumulation may intensify the triangular configuration and in both the 
pulsatory excursion of the borders is greatly diminished. 

blood supply is irregular, unresponsive or inadequate. Jurgensen also made the interesting 
observation that in pressure cases arterial tension was markedly increased unless the pres- 
sure of the gastric gas content was relieved. (C. I.. 



Aortic 






.-. 1: .1: :-■-. 



582 



MEDICAL DIAGNOSIS 



Sagit tal 
illumination. 



A reference to the "rationale" of exudative pericarditis, fully set forth 
under its proper heading, will make evident the difficulty or impossibility of 
roentgenograph^ detection in the case of many small pericardial exudates. 

All degrees of variation of the typical picture here depicted may be 
encountered. 




Fig. 294. — Large aneurysm of the ascending aorta. (Dr. Frank S. Bissell.) 

The Normal Aorta. — In the frontal (sagittal) position examination of 
the left side shows a shadow of semi circular contour above, which represents 
the projection of the upper descending portion of the aortic arch. Meas- 
urements are made to determine the total width of the arch at this point, 
and the distance which separates its point of origin from the sterno-clavicular 



HEART ROENTGENOGRAPHY 



583 



articulation. In normal adults of middle age this distance is on the average 
two or three centimeters. Its length diminishes in the old and tends to 
shortness in patients with a short thorax. However the upper margin of 
the aortic semicircle never overlaps the shadow of the left clavicle except 
in the presence of aneurysm of the arch. The above observations are made 
in the erect position and during shallow respiration. 




Fig. 



295. 



-Aneurysm of aortic arch. Enlarged mediastinal glands. Fibrosis pul- 
monium. {Dr. Frank S. Bissell.) 



The right anterior oblique position of 45 degrees offers the best view 
of the ascending aorta, extending with parallel borders toward the clavicle. 
At an oblique angle of 60 degrees the descending aorta appears as a convex 
projection into the retro-cardiac space. 



Aorta largely 

hidden. J 



Oblique 

illumination. 



5^4 



MEDICAL DIAGNOSIS 



Source of 
error 



' Middle lung 
field " or 

" retrocardial 

field." 



In diffuse dilatation of the aortic arch a gently curving, slightly flat- 
tened convex shadow appears, showing expansile pulsation. To the left the 
normal degree of projection may be doubled or so enlarged that its outer 
border intersects that of the heart at the upper part of the left ventricular 
silhouette or even beyond that point. Such an aortic shadow right and 
left may strikingly suggest a large aneurysm and frequently is so interpreted. 




Fig. 296. — Large aneurysm of the transverse and descending aorta. {Dr. Frank S. Bissell.) 

In such cases the retrocardial light-field is narrowed but not obliterated. 
In the form of aneurysm which it simulates the illuminated strip is darkened 
above by the circumscribed projection which represents the aortic aneurysmal 
sac. 



HEART ROENTGENOGRAPHY 



58; 



Expansile pulsation is usually present in aneurysm, but if the sac walls 
are excessively thick and rigid or the dilated portion itself is packed with 
clot, such pulsation may be absent or slight in that part accessible to view. 

But one form of malignant new growth shows anything even approaching 
true aneurysmal expansile pulsation and that is an extremely vascular 
type of sarcoma rarely encountered. 

Aneurysm. — Thoracic aneurysm occurs with decreasing frequency in 
the aortic arch, the ascending aorta and the descending aorta. 

77 may attain large proportions before producing characteristic symptoms 
or physical signs, and may be and often is wholly unsuspected and accidentally 
or incidentally discovered in the course of routine screen examination. 

A special search for aneurysm should be made in all cases of middle or 
advanced age in which complaint is made of pain in the back, pains radiating 
into the arms and, especially, when the aortic tone is not perfectly normal. 

Aneurysm of the Ascending Aorta. — The typical appearance of aneurysm 
of the ascending aorta is that of a sharply rounded prominence of the aortic 
shadow projecting into the right lung field. * 

Turning the patient into the first diagonal position with the screen to the 
right in front and the rays directed between the left scapula and spine, one 
may observe the same prominence projecting into the posterior mediastinum. 
If the aneurysm is of a moderate size and the ascending portion alone is 
affected, there are usually few pressure symptoms. When, however, the arch 
is also involved, the left bronchus and the esophagus may show early the 
effect of pressure. The arch appears widened in all directions; the course of a 
bismuth capsule showing the gullet to be displaced backward and to the right. 

The upper margin of the semicircle formed by the aorta approaches the 
clavicle until, as stated above, there is an overlapping of the two shadows. 
There is also an increase in the length of a line drawn from the sterno- 
clavicular articulation to the junction of the aortic semicircle with the heart 
shadow. 

Aneurysm of the Descending Aorta. — By reason of proximity of the 
esophagus to the descending aorta, displacement of this organ (with sub- 
jective difficulty in swallowing), is one of the early signs of aneurysm of 
this type. The shadow of the widened aorta projects into the left lung 
field, well beyond the normal heart shadow. 

The differential diagnosis between aneurysm and mediastinal tumor 
may be dimcult. A distinctly delimited and defined tumor showing ex- 
pansile pulsation favors the former, whereas the irregular, less definitely 
outlined mass speaks for the latter, but the character of the pulsation is the 
safest guide, though sometimes fallible.! Transmitted pulsation is, of course, 
relatively common in new growths occupying this region. 

* In three cases personally observed a massive tumor representing an aneurysm of the 
ascending portion of the arch extended downward and to the right, the percussion dulness 
in two of the cases reaching that of the liver. (C. L. G.) 

f By an extraordinary coincidence, observed some years ago, a malignant growth and a 
saccular aneurysm co-existed and permitted a tentative diagnosis of the combined lesion 
based upon the (then very imperfect) roentgenographic procedure. (C. L. G.) 



Often unsus- 
pected. 



Suggestive 
symptoms. 



Typical 
appearance. 



Dysphagia. 



Dysphagia. 



5 86 



MEDICAL DIAGNOSIS 



The "bob tail" 
heart. 



Extremely 
common. 



Begins in early 
stages. 



Denial of 
infection 
the rule. 



Test treat- 
ment. 



"Fatty" Heart. — Fatty overgrowth is characterized roentgenological^ 
by the appearance, under the use of a soft tube, of a lesser gray shadow filling 
the cardiophrenic notch at the apex and tailing of! from the pericardium over- 
lying the left inferior border and apex to the upper surface of the diaphragm 
It is roughly triangular in most instances. 

A similar gray shadow may occur at the corresponding angle on the right 
side. 

The Heart Silhouette in Nephritis. — The cardiac hypertrophy which 
occurs as a result of increased blood pressure, arteriosclerotic kidney, etc., 
offers no characteristic roentgen sign. There may be uniform increase in all 
the dimensions of the heart, and both pulmonary and aortic shadows may 
increase in width. With the development of stasis in the pulmonary circu- 
lation the lung field becomes clouded in appearance. 

The illustration of "general dilatation and insufficiency " here shown 
depicts a common late or terminal type. 

THE DISEASES OF THE HEART AND BLOOD VESSELS 
The Importance of Prophylaxis and Early Diagnosis 

Great Advance in Knowledge. — With relation to the causes and preven- 
tion of cardiovascular diseases much of the recent research work is of great 
value. 

Syphilis. — Lesions of the aorta, aortic valves and myocardium are found 
to be far more commonly associated with syphilitic infection than we have 
formerly believed, this fact accounting, no doubt, in large measure, for the relative 
rarity of aortic valvular lesions in childhood and for the effectiveness of the iodides 
and of fractional doses of salvarsan in many adult cardio paths. 

It is evident also that in the heart, the luetic process, as related to the 
stage of the disease, is one of relatively early inception, and slow but pro- 
gressive development. (See Cardiovascular Syphilis.) 

Denial of Syphilitic Infection. — In direct opposition to the views of some 
syphilologists recent reports on cardiac syphilis based upon the specific 
diagnostic tests and the result of autopsy, emphasize the extraordinary 
frequency with which luetic infection is denied even in public services. 

These facts emphasize the diagnostic and protective value of positive 
Wassermann and luetin tests in obscure cases, the importance of prompt 
antisyphilitic treatment in proven cases of infection and the propriety of 
test treatment in resistant aortic and myocardial cases. 

Space does not permit a general consideration of the entire etiology of 
arteriosclerosis or of myocardial inflammation and degeneration in general, 
but a word may be said in relation to acute rheumatism and certain other 
infections producing endocarditis and myocarditis. 

* Dr. Thos. B. Hartzell, Dr. Henrici, and Dr. Gray working in the medical clinic of the 
University of Minnesota, have demonstrated the extraordinary frequency of occurrence of 
the streptococcus viridans in pure culture in the peridental abscesses so commonly associated 
with chronic joint lesions. 



HEART DISEASE — EARLY DIAGNOSIS 



587 



Rheumatism. — The onset and course of acute rheumatism have always 
suggested an infection of a modified septic type, and the relatively recent 
work of Poynton and Payne, Beattie, Beatson, Longcope, E. C. Rosenow 
and many other observers has shown that a mildly virulent microorganism 
assuming any of three forms (a diplococcus, micrococcus or streptococcus) 
in its different strains, may be quite constantly recovered from the subsynovial 
areolar tissue of the inflamed joints of the rheumatic patients {Poynton) . 

Grown in pure culture and passed through a series of susceptible young 
animals these organisms are said to produce consistently an acute arthritis. 
Being extremely susceptible to phagocytosis, they are quickly destroyed, are 
recovered somewhat rarely from the blood, in which they do not multiply, 
and with difficulty from the joint exudate (Poynton). 

Foci of Infection. — The intimate relationship between acute and chronic 
non-suppurative arthritis, and chronic streptococcus infections of the tonsil, 
and, frequently, of the accessory nasal sinuses, jaw or prostate, seems to be 
definitely established not alone by the extraordinary frequency with which 
pure or nearly pure cultures of various strains of the pathogenic streptococci 
occur in the depths of the tonsils of rheumatic patients or in dental abscesses, 
but also by the astonishing immunity to or relief from the disease following 
the complete painstaking removal of all tonsillar tissue or the radical cure 
of other foci of infection. 

Rosenow's work, in clinical collaboration with Frank Billings, later indi- 
cates that the organisms above described, together with the streptococcus 
viridans, are strains of the hemolytic streptococcus, modified by the varia- 
tions of oxygen pressure attending their growth, and that the different 
varieties show more or less well-defined selective affinities for the endo- 
cardium, synovial membrane, myocardium and skeletal muscles respectively. 

Radical Treatment of the Chief Etiologic Factor. — Guerich advocates 
the removal of suspected tonsils at any stage of active rheumatism,* and 
though we may consider this a too radical rule of action, we must admit 
that, if diseased, or if past attacks of tonsillitis have occurred, their complete 
extirpation is indicated in all persons able to bear the operation who show a 
rheumatic tendency or who have passed through an attack of the disease. 

Indeed, bearing in mind the early or primary involvement of these struc- 
tures in diphtheria, influenza, scarlatina and other acute infections in which 
endocarditis and myocarditis frequently occur together, with their etiologic 
potency in relation to chronic arthritis, anemia, and probably in many other 
chronic ailments, it would seem that with respect to the urgency of surgical 
procedure we are justified in placing tonsils in the same category and at 
the head of the list which comprises adenoids, chronically infected accessory 
sinuses, chronic appendicitis, cholecystitis, prostatitis and the peridental 
infections. 

The author finds that many cases carrying curiously unstable intermittently 
toxic hearts, quite apart from actual valvular disease, and often with no history 

* In the relapsing form of rheumatism this procedure may be quite justifiable and ini- 
tiate permanent recovery after one or two days of post-operative exacerbation. 



Modified 
sepsis. 



Recovery of 
organisms. 



Portals of 
infection. 



Streptococcus 
strains. 



Radical 
suggestion. 



Justifiable 
procedure. 



Relation to 
other infec- 
tions. 



Tonsils head 
the list. 



5 88 



MEDICAL DIAGNOSIS 



Chronic inter- 
mittent myo- 
cardial 
toxemia. 



May appear 
normal. 



Prostrating 
infections. 



Myocardial 
toxemia. 



A striking 
contrast. 



of rheumatism or any related acute infection, recover myocardial tonus only 
after such foci are discovered and removed. 

Diseased tonsils, especially, are natural incubators, transmutators and com- 
missaries for invading organisms, and may appear misleadingly normal on in- 
spection even while breeding successive generations of pathogenic germs or con- 
taining actual pus in considerable quantity. 

Partial removal is a poor and usually a wholly ineffective substitute 
for complete enucleation. 

Again and again the Author has seen acute rheumatism develop after 
a tonsillitis affecting the tonsillar remnants persisting after a partial 
extirpation. 

Misleading Delayed Onset. — In seeking to establish the etiologic factors 
in a given case of acute rheumatism or endocarditis, one may readily overlook 
acute tonsillar inflammation. 

An acute tonsillitis though rarely absent in a carefully taken history, seldom 
accompanies the actual onset of arthritis, but more frequently precedes it by a 
period varying from a few days to three weeks, and may be very mild. 

Physical Debility and Cardiac Weakness. — Yet another point of practical 
value in relation to etiology, diagnosis and therapy is to be found in the 
consideration of acute rheumatism, diphtheria, scarlatina, influenza and indeed 
any acute infection associated with marked physical prostration. 

To the author it seems probable that in such cases the excessive, genuine 
weakness so often encountered is ordinarily not one primarily or chiefly 
resident in or directly affecting the skeletal musculature, though this and 
the nervous system must be important factors, but, in a large degree, repre- 
sents the relative inadequacy of a more or less poisoned myocardium. 

In the fatal cases of acute infections the cardiac muscle invariably shows 
at autopsy, greater or lesser local effects of circulating toxins even though a 
grossly demonstrable endocarditis or actual myocarditis be absent. The as- 
sumption that in all acute prostrating infections the myocardium suffers at least 
temporary damage is justified apparently by our present better knowledge of 
the symptomatology of minor cardiac insufficiencies and, of late, is generally 
accepted. The vasomotor control is also greatly disturbed. 

Heart Muscle vs. Skeletal Muscle. — The heart's intrinsic circulatory 
capacity is ten times that of skeletal muscles. It is an extraordinarily 
delicate and highly specialized tissue, and must maintain constant activity 
under conditions of direct and disproportionate exposure of its naked fibers 
to the toxins of disease.* 

The less delicate and highly organized skeletal muscles, on the other hand, 
are at rest during an illness, receive relatively a far less abundant supply of 
toxic blood and, in most instances of brief prostrating infections, fail to 
show under dynamometric tests any such degree of weakness as accords 
with the subjective and objective manifestations of exhaustion which may be 
present. 

Instrumental methods, moreover, have shown that auricular fibrillation, the 
* Heart-muscle fibres are unsheathed. 



HEART DISEASE — EARLY DIAGNOSIS 



589 



lesser degree of heart block and extrasystolic irregularities occur with suggestive 
frequency in various acute infections followed by recovery. 

Percussion Outlines. — In many of these cases, during such periods of 
weakness, carefully conducted percussion by modern methods, especially 
after slight exertion, reveals an abnormally increased cardiac outline, most 
frequent and most marked in such persons as structurally fall under the head 
of "chronic congenital asthenia," but by no means limited to that group. 

Abnormal Heart Sounds and Bruits. — Furthermore, one will often find, 
under like conditions, and even in the absence of profound anemia or actual 
endocarditis, not only transitory or inconstant murmurs, but also a weakness, 
undue sharpness, muffling, or abnormal accentuation of the cardiac tones, indi- 
cative of distinct though usually transient myocardial damage. 

Rest after Acute Prostrating Infections. — Many a case of persisting 
cardiac weakness and ultimate chronic degeneration of the myocardium 
dates its inception from the onset of such an attack, unrecognized and unsus- 
pected, and its persistence to a premature resumption of customary activities. 

Prolonged cardiac rest, rational heart stimulation, and a gradual and 
guarded resumption of normal activity, after diphtheria, acute rheumatism, scarlet 
fever, typhoid, severe influenza, and in fact, all acute infections attended by 
profound physical prostration, is a matter of vital prophylactic importance 
too little regarded at the present time. 

The almost universal failure to examine such cases thoroughly and critically 
after the resumption of full activity, results in the loss of many golden oppor- 
tunities to detect chronic cardiac and cardiorenal lesions in their early stages. 

The Viewpoint. — Obviously, a mere detailed study of individual lesions 
is by no means sufficient to prepare one to meet and deal with a branch of 
medicine characterized alike by the diversity and complexity of its problems 
and the interdependence and logical sequence of its morbid phenomena. 
Therefore, we must understand the genesis of such lesions and acquire a 
thorough knowledge of the symptomatic expressions of cardiovascular in- 
adequacy, more or less common to every organic lesion. 

THE VITAL POINT. — Heart-muscle is the paramount clinical factor in 
cardiovascular problems even though primary, associated, or consecutive valvular 
lesions, arteriosclerosis or pericardial inflammation are the most obvious and 
obtrusive elements in the given case. 

Diagnostic Limitations. — An impeccable antemortem differentiation of 
the many forms of pathologic change which may enter into myocardial degenera- 
tion and resulting cardiac insufficiency is an absolute impossibility. 

We cannot clinically differentiate the clinically indivisible, but we can and 
should recognize the resulting cardiovascidar insufficiency. 

Xor is it vitally necessary that we should finically differentiate the myo- 
cardial degenerative processes, if, relatively early, we are able to detect their 
presence and to retard their damaging effects upon the circulation and the body 
tissues which this nourishes and purifies. 

That which, even upon the autopsy table, leaves much for the microscope 
to determine does not lend itself to hair-splitting clinical diagnosis, and 



Toxic 
arrhythmias. 



Minor 

dilatations 

common. 



Significant 
signs. 



A neglected 
precaution. 



Always the 
myocardium. 



59° 



MEDICAL DIAGNOSIS 



No clean-cuf 
divisions. 



Shifts and 
changes. 



Subjective vs. 

objective 

symptoms. 



Loose use of 
term. 



Suggested 
limitation. 



A probability 
not a certainty. 



though one may definitely place an arrhythmia or a specific valvular lesion, 
the exact anatomic alterations of the heart muscle or of its coronary ar- 
teries cannot be determined antemortem. 

The Problem is Always Myocardial. — One properly may reiterate the fact 
that valvular lesions and the arrhythmias alone offer an opportunity for 
specific diagnosis and indeed their separate recognition is of great value and 
may strongly influence our management of the case. At bottom, neverthe- 
less, practically all problems are those of heart muscle and even our patholo- 
gists give few clean-cut differentiations of that composite of myocardial 
degenerations, invariably encountered post-mortem in the diseased heart. 
The question ever is that of predominance of one of the many pathologic 
processes present. 

Many Possibilities. — -A heart muscle may be congenitally unstable in 
strength and tonus, as in congenital asthenia; weakened by severe infections, 
by mitogenetic sepsis, or by the damage wrought by the physical handi- 
caps and associated myocardial damage, inseparable from valvular defects. 
To either condition, fatty overgrowth, fatty degeneration, cardiosclerosis, acute 
or chronic toxemias, actual bacillary invasion, coronary sclerosis, fresh 
endocarditis, or a pericarditis, may be superadded. 

Phasic Changes in Co-existent Lesions. — Several important lesions, 
valvular, vascular, or myocardial, may co-exist in the same heart, and, with 
the passage of time, the primary dominance of one may be submerged in that of 
another, and, ultimately, the combined, cumulative effect of all may be exerted. 

It is with relation to the myocardium especially, quite apart from manifest 
dilatation, that subjective manifestations are more important than objective 
symptoms as aids to early diagnosis and, as in the case of a positive Wasser- 
mann or the recovery of the streptococcus viridans or streptococcus rheu- 
maticus from a blood culture, may outweigh in therapeutic importance all 
the murmurs and thrills in the category. 

The basic symptoms are ever those of cardiovascular weakness, and im- 
paired "reserve" manifested in all varieties by much the same general symptoms 
and permitting no finely spun conclusions of a clinical sort as to the dominance of 
this or that form of degenerative process. 

"Chronic Myocarditis." — Myocardial degeneration or even "myocardial 
insufficiency 1 ' is a far better clinical term than the much employed " chronic 
myocarditis" until we shall have been told what actual chronic myocarditis 
really means in clinical terms. 

The author prefers to limit the latter term to cover, at most, the earlier 
periods in cases of chronic insufriciency distinctly following the acute infec- 
tions, in which severe acute myocardial processes, recognizable or not, have 
left residual nutritive deficiencies and degenerative processes which latter result 
in a dominance of fibrosis, fatty degeneration, brown atrophy or what not. 

We can no more than assume as probable the presence of a true chronic 
myocardial inflammation, from any antecedent history of a recent acute infection 
during which clinical signs and symptoms of myocardial insufficiency, still in 
part or whole existent, were clearly in evidence. 



HEART DISEASE — EARLY DIAGNOSIS 



591 



Recognition of Insufficiency Imperative. — Inasmuch as cardiac insuffi- 
ciency arising from any one of its many causes is so often exactly like that of 
the ott: :ust strive to recognize " insufficiency" itself, and as such. Upon 

thai foundation, we may build as stable a diagnostic structure as the ascertain- 
able, additional data permit and by this determine our therapeutic initiative. 

Cardiovascular Reserve. — A knowledge of these signs and symptoms 
peculiar to individual valvular lesions and those of gross myocardial insuffi- 
ciency together with the technical training necessary to their recognition 
are alike indispensable, but the therapeutically productive, life-extending 
field is that of conservation of cardiovascular reserve, and, as previously 
emphasized, the chief duty of the physician lies in the careful study of the 
signs and symptoms of the earlier and lesser compensatory defects. 

The Lesser Symptom -producing Insufficiencies. — These lesser cardiac 
insufficiencies and minor dilatations merit a far greater amount of study 
and therapeutic attention than they have hitherto received, for modern 
experience and investigation shows that damaging, acute and chronic, per* 
sistent, or temporary, but recurrent, toxemic overstrains with or without 
myocardial degeneration or underlying valvular disease, are relatively com- 
mon sources of many misinterpreted subjective or even objective symptoms.* 

CARDIOVASCULAR "SUFFICIENCY" AND "INSUFFICIENCY".— 
What Constitutes Compensation. — Although the so-called "compensatory" 
cardiac changes associated with and necessitated by actual diseases of the 
heart are usually adaptive rather than truly compensatory, they are never- 
theless wonderful in their efficiency and may remain effective as to the indi- 
vidual for decades in the case of certain lesions. Yet nothing can compensate 
more than partially or temporarily for the loss of a normal cardiovascular 
mechanism, and in certain forms of cardiac disease and in certain individuals 
compensatory changes are extremely imperfect. 

Even now we overestimate greatly the efficacy of those remarkable but 
imperfect retarding processes, which we term '•compensation."" Those of 
us who were privileged to serve in the Great War saw compensatory changes 
in the juvenile heart at their best, and it was difficult to realize the fact that 
if these young cardiopathic cases were as a body to be taken over by an 
insurance company the loss would run anywhere from 250 to 500 per cent. 
above that of an equal number of normal men. 

Nine hundred and ninety-nine out of one thousand confirmed cardiopaths 
today owe the major part of their protection from gross decompensation to 
symptoms, recognized or not by them, which automatically enforce a s' 
down of their activities, and most cardiopaths, with boaderline reserve, are 
constantly forcing their diseased hearts. 



The primary 
necessity. 



Early 
recognition 

imperative. 



Unrecognized 
inadequacies. 



Adaptation to 
conditions. 



Obligatory Dilatation. 



-In valvular lesions dilatation of some degree is 



* Homing's report upon a radiographic series of 1100 apparently normal hearts among 
which he found a considerable number of acute transient heart strains has served to show 
that the condition is more frequent than is generally supposed. 

Had his observations been directed especially to the "drop" heart and the remediable 
minor dilatations of the diseased heart his figures would have been yet more illuminating. 



592 



MEDICAL DIAGNOSIS 



primary and, ultimately, a certain increase in the cubic capacity of the heart 
chambers must be permanent. Secondary hypertrophy, responsive to the need 
of increased energy, limits dilatation and maintains reserve. Never strictly 
concentric, it is often a source of vascular degeneration from the associated in- 
crease of initial pressure involved. Almost invariably, it is soon in gradual 
process of being insidiously undermined by progressive myocardial degener- 
ation and an impaired coronary blood supply. The existence of aclinic ally and 
pathologically recognizable pure work-hypertrophy has never been demonstrated. 

Theoretically, hypertrophy may overcome completely any primary 
dilatation or be gradually induced without it as in the case of gradually de- 
veloped arterial hypertension or aortic stenosis, and adequately maintain 
the circulation for years by simple increase of ventricular force. 

Few, if any, cases justifying this assumption appear upon the autopsy table 
whatever the cause of death, nor can one understand the continued and stable 
effectiveness of such force increase, associated with normal rhythm, whether 
in the presence of free mitral or aortic regurgitation, aortic stenosis, or chronic 
hypertension, unless there is combined with hypertrophy an increase in the 
cubic content of the ventricular cavity. A certain amount of fixed dilata- 
tion is a necessary ultimate accompaniment of all such conditions, and with 
that the physician need not and cannot interfere. It is when tonicity and 
contractility begin to fail that aeticn is demanded. 

Morbid Dilatation. — Hypertrophy by limiting dilatation prevents over 
long peiiods that "overdistension" which represents the dominance of acute or 
chronic overstrain and excessive stimulus to contraction due to residual blood 
overload, venous stasis or both conditions in the presence of a diminished 
myocardial tonus. Such morbid dilatation produces symptoms, subjective 
and objective, in varying degree; narrows cardiac reserve; accelerrates ex- 
isting degenerative processes; and may properly be called morbid dilatation. 

An Apparent Fallacy. — One of the apparent fallacies of cardiac pathology 
is the theoretic assumption that inasmuch as the heart possesses the power to 
exert a thirteen-fold increase of strength to cover the field of response repre- 
sented by minimal and maximal demands, absolute rest on the one hand 
and severe physical strain on the other, it is quite capable of tiding over 
unaided and without additional damage, the period between the onset of a 
valvular lesion and the occurrence of established and adequate hyper- 
trophy, or even the increased dilatation which may result from infection, 
shock, or physical overstrain in established lesions. 

The normal heart of the individual who is reasonably "fit" may, and 
almost always does recover from temporary overstrain and dilatation 
provided that relative rest is secured. Otherwise, many, rather than a small 
minority, of college athletes would carry damaged or even crippled hearts."* 

* The heart of the perfectly trained robustly built athlete will actually diminish in size 
with quickened rhythm under strenuous exercise even if sustained during considerable 
periods, but the author has seen many congenitally asthenic or badly trained young ath- 
letes retired with badly dilated and extremely irritable hearts. Permanent damage is not 
uncommon. 



HEART DISEASE-EARLY DIAGNOSIS 593 



It cannot be true of the heart which had weakened and dilated under an 
acute toxemia of the sort associated with acute endocarditis or myocarditis 
or one which is more or less continuously subjected to chronic toxemia or 
sepsis and recurrent or persistent overstrain. 

Fortunately, however, from its large primary reserve fund enough usually 
is left available to keep even these hearts safe from actual disaster to their 




Fig. 297. — Normal heart, taken in inspiratory phase. Transverse measurement 13 cm. 

possessors until the necessary relief occurs, and some further self-protection is 
afforded the patient by the subjective sense of weakness, or an actual physical 
disability, which limits his activity during this period, but which he, unwatched 
and uninstructed, all too frequently disregards. brake 

That no damage is done in such cases is hardly conceivable nor is it in 
accord either with clinical experience or experimental work. 
35 



The automatic 



594 



MEDICAL DIAGNOSIS 



Big normal 
hearts rare or 
non-existent. 



Exaggerated Estimate of the Normal Dimensions of the Heart. — No 

radiographic examples of a normal heart of excessive size (exceeding 13.5 
cm. in total transverse diameter) have come under the author's observation. 
(See Cohn's Table under " Heart. "p. 429.) 



Damaging 
error. 



A common 
type. 




Fig. 298. — Beautiful example of the "hanging" ("drop") heart. The same quality 
is more or less well marked in all, if viewed fLuoroscopically during full inspiration. 
Total transverse, 9 . 5 cm. 

Many abnormally dilated hearts are accepted as normal in size because of 
a faulty conception of what constitutes a normal outline, together with a disre- 
gard of the law of proportionate weights and of individual peculiarities of body 
structure and conformation. 

THE "DROP" HEART OF THE CONGENITALLY ASTHENIC IN- 
DIVIDUAL. — During the past ten years the author has been deeply interested 



THE DROP-HEART 



595 



in the study of a host of cardiopaths showing predominant subjective mani- 
festations, together with clearly denned evidences of impairment of tonicity 
with or without either persistent cardiac dilatation or extreme dilatability, 
though the heart diameter, radio graphically, and by percussion, falls within the 
maximum "normal" 

The underlying condition corresponds apparently to what Mackenzie 
called the "X disease." His description is precisely that of a common type of 




Fig. 299. — An extreme instance of the "drop" heart (dorso- ventral aspect). Dimensions: 
Mr., 2 cm.; Ml., 5.5 cm.; total transverse, 7.5 cm. (Same heart shown in Fig. 158.) 

so-called "passive neurasthenia," and the physical and mental characteristics 
of these patients, as described by him, would seem to justify one in replacing 
his "sign of the unknown quantity" by the term " chronic congenital asthenia ." 
This, the constitutional defect of structure and function of which Berthold 
Stiller, of Budapest, has drawn so clear and vivid a picture as to secure 



What it 
represents. 



596 



MEDICAL DIAGNOSIS 




Fig. 300. — Dilated "drop" heart. (Outlines drawn from original roentgenograms (by 
E. Brill) and superimposed.) Dotted vertical white lines indicate outline after treatment. 
Case of premature resumption of activity after a very severe attack of lobar pneumonia. 
Note that in the case of this ambulant patient carrying a decidedly dilated heart the total 
transverse measurement is but 12 cm. Original measurements: Mr., 4.0; Ml., 8.0; total, 
12 cm. Final: Mr. 4.0; ML, 5.3; total, 9.3 cm. 




Fig. 301. — Dilated "drop" heart. (Original outline determined by orthopercussion; 
final profile, by roentgenogram.) Acute toxic dilatation associated with premature resump- 
tion of activity, following a severe attack of articular rheumatism. Syncopal attacks. 
Dotted vertical white line represents border after return to normal " drop." Original 
measurements: Mr., 4.3; ML, n. 5; total, 15.8 cm. Final: Mr., 4; ML, 6.5; total, 
10.3 cm. 



THE DROP-HEART 



: " 




Fig. zo2. — Dilated "drop" heart. (Outlines drawn from original roentgenograms by 

Note small transverse area (12.2 cm.) of the heart even when dilated. Vertical 

white dotted^line shows left border after treatment. Cause of dilatation unknown in this 

case. Right border of •'drop' 1 heart is ventricular not auricular as in normal heart. No 

objective symptoms of incompensation. Exertion dyspnea. Original measurements: 

_ : W ' : 2; total, ::.: cm. Final: Mr.. 4.; ML, 5. 7; total, :.- cm. 




— Dilated "drop" heart. (Drawn from original roentgenograms by E. Brill.) 
Perhaps the commoner acute type, showing decided involvement of the right ventricle. 
Case of influenza with marked prostration. Premature resumption of activity. Vertical 
dotted white lines show right and left borders after subsidence of dilatation. No objective 
ive a soft apical systolic bruit and exertion dyspnea. Complained of persistent sense 
of fatigue drowsiness during the day. Insomnia at night. Original measurements: Mr.. 
: 5. Ml., 8.0; total. 14.5 cm. Final: Mr 4.81; ML, 5.8; total, 10.6 cm. 



Clarifies 

obscure 
complexes. 



59S 



MEDICAL DIAGNOSIS 



its wide recognition by his European colleagues, nnd sits expression in a 
protean and kaleidoscopic symptomatology which satisfies a large portion 
of the terminology of several hitherto obscure syndromes, of which it con- 
stitutes apparently the basic factor. 




Fig. 504. — Re:ess:onof borders of a dilated ""drop " heart. Figures ;c^ and 505 sriowthe 
remarkable retraction attending the treatment of a dilated "drop"' heart. The case 
one of influenzal bronchopneumonia of long duration. Patient was ambulant when first 
seen by the author on February 17. Heart sounds short and sharp. Systolic bruits at apex 
and m pulmonary area. Apex beat diffuse. Systolic retractions over right ventricle. Pulse 
extremely labile but regular. Radiography showed a heart 16 cm. in total transverse 
diameter. On March 20 a second radiograph showed a reduction to- 13 cm. and a third 
taken on June 2, a further reduction to 0.5 err:. Fig. 305). 



The Heart of Congenital Asthenia. — If dilatation and hypertrophy are 
The "hanging" absent, these patients show usually a misleading!)' narrow, attenuated, extremely 
motile." mobile, more or less low-lying, ''hanging," heart {tropenform Herz), often asso- 



THE DROP-HEART 



599 



dated with a low diaphragm, arterial hypoplasia and marked vasomotor ar.c 
general circulatory instability and lability. 

During periods of impaired nutrition or toxemia the heart muscle is 
singularly deficient in sustained tonus or in any tendency to undergo decided 




Fi: - — rLesumption 01 ai 
laaon of the "drop" hear: th 

::-rtr.::i'_;- ~ri--: - i:~. : zr:j ir. 
line of massive pericardial enusi< 



id and full 



hypertrophy even when the seat of recurrent or more or less persistent minor 
".rains, but the readiness with which minor insufficiency or even dilata- 
tion occurs, under physical or emotional overstrain and, especially in acute 
infection, with or without associated murmurs of a peculiarly transitory 



DOatabiLty 



6oo 



MEDICAL DIAGNOSIS 



and evanescent character, is a striking clinical phenomenon which hitherto 
seems to have escaped specific recognition.* 




Fig. 306. — "Drop" heart of a man six feet two inches in height and of the asthenic 
type. He attends to business daily, but has so marked an exertion dyspnea as to make 
the ascent of a half dozen steps a cause of breathlessness. Reading aloud is difficult. 
Dimensions: Mr., 6.8 cm.; Ml., 2.8 cm.; total transverse diameter, 9.6 cm. There is 
no evidence of any attempt on the part of nature to repair the congenital defect. 

The signs of insufficiency are seldom strikingly objective even in decided 
dilatation and the change in the cardiac profile may be either very great, as in 

* So far as the author is aware attention to the direct clinical importance of this form of 
heart in the relationships here discussed dates from his delivery of the "Oration in Med- 
icine," read before the American Medical Association in 191 2. There is a wealth of liter- 
ature bearing upon the "drop " heart under its many variants of title. But the significance 
of its obviously defective musculature, misleadingly common clinical occurrence, tendency 
to obscure its own dilatations even when decided, and direct and constant relationship to 
visceroptosis seem to have been disregarded. See "Prognosis in Chronic Heart Disease as 
Adversely Affected by Certain Medical Traditions.'' Jour. A.M. A. vol. 59, p. 685-690, 1912. 



THE DROP-HEART 



60 1 



the case of severe acute dilatation in a prostrating acute infection or so slight 
as to make its recognition a matter of difficulty. In the latter cases, the 
quick response to rest and digitalis is illuminating. 

Effect of Environment and of Sex. — The series of illustrations offered show 
clearly the variations in form that these hearts may assume and suggest 
strongly the basic unity of the so-called " small heart" and the. "drop" heart. 




Fig. 307.— Stomach of patient whose heart is shown in Fig. 302. 

They also serve to explain the puzzling orthodiagraphic contours which 
have been presented, for example, by Adler and Krehbiel.* 

A dilated or a dilated and hypertrophied ''drop" heart may produce such 
outlines; a fundamentally normal heart, never. 

The so-called u small-heart" will be found almost invariably in suggestive 
association with the visceroptosis of congenitally asthenic individuals and 
in most instances represents a dilated or hypertrophied "drop" heart. 

* Archiv. Int. Med., Chicago, vol. ix, p. 346-361, 191 2. 



6o2 



MEDICAL DIAGNOSIS 



The "drop" heart is extremely common in the female; common in the male, 
and, probably, the effect of environment and mode of life in childhood has a 
great effect in determining its strict adherence or relative nonadherence to 
the type in development. 

In many if not most instances these individuals attain a degree of myo- 
cardial adequacy which enables them to lead an active life. 




Fig. 308. — Modified "drop" heart. Case showing distinct impairment of cardiac 
reserve, although heart measures but 9 cm. in total transverse diameter: Mr., 3 cm.; ML, 6 
cm. A soft localized systolic murmur was present at the apex. Right ventricle is enlarged, 
left also probably. 

To what extent the almost universally present roentgenographic signs of 
obsolete, latent or, more rarely, active tuberculous infection, affects the devel- 
opment of this type of heart is a question of interest. Such infections almost 
wholly, no doubt, date from childhood; for the " asthenic" tissues afford a 
favorable locus for the tubercle bacillus. 

Misleading Bruits. — Murmurs when present over these hearts are systolic 
and may be maximal in the mitral, tricuspid or pulmonic auscultation areas. 



THE DROP-HEART 



603 



The last are usually ascribed to anemia alone, but in such cases they may and 
often do occur in its absence or tend to persist or recur after any existing initial 
anemia is relieved. (See "Anemic" and "Accidental ^lurmurs.") 

Therapeutic Test. — In such cases the administration of full test doses of 
digitalis with, or oftentimes without, enforced rest, usually causes distinct amel- 
ioration or disappearance of some or even all subjective symptoms and, not 




Fig. 309. — "Drop" heart. 



It will be noted that the right border is hidden by the sternum- 
Ml. in this case is 5 cm. 



infrequently, a more or less decided but demonstrable shrinkage in the cardiac 
area of what may have seemed originally to be a heart of normal dimensions, but 
which proves to have been a dilated "drop." 

As previously stated, a "normal" transverse diameter, as usually defined, The cardinal 
represents in the heart of the congenital asthenic an enlargement, or, in 



604 



MEDICAL DIAGNOSIS 



Deceptive 
measurements. 



Such hearts 
Qf ten adequate. 



other words, the heart that is normal for the congenital asthenic is 
abnormally narrow for the individual of good physique. 

The undilated and non-hypertrophied asthenic heart may measure no 
more than 7.5 cm. in total transverse diameter in thin subjects and 9.5 to 
10.5 cm. constitute the usual normal. 




Fig. 310. — A modified "drop" heart associated with a soft mitral murmur and distinct 
signs of minor incompensation. A common form. Heart dimensions: Ml., 6 cm.; Mr., 
4 cm.; total transverse, 10 cm. 

Occurrence of Symptoms. — Possessors of "drop" hearts even of the nar- 
rowest type need yield no subjective symptoms or physical signs abnormal 
for the (abnormal) individual unless an acute infection, emotional shock, or 
actual and unusual physical overexertion initiates it. Furthermore, their 
resistance to such influences seems to depend to an amazing degree upon 
the state of nutrition of the individual, all well-marked and physically unre- 
generate asthenics being nutritional barometers. 



THE DROP-HEART 



605 



nutiitiun. 



/;; addition to subjective symptoms due to cardiac inadequacy these individ- 
uals, as patients, show a wealth of obscurant subjective symptoms resulting from 
their general structural deficiencies, and their chronic tendency to subnutrition Unstable 
and psychasthenic. A congenital muscular weakness and relaxation is present, 
which, as manifested by uterine displacements, loose kidneys, gastroptosis, intes- 
tinal kinks and the like, have afforded a large, though usually a thankless field 
for surgery. 




Fig. 311. — Stomach of same patient showing high grade gastroptosis. These cardiac and 
gastric types are apparently well nigh, if not wholly, inseparable. 

Constancy of Concurrence of "Drop" Heart and Visceroptosis. — So con- 
stant is the concurrence of this cardioptosis with abdominal visceroptosis 
that, finding a decided "drop" heart, one may assume with certainty a 
demonstrable gastroptosis and enteroptosis, and vice versa. Within slightly 
varying limits the degree of ptosis in the one is reflected in that of the other. 

Frequency of Occurrence. — One who is constantly using roentgenography Extremely 
as a part of the routine examination of patients, will find the "drop" heart in 



6o6 



MEDICAL DIAGNOSIS 



A bastard 
syndrome. 



some of its various forms just as common as is the abdominal visceroptosis 
with which it has run parallel in the author's experience. 

''Neurasthenia." — In this connection the author ventures the hope that 
the term " neurasthenia. '" which, though professedly a descriptive name for a 
supposedly concrete ailment, at present serves to obscure the true nature of 
so many of these cases, will either drop out of medical literature or be con- 




Fig. :::. — Modified •''drop* 5 heart. Periods of decided incompensation marked by 
syncopal attacks, exertion dyspnea, and precordial and epigastric distress. Total trans- 
trie diameter, 9.5 cm. 



hned to the extremely few cases left without a more definite assignment under 
the application of modern diagnostic methods. i,See '"Neurasthenia.'"' 

Psychasthenia.* — Recurrent or long-persisting subjective mental fatigue 
and excessive psychic irritability are the logical symptomatic results of a 
basic condition in which a constant tendency toward poor circulation, chronic 

* The term is used in its literal sense. 



THE DROP-HEART 



607 



subnutrition, toxemia, anemia, and secretory anomalies of the digestive 
tract and ductless glands, play the important part, and an hereditary struc- 
tural and constitutional disposition to psychic instability furnishes a fertile 
soil for the ready production of diverse and often bizarre symptoms. 

The Rest Cure. — Fortunately the u n so widely and effectively 

employed under the diagnosis oi "'neurasthenia." exactly suits the needs oi 




Fig. 313.— Same 



of "drop" heart. 



Usui: 



Lent 



the asthenic cardiopath from the standpoint of both nutrition and cardiac 
muscle tone, as indeed it fits the therapeutic needs of a vast number of other 
chronic diseases. 

SOLDIER'S HEART. — For the past ten years the author has been try- 
ing to emphasize the great clinical importance of the structural peculiarities prediction. 
of these people with relation to the heart itself. In 1915, in making a revision 



6o8 



MEDICAL DIAGNOSIS 



"Heart ex- 
haustion." 



Heart diseas 
may be 
lacking. 



of his "Medical Diagnosis" he predicted that a vast number of such cases 
would arise in army service and prove an embarrassment to the carrying 
on of military operations and also outlined the clinical picture which such 
individuals would present.* 

"Civil War" Cases. — These congenitally underpowered^ functionally 
unstable persons are born with defective or potentially inadequate {not 
diseased) myocardia and furnish the most typical examples in army service 
of that condition described originally by the elder DaCosta during our 
Civil War as the "irritable heart of the soldier," and better and much more 
aptly by Dr. Hartshorn, also of Philadelphia, as "heart exhaustion." 

Basic Factors. — During the war just past great numbers of cases of 
profound myocardial exhaustion were denominated "soldier's heart," "neuro- 
circulatory asthenia" "neurocirculatory myasthenia " or "effort syndrome" 
but fundamentally the larger and more interesting group was composed of 
victims of universal congenital asthenia wholly free from any actual disease 
of the heart yet showing abundant evidence of myocardial exhaustion. The 
condition of the heart in these soldiers differed in no essential feature 
from that encountered by the author in civil practice during the past decade, 
save that the degree of decompensation present was much greater on the 



Myocardial 
exhaustion. 



The Commoner Symptoms. — The cardiovascular symptoms present in 
these "soldier's hearts" are simply those of myocardial exhaustion or 
impairment of various degrees accompanied no doubt in many instances by 
those of an acute dilatation which in all probability was recognized as such 
only in the rarest instances because of the initial narrow diameters of 
the "drop" heart and its modification. These maybe summarized as 
follows : 

(a) Persisting sense of fatigue or an unusual fatigability. 

* ' ' The elements of shock, emotional crises and physical exertion which enter so 
greatly into modern warfare must produce acute heart strain in vast numbers of young 
soldiers of the slender congenitally asthenic type. One may venture to predict that 
the condition will prove to be extremely common in the European war and that it will 
fall upon this type of individual in a large proportion of the cases. This being the 
case the clinical picture presented will be one of profound physical exhaustion, a high 
pulse rate, without any marked constancy of arrhythmias save of the juvenile type, except 
there be a history of antecedent ''trench fever," "rheumatism," " tonsillitis " or 
antecedent organic heart disease. 

Arrhythmias should occur chiefly in the older groups in whom antecedent degenera- 
tive myocardial processes might be anticipated. 

In young asthenics high grades of functional nervous disturbances might be expected. 

The heart outline in the older or previously tainted individuals might be abnormally 
large. 

In members of the asthenic group it should seldom exceed greatly the normal maximum 
diameter (13 cm.), by reason of the fundamentally small size of the "drop" hearts which 
constitute their normal. 

Both subjective and exertion dyspnea should be present initially and vertigo, faint- 
ness or actual syncopal seizures would be noted at the onset of the attack in many instances. 

The symptoms of more or less profound psychasthenia might be assumed as inevitable 
in a large number of cases." 



THE DROP HEART 



609 



(b) Dyspnea on exertion or, in the severer cases, more or less persistent 
even when at rest. 

(c) Vertigo in the more extreme cases. 

(d) Discomfort and, in the more acute cases, actual precordial pain. 
This sensation varied from a mere sense of substernal fulness, crowding 
or pressure, dull aching, to actual angina of the severest type. 

(e) Syncope. Syncopal attacks seem to have occurred with far greater 
frequency than would be the case in civil practice, no doubt because of the 
more complete and acute exhaustion sustained by the myocardium under 
service conditions. 

(/) Tachycardia. As might be expected, tachycardia was a symptom 
very generally encountered and this sometimes persisted over long periods 
or even after treatment had been abandoned. On the other hand, persistent 
arrhythmias seem to have been relatively infrequent. 

Heart murmurs, if present, were slight, often transient, systolic, and of 
the type usually termed functional or accidental. 

Failures in Primary Selection. — In 191 7, when acting on a Cardiovascular 
Board, the author found and reported that we were passing large numbers 
of these congenital asthenics into all branches of army service who could 
not prove otherwise than a burden to any command, but practically no 
recognition had been given to this clinical group and consequently there 
were no rules of selection in effect adequate to protect the army from their 
undesirable presence. 

As is now known, to an astonishing degree they proved an element of 
embarrassment in the conduct of military operations, many breaking, at 
the outset and during training, others going on and yielding only under 
the stress of actual front-line service. 

Vital Points. — Surprisingly, one finds even in the recent literature little 
understanding of the fundamental structural and functional inferiority which 
pertains to this most interesting body of men and women. 

The author would especially lay stress upon the fact that, although in 
them as in other individuals, any and all kinds and degrees of organic myo- 
cardial or valvular defects may occur, yet the interesting and outstanding 
feature is the relative ease with which varying degrees of myocardial insuffi- 
ciency, from slight to grave, may be produced in the absence of actual disease 
of the heart muscle, its valves, or its blood vessels, by causes insufficient 
to affect adversely the hearts of sthenic individuals. 

Adaptation and Self -protection. — Furthermore, a large proportion of 
these congenital asthenics, though born under a handicap, achieve through 
favorable environment an amount of myocardial reserve and a degree of 
functional sufficiency which does not permit us to distinguish them from 
the more favored individuals of our general population except by the detec- 
tion and assessment of certain stigmata to be referred to later. 

In civil life the congenitally asthenic individual in many instances 
consciously or unconsciously acquires the habitude of self-limitation of 
effort and self-protection from adverse influences which threaten his 
39 



Non-recogni- 
ion. 



Its result 



Self- 
protection. 



6io 



MEDICAL DIAGNOSIS 



inadequate myocardial reserve. In the Army such self -protection was 
impossible. 

Period of Breakdown. — The cases which figure so largely in the medical 
reports of all armies engaged in the "Great War" fall naturally into two 
groups. 




Fig. 314. — (E 72). So-called "soldier's heart" in civilian patient. A typical ex- 
ample of what is so frequently described as the "small" heart. ■ Is actually an enlarged 
drop heart. The electrocardiogram shows marked right ventricular preponderance. 

i. The particularly unstable group which broke down at the outset. 

2. Those who "carried on" until their greater yet fundamentally less- 
ened reserve yielded to the tremendous strains imposed upon them in actual 
service or in combat warfare. 



THK DROP HEART 



6ll 



It may be added that this same group of individuals furnished a large 
proportion of the persisting psychoneuroses which were returned to our 
country and to others for treatment. 

Leading Characteristics. — The chief characteristics of this group, aside 
from the presence of the "drop heart" or its modifications (usually described 
as the "small" heart), are: 




Fig. 315. — ''Drop" heart in patient suffering at intervals from definite but not 
extreme decompensation. All through life there has been conscious self protection from 
overexertion. Xo murmurs were present even during periods of decompensation. Elec- 
trocardiogram shows right heart preponderance. 



(a) A slender build, in general representing what used to be called the 
pre-phthisical habitus." with slender bones, slender and oftentimes poorly- 



6l2 



MEDICAL DIAGNOSIS 



developed muscles, an especial flabbiness being present in many cases in the 
abdominal musculature. 

(b) Most of them are possessed of a long and narrow or flattened thorax 
with a sharp or relatively sharp intercostal angle. 




Fig. 316. — Enlarged and insufficient "drop" heart. Total transverse diameter 
n. 1 cm. The type of heart frequently miscalled the " small" heart. Skeletal musculature 
in this young woman unusually developed. Abdominal muscles relatively flabby. Marked 
gastroptosis present with atony. Dyspnea on exertion pronounced; fatigability decided. 
Patient has been very strong with respect to individual and brief physical effort but has 
lacked endurance all her life. Such hearts at present are almost invariably passed as 
normal by the physician or life insurance examiner. 

This does not mean that such individuals are necessarily meagre, emaciated, 
or underweight. Indeed many are "heavyweights" and some carry an amount 
of adipose tissue which tends to obscure their structural peculiarities. 



THE DROP HEART 



6l 3 



(c) All are predisposed to the curious instability of function which is 
universal, and to another peculiarity of the utmost importance in connection 
with war, namely, a remarkable dependence upon nutritional reserve and a 
peculiar instability of this reserve. Furthermore, they are especially vulner- 







Two vital 
factors in 
causation. 



Fig. 317. — Markedly dilated "drop" heart the seat of myocardial degeneration. 
Symptoms of decompensation marked during preceding six years. No murmurs present. 
Gastric disturbance a prominent feature. Dyspnea on exertion, constant fatigue, slight 
edema of lower extremities, marked tenderness over left heart border. Gastroptosis 
decided. Patient a woman, weighs 200 pounds. Under treatment the diameter of this 
heart (i6.4.cm.) was reduced to 13.8 cm. as shown in Fig. 318. It will be noted that the 
original "drop" heart contour has been measurably resumed although both right and left 
ventricles are hypertrophied. Such silent degenerated "drop" heart are especially decep- 
tive and misleading. 

able with respect to infections, and well-defined cases convalesce slowly and 
oftentimes imperfectly from such infections. 



614 



MEDICAL DIAGNOSIS 



Visceroptosis. 



(d) The great majority of them go on without any symptoms so long 
as they are well-fed, well-nourished, and well-environed. Reverse this and 
they become subjectively, or, less often, frankly ill. 

(e) More vital, from a diagnostic standpoint, than these traits just 
named is the presence of universal visceroptosis in varying degrees. 




Fig. 318. — Same heart as shown i-n Fig. 317 showing shrinkage of outline under 
treatment and the approach to the original "drop" heart outline, which has been obscured 
by the dilatation existing over a long period of time. 

Many years ago the author pointed out that, with rare exceptions, in fluoro- 
scopic examinations one might make an immediate diagnosis of "drop-heart" 
in examining the abdomen and finding a gastro ptosis or decidedly movable 
kidney. So on the other hand, finding the heart of congenital asthenia, one 
could accurately affirm the presence of a ptotic stomach. 



THE DROP HEART 



615 



One must not understand that all cases of so-called ''effort syndrome," 
or ''soldier's heart" are congenital asthenics. The symptoms characteristic 
of this syndrome are merely those of profound myocardial exhaustion. 
extreme narrowing of reserve, and may be produced most readily in these 
individuals congenitally unfit or potentially so. 




Fig. 319. — (E 86). "Soldier's heart" in civilian male. Type of individual who in the 
Army broke down under the severer stress and strain of actual campaigning. This man 
had lead an active out-of-door life as a ranchman but following severe overstrain com- 
plained of syncopal attacks, precordial pain on or following exertion, marked fatigability, 
recurrent edema of ankles and feet, and intervals of arrhythmia apparently due to recurrent 
fibrillation. 

Note that total transverse diameter of heart at this time was but 11.7 cm. The gastro- 
ptosis present in this case is shown in Fig. 320. (See also Fig. 321.) 

On the other hand any and every cause operating upon any heart and 
adequate to produce a marked diminution of tonus may produce exactly the 



6i6 



MEDICAL DIAGNOSIS 



same symptoms, for these are identical with those shown by individuals carrying 
normal hearts but subjected to intense exhausting myocardial overstrain. 

Indeed, the recognition of the "soldier's heart" rested largely upon 
the ease with which these symptoms were produced under physical 
effort, mental strain, or both combined in individuals lacking the signs 
of frank organic heart disease. 




Fig. 320. — Gastroptosis associated with insufficient drop heart shown in Fig. 319. 

Obligatory Exposure to Adverse Influences. — The adverse influences 
operating upon the victim of universal congenital asthenia who had been 
inducted into army service varied greatly with the type of service demanded 
of him but embraced on the whole everv factor calculated to break down 



THE DROP HEART 



617 



the reserve of a considerable proportion of the young adults carrying this 
constitutional defect. 

As has been stated, the element of self-protection often unconsciously 
plays a large part in the ability of large numbers of the congenital asthenics 
to endure such stress and strain of life as falls upon them, but when brought 




Fig. 321. — Same heart as shown in Fig. 319 showing increase of diameter to 
12.7 cm. following the undertaking of heavy work against physician's orders. This 
enlargement was associated with a renewal of the old symptoms which had disappeared 
under treatment. 

Note that even when thus dilated the heart falls well within the so-called "normal'' 
transverse cardiac diameter. 

into army service these safeguards, consciously or unconsciously established 
bv them, were of necessity abolished. As a result large numbers could not 
withstand the "hikes" and drills even of the opening days or weeks of their 
period of military training. Others with greater reserve weathered the 



6i8 



MEDICAL DIAGNOSIS 



training period only to become unfitted for service under conditions of actual 
campaigning across the water or the yet more strenuous demands, psychic 
and physical alike, of actual fighting at the front. 




Fig. 322. — "Soldier's heart" in civilian. Another example of the "drop" heart 
which played so important a part in the cardiac disabilities of our troops in Army 
service. This individual was able to do heavy farm work up to the age of 18. Collapsed 
while working in hayfield during very hot weather. At the time this exposure was made, 
showing a heart only n. 7 cm. in total transverse diameter, decompensation symptoms 
were pronounced, there being marked dyspnea on exertion, subjective persisting 
dyspnea and precordial discomfort. Patient's recovery was reasonably prompt under 
treatment and all active symptoms disappeared. Nevertheless his reserve is per- 
manently impaired and heavy work cannot how be undertaken. 

Myocardial Toxemia. — Aside from this, it should be remembered that a 
very large proportion of these individuals carried concealed septic foci or 
I larval tuberculous infection such as might be, and often were, relighted under 
I conditions of army service. 



nn: drop in: \u r 



619 



Furthermore, many were subjected to primary acute infections such as infections, 
mumps, measles, pneumonia, and influenza and were not giveii that pro- 
longed period of convalescence necessary to individuals of this type. 




6 A.V 






Fig. 323. — "Soldier's heart'' in civilian. A type frequently encountered in Army 
service. Reserve capacity good but failing under great physical and mental stress, 
or both of these elements combined. This individual was seen first in an attack of acute 
dilatation associated with fibrillation; both of which conditions endured only sixteen hours 
as nearly as could be determined at the time. Young active man. The outline is that of 
a "drop" heart. There still exists (after treatment covering about three weeks) mani- 
fest enlargement of the left ventricle which probably is permanent and represents hyper- 
trophy. This finding is confirmed by the electrocardiogram. 

Condition Common to Civilian and Soldier. — The author would repeat 
that "soldier's heart," "effort syndrome," "neurocirculatory asthenia," 



620 



MEDICAL DIAGNOSIS 



Non-recogni- 
tion of 
dilatations. 



"neurocirculatory myasthenia' ' not only are one and the same thing 
but represent conditions in no way peculiar to army service. 

As stated previously, the cardiovascular symptoms presented by these cases 
differed in no way from thoseeencounyered every day in cival practice though 
in a larger proportion the evidence of exhausted myocardial reserve were more 
extreme and the difficulties attending its rehabilitation and restoration were 
correspondingly greater. 

Undoubtedly, owing to the adoption of faulty standards with relation 
to heart measurements, a great number of cases of actual dilatation were 
overlooked and, furthermore, the treatment which these men received in 
general was not such as would in the highest degree promote their permanent 
recovery. 

One is not surprised, therefore, to find that a large percentage of such 
cases were discharged unbenefited, or but partially restored to health. 

Unstable Reserve. — In the heart of the congenital asthenic there is a 
degree of instability with relation to reserve which makes the rebuilding 
of the myocardial strength a matter of the utmost difficulty. This is 
peculiarly true of such cases as arose in a multitude of instances during 
army service where, because of unavoidable and obligatory exposure to 
adverse influences, the exhaustion of the myocardium was unusually 
profound. 

Fundamentals in Treatment. — In treating profoundly exhausted cases 
the utmost care should be observed throughout with respect to the resump- 
tion of physical activity. One must be satisfied with slow, tedious, incre- 
mental renewal of reserve power through primary rest followed by a most 
carefully regulated resumption of walking exercise. Under no circum- 
stances should such individuals be " tested out" from time to time to a 
point of fatigue or the revival of any of those symptoms characterizing their 
condition. 

According to the author's experience in civil practice, it is as easy to 
empty such hearts of newly acquired reserve in the earlier stages of their 
improvement as it is to pour water out of a glass, and the utmost care is 
necessary to prevent the patient from putting his newly acquired strength 
to tests long before he has reached a degree of restoration which makes this 
safe. He must not only be kept within the limits of his reserve during his 
slow progression but always well within the safety zone. 

Another curious factor in relation to such cases with marked degrees of 
reserve impairment has been the deleterious effect of upper-arm exercises or 
marked body flexion, and in the author's private practice these are carefully 
avoided. 

It is to be hoped that in the deplorable event of another war the rules 
and the means of selection may be such as will better protect the army 
and its various services from those members of the congenitally asthenic 
class who are likely to break down under the stress of war, and, on the 
other hand, secure to selected members of this grouo opportunity for patriotic 
service suited to their physical ability. 



THE DROP-HEART 



621 



MINOR INSUFFICIENCIES.— The symptoms of cardiac origin as mani- 
fest oftentimes in such cases as fall under the ailment just described, namely, those 
of chronic congenital asthenia with weakened hearts, throw much light on the 




Fig. 324. — Modified '"drop" heart often encountered. Young man of nineteen 
Never robust, yet six feet tall and inclined to athletics, in which he is fairly proficient 
Inherits the powerful build of his mother's family and the "drop" heart of his small-boned 
father (radiographically demonstrated). Boys may attain a good heart despite congenital 
handicaps, but frequently pass through phases of partial inadequacy. Many break down 
on the athletic field, but only temporarily in most instances. A young man of this type 
with exactly the same inheritance and heart outline, stroked one of the greatest crews in this 
country for a year, only to break down in his second year with wide dilatation. 

subjective manifestations of cardiac insufficiency of minor grades arising from 
more serious causes. 

The peculiar clinical features of the ptotic heart and its chief relationships 
mav be thus summarized. 



622 



MEDICAL DIAGNOSIS 



The "drop" heart is merely one manifestation of what is usually 
a general visceroptosis, slight or decided, and may or may not consti- 
tute its dominant feature clinically and anatomically. 

The author is convinced that the parallel between the "drop" heart and 
the "'drop" stomach especially is a relatively exact one. 



v 1 


I 


- 









Fig. 325. — (E 66). Interesting example of enlarged "drop" heart in a female of 
Amazonian type, representing probably a case of crossed inheritance. General build and 
skeletal musculature was extraordinarily good. The symptoms were almost wholly gastric. 
There was slight edema of the lower extremities which had gone unnoticed by the patient. 
Slight exertion dyspnea also was present. Gastroptosis decided. (See Fig. 259 for com- 
parison.) 

Both are evidences of constitutional defect in great measure. 
Both are extremely common but may show all gradations from the typi- 
cal to that which closely approximates the normal. Both tend to show 



THK DROP-UK \R I 



()2 . 2 > 



symptoms only under conditions of impaired nutrition and in each these 
take the form of atony, functional instability and the production of trouble- 
some subjective symptoms often of a most misleading character. 

Both are peculiarly responsive to functional rest and other measures cal- 
culated to restore their labile nutritional balance and increase their tonus. 




Fig. 326. — (E 66'). Outline of heart shown in Fig. 325 following treatment. Total 
transverse diameter has been reduced 1 cm. All symptoms have disappeared and the heart 
is shown to be of the modified "drop" type with enlargement of both right and left ven- 
tricles. This is the type of heart so often described misleadingly as the "small" heart. 

Neither, of itself, is a fatal or even serious ailment and under favorable 
environment both conditions may be carried throughout a lifetime replete 
with good health and characterized by what is essentially normal activity, 
both mental and physical. 



624 



MEDICAL DIAGNOSIS 



On the other hand, both may make their possessor trouble from child- 
hood to the day of his or her death from some other cause. 

The heart by reason of the peculiarly insistent and persistent demand 
upon its musculature and its abnormal sensitivity to acute and chronic 




Fig. 32; 



-Modified insufficient "drop" heart in a heavy woman carrying beneath her fat 
the basic asthenic stigmata. Transverse measurement 8.5 cm. 



toxemias is especially Uable,remittently or persistently, to show a diminution 
of reserve and consequent limitation of the field of symptomless forced 
response. 

In the heart both periods of impaired tonicity and even of actual minor 



THE DROP-HEART 



625 



but pathologic dilatation are extremely common. See Figs. 329 and 330 
and, especially, Figs. 356 and 357. 

Finally, that these periods have, in the past, almost wholly been over- 
looked and disregarded. 

Fundamental Assumption. — It is obvious that one would not await 
the onset of pulmonary or renal congestion, hepatic engorgement, marked 
dyspnea, ascending edema and flagrant and obtrusive dilatation, before 
feeling justified in active therapeutic interference in heart disease if he pos* 
sessed the means of recognizing with some degree of certainty the minor 
grades of actual insufficiency. 

These major symptoms represent the expression of serious or extreme cardiac 




Fig. 328. — Heart of a fat male asthenic with poor resisting power and endurance. 
"Hanging-drop" heart typical save that it gives evidence by its contour of a musculature 
far above the normal for that type. Total transverse measurement only 9 . 2 cm. 

weakness, a dangerously narrowed field of myocardial response, and, fortunately 
for the patient, often serve him both as danger signals and emergency brakes, 
but they should not constitute the sole criteria of therapeutic initiative. 

Unavoidable Effects of Cardiovascular Lesions. — However chronic and 
slowly progressive the condition, crippling valvular lesions, progressive myo- 
cardial degenerations, sclerosis of the coronary arteries or of the entire 
vascular system, high arterial tension and the like, once established, after 
a variable but usually greatly prolonged period of adequate balance inevit- 
ably embarrass and hamper the intricate, exquisitely responsive and deli- 
cately balanced mechanism of the circulation and tend constantly or inter- 
mittently to overwork the heart and blood vessels, narrow the field of pre- 
viously effortless response and reduce the legitimate life expectancy of the 
patient. 

COMPENSATION AND DECOMPENSATION.— Sequence of Events 
in Decompensation. — This varies somewhat with the nature and site of the 
40 



Avoidable 
delay. 



626 



MEDICAL DIAGNOSIS 



Over- 
distention 



Dilatation 



primary or dominant lesion. If one assumes as an example the sudden 
production of aortic leakage, his mind's eye at once sees the diastolic back- 
rush of the blood from the aorta to the left ventricle, the overdistention of 
that elastic pumping chamber by the opposing currents represented by 




Fig. 329. — (E 80). Same heart as shown in Fig. 330. showing the reduced diameter 
following a short period of ambulatory treatment. The heart was originally a 
"drop" heart, marked associated gastroptosis being present. The outer white line shows 
the passing out of the left border by renewed dilatations after the patient had broken 
treatment and disregarded all instructions, the result being the recurrence of pulmonary 
congestion and other signs of minor decompensation. 

that pouring through the open mitral valve from the auricular reservoir 
above and the abnormal inrush from the aorta below. 

One finds primarily a dilatation of the left ventricle, limited and con- 
stantly resisted by muscle tonus and contractility, and usually, by an in- 



Ill ART- COMPENSATION 



627 



creased frequency, evidently adapted to lessen the load per heart beat, and 
yet supply the vitally necessary nutriment to the body tissues and burn their 
waste products. It is evident that the intermittent shock and overaction 
now experienced by the aorta and to a less degree by the blood vessel Arteries. 
throughout the body cannot but tend gradually to produce degenerative 




Fig. 330. — E 80'). Readily dilatable "drop" heart in obese young woman. Decom- 
pensation when present manifested chiefly by pulmonary congestion. Exposure shown 
was made during such a decompensate ry period. The total transverse diameter is 14.7 
cm. See Fig. 329 for comparison. 

arterial changes and a slowly progressive increasing deficiency of the 
peripheral circulation and of the heart itself. 

Men do not often die of chronic valvular disease, per se, but of its inevitable 
accompaniment, myocardial degeneration. 



628 



MEDICAL DIAGNOSIS 



Acquired 
equilibrium. 



Hypertrophy is gradually superadded to dilatation and after a variable 
period, in young hearts at least, the increase of muscle and the dilatation 
limiting tonus establish a circulatory equilibrium backed by a variable amount 
of "reserve," often wholly adequate to hard labor, and a normal pulse 




Fig. 331. — A type of cardiac outline frequently observed in high blood-pressure cases. 
Note underlying "hanging drop" type and extremely small transverse diameter despite the 
increase of left heart area. 



rate. There remains, however, perhaps only in slight and unnoticeable 
degree, a constant slowly progressing damage in the vascular field. In such 
cases we inaccurately but conveniently say that " the lesion is compensated." 



HEART-COMPENSATION 



629 



A Cardiovascular Paradox. — So wonderful is this adaptive change that 
for years a man may pursue a laborious occupation without any serious 
break in this circulatory equilibrium, yet he may and often does break down 
suddenly under some unusual physical strain, no greater, less perhaps, than 




May endure 

for years. 



Fig. 332. — A "drop" heart, once typical roentgenographically, which has assumed a 
modified aortic profile during the past ten years by reason of the development of an inter- 
stitial nephritis and sclerotic changes in the aortic valve, associated with systolic and dias- 
tolic bruits, persistent arterial hypertension and a sustained high diastolic level. Viscer- 
optosis and other stigmata of congenital asthenia typical; patient during many years 
was typical "neurasthenic" and "nervous dyspeptic;" and bears scars of several futile 
abdominal operations. Cardiac compensation never more than "fair." Best for several 
years at the time this exposure was made. Dotted line shows approximate form and 
position of left border before the period of change. Under author's observation twenty 
years. Despite the great relative change in size, the heart measures but 14 cm., total trans- 
verse diameter. (Died of cerebral hemorrhage since the legend was written.) 

that of his daily labor, to the peculiar strains and vicissitudes of which 
cardiac and skeletal muscles alike have become trained and habituated. 



6.SO MEDICAL DIAGNOSIS 



Progressive Diminution of Cardiac Reserve. — Year by year the margin 
of relative safety for such patients diminishes under the effects of more or less 
Potent causes, constant myocardial overstrain, the abnormal arterial and venous pressure, the 
toxins of fatigue, disturbed metabolism j the constantly impaired and ever 
diminishing coronary blood supply, and the invariably progressive cardio- 
vascular degeneration. 




Fig. 7)33' — -^ n interesting example of the dilated and hypertrophied imperfectly com- 
pensating "drop" heart. The patient's heart formerly measured about 10 cm. For the past 
eight years she has carried arterial hypertension 170 to 220 + and passed through a cerebral 
apoplexy. Weight of patient was 185 lb. but the structure was typically asthenic. The 
diseased and greatly enlarged heart shows a "normal" (13.5 cm.) measurement. An 
impure mitral first sound or an actual apical bruit has persisted. Slight edema is present 
usually, but patient is ambulant. 

Direct factors. To t k e5e constant f ac t rs one must usually add the effects of recurrent 

infection or toxemia from primary cryptogenetic sources or from without. 



HEART COMPENSAT: 63 1 



The Laboring Heart, — Certain direct decompensatory factors are com- 
mon to all valvular and myocardial lesions and the chief of these are muscle 
strain, gradually oUininishing tonus with progressive or recurrent in 
both of dilatation and dilatabilitv, and progr .isceptibilitv to fatigue. 




Fig. 554- — Widely dilated heart of the ''drop'* type. Ambulant patient extremely weak 
and dyspneic. Case of pernicious anemia, erythrocyte count 1,325.000. Heart undoubt- 
edly the seat of fatty degeneration and shows evidence of fatty infiltration in the shape of 
an illy-denned "tail" at the apex. Heart measurements — _: _ ML, 11.5 cm.; 

total transverse. 16 cm. Typical stigmata of congenital asthenia. Death six weeks later. 

representing a slow but constant contraction of the field of cardiac 
response. 

The wonderful cardiovascular mechanism can and does overcome unaided its 
more or Jess frequently recurring periods of minor insufficiency, though at a con- 
stantly increasing cost f but not without flying distress signals other and earlier 
than the classic symptoms of the later stages of decompensation. 



632 



MEDICAL DIAGNOSIS 



Permits effect- 
ive therapy. 



Early Diagnosis. — We are just learning the importance and value of the 
early diagnosis of heart disease and of prompt recognition of myocardial 
insufficiency of lesser grades as prerequisite to timely and effective treat- 
ment. The aim and end of diagnosis is effective therapy and no department 




Fig. 355. — Interstitial nephritis with progressive increase of arterial hypertension 
Effect upon a "drop*' heart. Patient under observation twenty years. Change in outline 
associated with periods of transient dilatation and increased arterial tension nve years ago. 
At present systolic pressure varies from 185 to 200 -p and incompensation is manifest in slight 
diurnal leg edema, slight dyspnea on exertion and persistent subjective fatigue. Heart 
only 13.8 cm. in total transverse diameter. (Death from acute dilatation and pulmonary 
edema since legend was written.) 



of medicine offers a broader, better, or more fruitful field than that of cardio- 
vascular disease. 

A suggestive parallel is to be found between the present neglect of the early 
evidences of decompensation in the cardiopath and the like failure to recogjiize 



HEART — COMPENSATION 



(>33 



and direct or treat the victim of incipient and early phases of tuberculosis but 
a few decades ago. Results may be obtained in heart disease through early 
recognition, wise supervision and direction in minor grades of insufficiency, 
which will compare most favorably in respect to bestowal of added comfort and 




Fig. 336. — Aortic regurgitation and mitral insufficiency superimposed upon a "drop" 
heart. After several years the heart has attained a transverse diameter of 11.5 cm. 
Ml. 8.5; Mr., 3 cm; total. 11.5 cm. The "hanging" quality is shown even better in 
the original negative. The patient's reserve was distinctly impaired. 

increase of longevity, with those now obtained in tuberculosis. One cannot but 
surmise that, if the cardiopath were infective in proportion to the presence or 
increase of decompensatory signs, he would fare better. 



634 



MEDICAL DIAGNOSIS 



Retardation and Rehabilitation the Primary Need. — As in the case of 
tuberculosis, so also in heart disease, the effectiveness of its management 
depends upon the earliest possible recognition of the lesion itself and of its 
decompensations. Such management involves intelligent oversight, sane 
counsel and, when any insufficiency is discovered, rational and timely thera- 




Ftg. 337. — Despite obvious enlargement of the left ventricle the total transverse 
measurement is but 10.5 cm. i^See Fig. 338). 

peutic aid directed especially to the relief of those lesser decompensatory 
phases which are inevitable sooner or later, once the lesion is definitely 
established, though often almost unbelievably slow in. reaching a recogniz- 
able stage, once the primary insufficiency has been compensated. 



HEART — JNCOMPENSA TM\ 



635 



MEANS OF EARLY RECOGNITION OF FAILING RESERVE.— It 

is evident that the means of such prompt recognition of cardiovascular 
insufficiency deserves first consideration and discussion. 

Direct Tests of Cardiac Sufficiency. — We have sought long, but never 
yet found a direct, single, simple test of cardiac sufficiency of moderate grades. 

Even the wonder-working modern instruments of precision fail to supply 



Unreliable 
tests. 




Fig. 338. — Stomach of patient whose heart is shown in Fig. 2i 

gastroptosis. 



Note decided 



this need in any degree at all commensurate with the time and training neces- 
sary to their intelligent and critical use. 

The muscle antagonism test of Herz* the pulse rate recovery test of Mendel- 

* Flexion of the forearm at the elbow if firmly maintained is supposed to slow the pulse 
if the heart be weak. 



::: 



MZDICAL DIAGNOSIS 



3ohn and Graupmer* or thai of KaktnsUinJ ore alike uncertain and 

Varioos other tests based upon the variations in blood pressure attend- 
ing changes in posture or stated exercise, and even resort to the deter* 




±zz: 



:- - 



; :zs: iere-d 



:i;i:::; 



::":: :e 



*Tnnerec 

" Iz-Ztn: 

± ::: Ilrr I Z 



hear: 



DECOMPENSATION 



657 



Many other similar tests are alike indeterminate, but fortunately we may in 

most instances detect existent cardiac insufficiency bx the response of anx sub- Valuable 

, . . /•', ,. ■ simple 

w symptoms present, and. m many instances, oj the cardiac percussion area method. 




Fig. 54c. — Same heart as shown in Fig. 2 So. showing remarkable change in outline 
under treatment and full recovery of compensation. Mr.. 5 .5 cm.; ML, 10.5 cm.; total 
M., 16 cm. A reduction of 3 cm. in transverse diameter is evident, a remarkable figure for a 
hypertrophied and dilated heart of this type. One has to think of the circumferential 
reduction obtained to appreciate the full measure of change. Another patient under treat- 
ment at the same time (transverse measurement 17 cm., and showing initially the same 
conditions less the Cheyne-Stokes breathing, left the hospital rehabilitated, yet showed a 
shrinkage of but 0.5 cm., an amount too small to be exactly determinable. The cases 
emphasize the fact that impaired tonus rather than mere relief of dilatation is the funda- 
mental factor. 

of the suspect, to a few full and adequate but physiologic doses o T ' a direct cardiac 
stimulant with or without absolute rest, as the individual case demands. 

y either the normal heart nor the efficiently compensating hypertrophied Heiphii fact 
heart should show a decided change [Frankel and Schwartz, Cloetta;. 



6;S 



MEDICAL DIAGNOSIS 



Una voki able 
errors. 



Know and 
demand 
the normal. 



The readiness with which decided dyspnea is produced under exertion 
doubtless remains the mcst useful direct rough test of myocardial inadequacy. 

Great Value of Skilful Percussion. — As may readily be shown by X-ray 
control, serious error in skillfuly applied percussion by modern methods, 
though occasionally unavoidable, and sometimes gross, is far less frequent 
than is generally believed if one adheres to like conditions on different occa- 
sions, outlines both borders, and substitutes the modern rectilinear ortho- 
percussion method, with or without threshold percussion, for the heavy 
flat-finger technic of former days.* 

In the case of acutely or subacutely dilated hearts even though preexisting 
hypertrophy is present, the shrinkage of outline is usually marked and the 
lessened area is often so well maintained under and following the therapeutic: test 
as to be most illuminating, but the most important and constant factor is the 
rapid amelioration or disappearance of troublesome symptoms oftentimes pri- 
marily obscure and remote. 

The most dramatic relief of symptoms may result in cases showing 
a roentgenographs or roentgenoscopic change of cardiac outline so slight 
as to be useless for purposes of routine clinical comparison and this is 
especially true of many symptom-producing "drop" hearts and of old 
lesions with well-established enlargement of the ventricular cavity and 
hypertrophy of its walls. 

This statement applies both to those cases presenting subjective symptoms 
only, and to such as carry objective signs of the grossest and most obvious type. 

One has but to recall the ratio of circumference to the diameter to realize that 
a very definite and decided shrinkage may fail to diminish the cardiac profile 
by even one centimeter. 

It is evident also that a symptom-producing diminution of tonus may be 
unaccompanied by a dearly demonstrable extension of the cardiac silhouette. 

Auscultation. — With respect to auscultation our great need is of an accur- 
ate knowledge of normal sounds and the range of permissible variations, together 
with a concentration of our attention primarily upon the question of their 
presence or absence in the given case.T One may suggest the need of more 
careful attention to weak and impure sounds and abnormalities of accent, and 

* Treupel found in 97 per cent, of the cases examined by the method of threshold per- 
cussion a variation of less than 1 cm. in the position of the right border as compared with the 
orthodiagraph^: outline. 

In 95 per cent, the left border- was established with the same accuracy. Such 
remarkable figures are not applicable of course to the ordinary routine of a busy 
practitioner. inasmuch as they represent doubtiess examinations made under ideal 
conditions of time and place. 

The author finds accurate determination of both the left and right borders sometimes 
impossible, for him, by any method, when working under ordinary office condition s-which 
embody noise and interruptions. In general he finds that an error by one careful man is 
shared by those who follow him. Roentgenography and roentgenoscopy long since were 
adopted therefore as an unvarying part of the routine of his consulting-room work. 

f In the section dealing with the exa min ation of the heart the author has referred to the 
common mistake of seeking primarily the abnormal; rather than the proving of the pres- 
ence of the normal. The difference is a email v vital. 



HEART DECOMPENSATION 



639 



a less exclusive concentration on actual murmurs which are the most obvious 
of the phenomena of cardiac disease. 

Cardinal Factors in Timely Diagnosis. — Five decided steps in advance 
make this possible, viz.-' 

(1) A fuller realization of the importance of the anamnesis and of the cardinal 
value of the sensations of the patient together with a knowledge of the number and 
diversity of subjective symptoms of cardiac origin. For this we must thank 
chiefly James Mackenzie and Henry Head. . 

2. A more accurate standard of "normal" heart measurements. 

3. .1 proper valuation of alterations in subjective and objective symptoms 
and, oftentimes, in the heart outline under tentative therapeutic measures. 

4. The knowledge that both the wholly normal and the fully compensating 
'though crippled heart fail to show material response to doses of digitalis * which 
are clinically effective in decompensation. 

5. The substantial increase in accuracy afforded by modern percussion 
methods and the use of the x-ray. 

6. The use of instruments of precision yielding graphic records of the heart 
action. 

It is to be hoped that before long one may be able to add — 

The abandonment of the flat-finger method in heart percussion. 

Proper Valuation of Subjective Symptoms. — The early recognition of 
cardiac incompensation demands a better understanding and truer valuation 
of the subjective manifestations of cardiovascular disease, until recently 
submerged and concealed by our ignorance of their genesis, nature and 
peculiarities of localization and by a natural but most unfortunate tendency 
to attribute them nearly always to sources other than the heart. 

THE RECOGNITION OF SUBJECTIVE SYMPTOMS.— The subjective 
symptoms of heart disease are many, varied, and invaluable, though few are 
peculiar to cardiac insufficiency and none are pathognomonic. 

The fundamental factors in interpretation are: 

1. The relation of their occurrence to concurrent or precedent physical 
exertion, especially if this be of an unusual nature. 

2. Their occasional association with the lesser demonstrable dilatations. 

3. Especially in the case of the middle-aged patients and to a less degree 
in. younger persons, their relation to excitement or emotional strain. 

4. But chiefly their favorable response, and oftentimes that of the cardiac 
outline, when increased, to cardiac stimulation, with or without physical rest 
or regulated exercise, as may be found necessary. 

Subjective Dyspnea. — A subjective sensation of dyspnea, diurnal or 
nocturnal, even of the milder types, is a striking symptom of value, too readily 
ascribed to hysteria or "neurasthenia." Even a persistently increased 
respiratory frequency or an inability to hold the breath is frequently over- 

* Frankel: Ueber Digitaliswirkung auf gesunden Menschen, Miinchener med. Woch- 
enschr., Hi, p. 1537, 1905. 

Cloetta: Einfluss der chronischen Digitalis behandlung auf das normale and patholo- 
gische Herz, Therapic der Gegenwart, vol. xlix, p. 437, 1908. 



Why formerly 
unrecognized. 



Fundamental 
factors. 



Very im- 
portant. 



640 



MEDICAL DIAGNOSIS 



Of corrobor- 
ative value. 



Hypertension. 



Muscle cramp. 




looked in the absence of any complaint of dyspnea or too hastily credited 
to the same diagnostic " catch all."* 

Another cardinal early symptom of failing reserve is subjective dyspnea 
initiated by relatively slight, but unusual effort. 

Purely Subjective Symptoms. — A sense of lassitude, of easily induced 
physical fatigue, vertigo, unexplained drowsiness during the day time and 
unrelated to heavy meals, f or insomnia, wakefulness, lack of concentration 
and sustained application, mental 
confusion, faintness, actual syncope, 
heaviness of the legs or the sensa- 
tion of wading through water, 
together with disturbed sleep, bad 
dreams and subjective gastric dis- 
turbances of the most varied kinds, 
are extremely common, helpful and 
suggestive, though by no means dis- 
tinctive, symptoms. 

One of the most important of 
all symptoms is an inability to per- 
form without conscious added 
effort and fatigue everyday tasks 
formerly easily dispatched. 

This represents in most in- 
stances the first evidence of a nar- 
rowing of the cardiovascular reserve 
and may be associated with any 
one or several of the other symptoms 
mentioned. 

In cases of insufficiency asso- 
ciated with high arterial tension, 
numbness and prickling of the lower 
extremities frequently occur, often 
being manifested only under a coincident increase of cardiac dilatation and 
increased arterial pressure and subsiding as these are relieved. 

Pain or Discomfort Due to Muscle Fatigue and Overstrain. — Any muscle 
in the body may give rise to manifestations varying from mere subjective discom- 
fort to agonizing cramp-like pain when forced to continue maximal effort under 
conditions of excessive strain and fatigue. 

We have the report of forced marches, the records of various long-dis- 
tance contests, as well as the histories of acute heart strain in patients to 
* In a number of instances observed by the author the recurrent or paroxysmal dyspnea 
attending excitement or emotional strain has had all the earmarks of the hysterical form, 
which doubtless can occur, yet was found to be associated with cardiac insufficiency and 
arterial hypertension. In such cases not only the emotions, but even slight gastric or intes- 
tinal overdistention, or mere corset pressure, may precipitate an attack. 

t A very common symptom in the author's experience and one of the most responsive 
to the therapeutic test if due to circulatory insufficiency. 



Fig. 341. — Case of mitral leakage and 
moderate dilatation. Pain during preced- 
ing year. Illustrates curious distribution 
of pain and tenderness, occasionally ob- 
served in cardiac insufficiency. Dark areas 
indicate maximal points of chronically 
recurring pain; shaded area — its distribu- 
tion. Patient was to undergo exploratory 
operation. Entirely free after four days 
of partial rest and full doses of digipuratum. 
Has remained free for past two years. 
(Another case showing this pain reference 
has been observed since this legend was 
originally written.) 



HEART DECOMPENSATION 



<>4 



attest this fact ami to explain one of the chief manifestations of chronic 
cardiac overstrain. 

Multiple Factors. — In most heart cases many factors other than actual 
overexertion diminish the tonus and contractile power of a diseased heart, 
and in varying degree the other functions of the heart muscle, until accus- 
tomed use, and later mere existence, involves serious overstrain. 

Sclerosis of the coronary arteries not only may produce a persistent I intrinsic 
deficit in the intrinsic blood supply of the heart and render its response 
to increased demand distressing or actually impossible, but may also cause 
attacks of angina pectoris under conditions of physical rest (see "Angina 
Pectoris"). 




Fig. 342. Fig. 343. 

Figs. 342 and 343. — Interesting areas of pain and residual tenderness associated with 
certain cases of cardiac decompensation, induced by over-exertion or acute infections. 
Dull pain or discomfort and more or less marked hyperesthesia over the region of the left 
heart border are extremely common. Occasionally it is bilateral and in such a case is 
almost invariably referred to hysteria or "neurasthenia." 

Minor Crises. — From time to time, long before the terminal period is 
reached, the struggling heart cries out for relief. Our clinical interest must, 
therefore, be directed primarily to the lesser painful or distressing expressions 
of cardiac fatigue and overstrain and the regions to which these may be 
referred. 

Extracardial Factors in Diagnosis. — Both subjective and objective symptoms 
of chronic myocardial insufficiency arise in considerable measure, in both the 
minor and the grosser insufficiencies, from districts lying outside the precordial 
area and the heart itself, and this is strikingly true of certain types of pain. 

Referred Pain and Discomfort. — The work of Henry Head, Sherrington, 
Mackenzie and others shows that despite the relative insensitiveness of the 
heart parenchyma itself, painful sensations, with or without hyperesthesia, Referred pains. 



blood supply. 



Deceptive 
localization. 



642 



MEDICAL DIAGNOSIS 



Many types. 



Often 
epigastric 



arise from cardiac embarrassment, follow the direct embryonic distribution 
of the primitive cardiac tube and, because of the distortion attending fetal 
development, may be referred to the chest wall, axilla, neck, shoulders, inner 
aspect of arm, epigastrium and even the right and left hypochondrium.* 

With such a wide area of distribution for cardiac pain and granting the 
logical assumption that various sensations of discomfort may substitute pain 
in cardiac overstrain, toxemia and fatigue, as in like conditions affecting any 
other muscle, we see the possible relationships not alone of precordial dis- 
tress, but of the many axillary, neck, 
shoulder, thoracic and upper ab- 
dominal pains or uncomfortable sen- 
sations, such as are usually, and 
rightly given the more obvious in- 
terpretation suggested by their sur- 
face relation to underlying tissues. 

Epigastric, Substernal and Pre- 
cordial Discomfort. — This usually 
takes the form . of precordial or 
epigastric discomfort and, fre- 
quently, both combined; a sense of 
weight or pressure; a subjective 
sense of "crowding" distention, sub- 
sternal gripping or constriction, 
usually mild, but sometimes de- 
scribed as "vise-like," even when 
unassociated with true angina 
pectoris. f 

These sensations are referred to 
the stomach more frequently than to 




Fig. 344. — Darker shading indicates 
pain maxima. Lighter shading, its distri- 
bution. Recurrent acute major angina. 
Widely dilated heart. History of acute 
overstrain ( electric-car accident). Opera- 
tion for gall-stones advised. Prompt relief 
from rest and digitalis. No recurrence 
until return of dilatation and signs of major 
insufficiency several months later. 



the precordium and by the physician 

are interpreted usually as of gastric original or, not infrequently, in nervous 

women, as hysteria ("globus hystericus," etc.). 

The irritable overstrained or degenerated heart is affected greatly by an over- 
distended stomach or an overloaded portal system. 

An Old Rule Reversed. — So frequent is the occurrence of gastric symp- 
toms even in the minor decompensations that it would seem that in the case 

* The auricles may refer their pain to the lower axilla and shoulders; the ventricles to 
the chest wall, epigastrium, inner aspect of the upper arm, ulnar surface of the forearm and 
wrist or to the little and ring fingers. Pain from the ascending aorta may be referred to the 
entire neck, including the occiput. Cases of major angina, to which all portions may con- 
tribute, are reported in which even the gums were painful and others produce pain and 
residual hyperesthesia over the entire thorax, neck and upper abdomen. 

t Many patients report voluntarily, after successful treatment, even though no marked 
shrinkage of the cardiac outline is demonstrable, that for the first time in many months or 
years they feel that their heart is not "crowded" or "too large for the chest." 

% The number of so-called "dyspepsias" relieved promptly by digitalis, with or without 
rest, is surprising. 



HEART — 1) ECOMPENSATION 



643 



of the elderly patient, especially, we should reverse the traditional rule, "indigestion' 
and instead of considering first the stomach when he complains of his heart, complaint, 
look rather to the arteries, blood pressure and kidneys primarily and the 
stomach secondarily when he complains of either the heart or stomach. 







Fig. 345. — (Ej;77). Decompensated and dilated heart of the " drop " type associated 
with dyspeptic symptoms which dominate the clinical picture. The most pronounced dys- 
peptic symptoms appear during the latter part of the day or following, either directly 
or after a short period, unusual physical exertion. Vertigo and fatigability were also 
present. Exertion dyspnea was slight and there was no edema of the extremities. This is 
of the type commonly miscalled the "small" heart. (See Fig. 346. : — (E 77'). for com- 
parison.) 



Simulation of Urgent Abdominal Lesions. — Occasionally a patient with 
chronic myocarditis or coronary sclerosis and a dilated laboring heart is. con- 
fidently but vainly explored for gall-stones or gastric ulcer under a not 



644 



MEDICAL DIAGNOSIS 



unnatural misinterpretation of referred cardiac pain and hyperesthesia. 
Such errors may be avoided usually if the radiation of the pain with 
reference to the precordium, upper thorax, neck and arms is studied. 
Though such pain may be maximal over the upper abdomen, it usually 




Fig. 346. — (E 77'). Same heart as shown in Fig. 345 showing the reduced diameter 
following a short period of ambulatory treatment. The heart was originally a " drop " heart, 
marked associated gastroptosis being present. The outer white line shows the passing out 
of the left border by renewed dilatations after the patient had broken treatment and 
disregarded all instructions, the result being the recurrence of pulmonary congestion and 
other signs of minor decompensation. 

shows a tendency to involve the other regions in part at least. Careful 
examination of the heart, and blood-pressure estimations, usually reveal an 
adequate cause. 

A Word of Warning. — It must be remembered that gastric, duodenal, 



H1AK r DECOMPENS \ HON 



645 




Fig. 347. — Toxic heart. Patient had suffered from gall-stones 10 years previously and 
temporary relief had been afforded by the passage of a large number of small biliary calculi. 
Previous to, and from that time, recurrent severe precordial and epigastric pain and increas- 
ing disability had been present, all being charged against the gall bladder, though no opera- 
tion was attempted. When seen by the author in 1914 she carried decided edema of the 
legs, some hepatic engorgement, and marked enlargement of the heart, with auricular fibril- 
lation. A history of recurrent typical attacks of cardiac angina combined with epigastric 
distress was obtained and the nature of some of the abdominal pain distinctly suggested 
the participation of the diseased gall-bladder, although no local tenderness or fever was 
present. The heart measured 15.5 cm. in total transverse diameter a-nd decided diffuse 
enlargement of the transverse and descending portion of the aortic arch was evident in the 
original negative. The patient was placed at rest and under digitalis with the result 
that all symptoms were relieved promptly and the heart rhythm became extrasystolic. The 
outline of the heart at the end of this period is shown in Fig. 348. Aside from a slight 
inconstant and untransmitted mitral bruit or "murmurishness" the heart was silent. 

She had been told repeatedly that her heart was wholly normal. 



6 4 6 



MEDICAL DIAGNOSIS 




Fig. 348. — Toxic heart after treatment. The total transverse measurement is reduced 
from 15.5 cm. to 13.5 cm., a normal area, apparently, for so large a woman (weight 185+) 
but actually a greatly enlarged heart primarily of the "drop" or modified "drop" type, in 
a very small-boned individual. It will be noted that with the subsidence of the fibrillation 
the right border is lost behind the sternum and the left has lost its mitral configuration 
above, though in this printed reproduction the prominence of the left hilus shadow obscures 
the true outline obtained. Despite all warnings the patient so imposed upon the immunity 
from suffering obtained as to create from time to time through rash overactivity a recur- 
rence of fibrillation and intervals of diurnal edema of the extremities. Finally, while on a 
visit certain purely abdominal seizures arose which were apparently due to gall-stones alone. 
Upon her return it was evident that definite fibrillation and other decompensatory signs 
were present. The patient was put to bed, but after a brief period of improvement a 
definite attack of cholecystitis occurred. The evident hazard involved in an operation upon 
one with so slight a margin of reserve led the surgeons to decline interference, but after 48 
hours, at the patient's urgent request and by reason of the threatening nature of the symp- 
toms, an operation was attempted and expeditiously performed. The patient never 
reacted. The heart dilated acutely and she died 12 hours after removal from the table. 
It will be noted that the existence of a highly toxic, greatly enlarged silent heart had been wholly 
unsuspected up to 1914. Yet so far had the process advanced as to render periods of 
fibrillation frequent and maintain a decided edema for many years. 



HEART — DECOMPENSATION 



appendiceal, and choice ystic conditions may be coexistent with and sometimes 
the basic cause of a toxic heart (see Figs ad ;44 . 

Moderate or trivial pain oi a slight, vague character or in the form of 
sharp '\ may occur over the heart itself, often extending upward 

to the left or behind the sternum. 

Tenderness. — Not infrequently one encounters tenderness just within 
the apex and for a few centimeters up the left border of the heart. This commonly 
curious hyperesthesia is often mistaken for the hysterical breast stigma mi * mt 
when occurring in nervous women, but is common in the chronic tonus de- 
derate dilatation and chronic overstrain of myocardial degeneration 
or mere asthenia, as well as in acute toxic dilatation and mitral stenosis* 

It sometimes shifts its maximal point with the recession of the left border 
as a toxic widely dilated heart contracts. 

Major Anginal Pain. — Intense pain of the severe paroxysmal type may 
occu - iated with fear of impending death, pallor and cya :ld 

perspiration, orthopnea and tense immobility on the part of the patient, 
shallow breathing, weak, rapid or unduly slow pulse and high arterial tension. 
Pain may extend to the left arm, wrist, and ringers up into the neck, or involve 
the arm and neck of both sides. In rare instances such paroxysmal pain 
of cardiovascular origin may be maximal over the epigastrium and gall- 
bladder area and be preceded or followed by nausea or vomiting, f 

Miniature replicas of such attacks have been I and reported by Rqikas ia 

the author, oftener fragmentary clinical pictures, and a marked and wide- 
spread hyperesthesia may follow the severe attacks. 

Paroxysmal Pain of the Sciatic Type. — Sciatic pain, lameness, quickly 
induced leg-fatisrue or sudden temporarv loss of power, in the lower extrem- Art* 

i i i er i spasm. 

lties or even the arm. may attend attempts to put the aire :te 1 extremities to 
accustomed use (" inter mitt ierende kinken"), and in many such cases the 
pulse of the affected member will be weak or absent, the accessible arteri— 

rotic. and the heart degenerated. 

When the sciatic pain is marked, an erroneous primary diagnosis is 
common. 

OBJECTIVE SYMPTOMS OF DECIDED CARDIOVASCULAR IN- 
SUFFICIENCY. — Subjective dyspnea has ed elsewhere. Ob- 
jective dyspnea may be present only on exertion or in one position of : 
body, or be constant, paroxysmal, of the type of '"air hunger." Cheyne- 
Stokes. or a replica of spasmodic asthma. Occasionally it is no more than 
an evident inability to hold the breath but in some cases it will abruptly en- 
force the sitting posture or even force the patient to stand suddenly erect 
see "Dyspnea"' . 

* "Stitch in the side" is, of course, common and unimportant in the absence of other 
signs, but occurring in the precordium, and especially in middle-aged individuals, often 
represents a minor angina. 

e author has seen a number of such cases in one of which a very large aneurysm of 
the transverse portion of the arch was present and ruptured during the early period of 
general anesthesia incident to an attempted operation for gall-stones. 






MEDICAL DIAGNOSIS 



Stasis and 
edema. 



Portal conges- 
tion. 



Engorgement. 



Variations. 



Pulsation. 



Ominous if 

persistent. 



Important sign. 



Varying output. 



Laboratory 
findings. 



Obscures 

existing 

nephritis. 



The Lungs. — Recurrent acute or subacute bronchitis, chronic bronchitis, 
blood-stained sputum, with the pigmented ("heart") cells, actual hemoptysis, 
or pulmonary edema, may occur as the result of passive congestion of the 
lungs or pulmonary infarct, in the failing heart of certain valvular lesions 
or primary myocardial degenerations. 

Crepitations at the lung bases, persisting after the first deep inspiration 
indicate right heart weakness and become of importance in the diagnosis of 
myocardial insufficiency and its treatment. They may be more marked 
on one side or present only as persistent rales. In such instances one finds 
usually that the patient lies upon that side by preference or has so lain for a 
considerable period. 

Gastrointestinal Tract. — Misleading referred cardiac pain or discom- 
fort and gastric disturbances more or less directly attributable to passive 
congestion occur frequently together with constipation, diarrhea, anorexia, 
excessive flatulence or nausea and vomiting. 

Usually all these symptoms are significantly relieved or ameliorated by rest 
aftd cardiac stimulation if they are of cardiac origin. 

The Liver. — The liver is frequently enlarged in the myocardial degenera- 
tions attended by gross decompensation, especially when these are associated 
with valvular lesions involving right heart stasis (mitral or tricuspid lesions 
especially . 

Its variations in size may roughly reflect the degree of decided incompensa- 
tion present at a given time. Systolic venous pulsation, palpable or shown 
by instrumental registration is not uncommon and the liver may become 
permanently indurated ("nutmeg liver" ] . though in many instances that 
which may have seemed a permanent change wholly or almost wholly 
disappears under proper, prolonged treatment. 

Jaundice of slight or even marked degree is not uncommonly seen in 
advanced tricuspid lesions, whether primary or secondary, in association 
with long-established passive hepatic congestion. 

Kidneys. — Chronic passive congestion is one of the manifestations of 
advanced incompensation in primary myocardial degenerations and mitral 
or tricuspid lesions. 

The amount of urine is more or less reduced and diurnal variations 
in the amount roughly measure the variations of severe incompensation 
if tfe fluid intake is maintained at a uniform level and no sweating or 
purging occurs. 

The color and specific gravity are high. Albumin is present in small amount 
and hyaline with occasional granular casts may be found. 

If other forms of nephritis co-exist, their typical urinary signs will be 
obscured, intensified, or modified by any existing passive renal congestion and 
uncovered or rendered clearer by an improvement in the heart strength. 

EDEMA. — This, when pronounced, is the most strikingly objective of the 
commoner gross symptoms and the most marked of any save pronounced dyspnea 
or the profound cyanosis of right heart stasis. 

In its slighter and localized forms it is very likely to be overlooked, espe- 



HEART DECOMPI 



649 



dally if it occurs only in unusual locations. In a number of cases the author 
has found it present over the calf of the leg and absent at the ankle. 
x :ht. equal, bilateral edema is almost invariably overlooked in 

xaminations an,: ■erally. in the ordinary office or hospital 

procedure. 

its presence or thinks so 



Usually seeks 

dependent 

parts. 



/*//; 



The patient carr 
v of it as to jail to report it. 

rs before : ptoms of decompensation mani- 

and is a symptom of cardinal imports 

Cardiac edema appears as the right heart fails.* seeks primarily the de- 
pendent portions of the body, is markedly affected by decubitus, and, in 
advanced cases with primary or secondary right heart weakness, is pro- 
nounced, slowly progressive in the absence of effective treatment, and tends 
to superadd to the already obstructed blood flow and the laboring heart 
behind it (see "'Edema"'., the adverse pressure effects of effusion into the 
peritoneal, pleural, or even the pericardial cavities. 

Rationale of Cardiac Edema. — Under conditions of rapidly induced or 
persistent venous congestion and consequent increased pressure and slowing 
of the blood stream in the capillaries, a great excess of fluid, poor in albumin, 
is poured out and distends the connective-tissue spaces. The general circu- 
lation is thus further slowed, the distension and loss of tonus of the con- 
nective-tissue spaces invites further invasion, and the pressure of collected 
fluid tends further to block the flow of blood and establish a vicious circle. 

The loss of tonus in the connective tissue is sufficiently proven by the 
persistent indentations left by finger-pressure. 

Weigh Cardiac and Renal Cases. — In both renal and cardiac cases show- 
ing a tendency to edema it is of great importance to weigh the patient from 
time to time. Any sudden increase in weight should suggest the possibility 
of an exudate either into the connective tissue or the enclosed cavities of the 
body and the pleurae should be watched with especial care. 

Cyanosis. — Any and every type of cyanosis may be encountered in cardiac 
insufficiency according to the anatomic seat and chief effect of the dominant 
lesion, the degrt Element and the grade of incompensation present. 

All cardiac incompensations or pulmonary diseases weakening the right 
heart, directly or indirectly, and hindering or preventing free oxygen and CO2 
exchanges, produce cyanosis 

In most forms of congenital heart disease it is so obtrusive and extreme 
and so evidently related to infancy in its inception as to be an almost 
pathognomonic sign. 

In the least rare type of congenital insufficiency (pulmonary stenosis or 
atresia; the patient is almost invariably blue and, on exertion or in paroxysmal 
seizures, deep purple or even black. 



EmDarras5.z£ 
transudates. 



.•Another 

-5 circh 






Weight often 
varies with 
edema. 



Diminished 
oxygen and 
CO : exchanges. 



Blue babies. 



* Edema may be absent throughout the entire course of an aortic stenosis or even a 
regurgitant lesion, for the patient may and often does die before the right heart is rendered 
markedly insufficient, the burden in either instance being carried wholly or m large measure 
by the left ventricle until the terminal stages are reached. 



650 



MEDICAL DIAGNOSIS 



Absent in pure 
aortic cases. 



Relative 
insufficiencies. 



Therapeutic 
test Invaluable. 



Factors deter- 
mining 
severity of 
symptoms. 



Age. 

Congenital 
asthenia. 



Avoid mere 
meddling. 



In aortic stenosis or regurgitation it may never be present to any marked 
degree until the mitral yields or becomes involved structurally in the disease 
process, and throws back its burden in part upon the pulmonary circuit and 
the right heart. 

Cyanosis is decided in incompensated mitral lesions and still more so if 
secondary tricuspid insufficiency or the far rarer pulmonary leakage 
ensues. 

Heart Sounds. — Absolutely normal heart sounds are always absent in 
primary or secondary valvular disease and murmurs are usually present or 
more or less readily elicited under exertion, change of posture, properly regu- 
lated stethoscopic pressure, rest, or direct cardiac stimulation. 

In myocarditis, acute or chronic, or in the myocardial degenerations 
of marked degree, there is a tendency for murmurs to develop, especially in 
the mitral area, as the disease advances, the valvular deficiency being due 
either to an extension of the disease to the valve itself or to weakening of the 
valvular ring. 

Abnormalities of accent, sharpness, undue brevity, and heightened pitch of 
heart sounds, no less than impurity, " ' murmurishness ," or "muffled" tones, are 
also to be noted. 

Arrhythmias. — Any and every variety of abnormal rhythm may be 
encountered (see "Arrhythmias"). 

CARDIAC OUTLINE. — As previously stated, the cardiac outline as de- 
termined by the more modern percussion methods with or without the reenforce- 
ment of the fiuoroscope is one of the chief means of detecting otherwise dubious 
or indefinite lesions. 

Almost invariably an enlarged profile due to coincident increase of dilatation 
is present in the case of a grossly incompensating heart and this yields oftentimes 
a significant recession in response to full doses of digitalis and rest, both of which 
measures are without effect upon a normal heart or one fully compensating any 
existing lesion. 

The cardinal sign is, however, a decided and demonstrable amelioration or 
relief of symptoms under such therapeutic procedures. 

Summary. — (a) The severity or degree of all symptoms of cardiac insuffi- 
ciency depends upon the nature and location of the lesion and the stage and 
duration of the incompensatory period. 

(b) The frequency of damagingly reduced tonus, lacking the coarser and 
more obtrusive incompensatory signs, is as striking as is the relief of its vague 
and ojten misleading symptoms under a brief period of treatment and proper 
instruction. 

(c) Such hearts occur with especial frequency in patients who have entered 
the fifth or sixth decennium and in younger patients as well, if they are under- 
nourished and carry the stigmata of chronic congenital asthenia and its movable, 
pendant, low-lying, unstable and, oftentimes, readily dilatable heart. 

Truly Effective Therapy. — The larger, most effective and most permanent 
part of an effective therapy lies in the regulation of occupation, habits, 
physical and mental exertion, diet, and above all an intelligent appreciation 



hear: 



= 



651 



t that neither cardiac murmurs nor cardiac arrhythmia, in and of ike 
selves, demand active treat n: 

Neither Drugs nor Rest, Whether Alcne or Combined, are Adequate.— 
One of the most important factors in the therapy of cardiac disorders cons:- - 
in the use 0: . and definitely graduated and conservatively increased Vmiue of regn- 

exercise, following the correction of any acute or chronic insufficiency re- 
quiring primary limitation of activity or an insistence upon a sufficiently 
prolonged period of absolute re- 

Reiteration. — The student should carefully consider the following p<: 
in revie 

1. An early diagnosis of myocardial insufficiency is essential to the best 
re and maximal longevity of the cardiopath. 

:. Such early diagnosis necessitates an acquaintance with symptomatic 
expressions of the subjective type, and the determination of the presence and 
symptomatic relationships of any existing cardiac dilatation. 

A large group of structurally deficient individuals many of whom are 
commonly classed as "neurasthenics." while, possibly, comparatively free The heart* 
from organic heart disease of the valvular or luetic type or that taking asthenia, 
the form of primary myocardial or vascular degenerations, are peculiarly 
lacking in resistance and prone to undernutrition, to acute infections, 
and recurrent or persisting deficiencies in heart muscle tonus, and possess 
ptotic, readily dilatable, symptom-producing hearts as a part of their 
fundamental and usually congenital defects in general body structure and 
function.* 

The author's more recent experience has convinced him that such hearts are 
in no sense immune to infection whether of the juvenile degenerative or luetic 
type, but that in the past we have failed to recognize the i% drop" heart when 
transformed by valvular or primary degenerative disease. If, as the author 
hopes, he has found the key in associated gasiroptosis and more or less definite 
peculiarities of outline, much more light upon this subject may be anticipated. 

4. Such hearts, in individuals of this type, are narrow when undilated, 
mobile, and even when pathologically enlarged show a transverse measure- 
ment which is usually less than that of the undilated heart of the non-asthenic 
individual. 

5. In many patients of this type a relative cardiac ^sufficiency may 
play a large part in their disability and be accountable for many symptor 

usuallv referred to such svndromes as "neurasthenia*" and '"nervous dvspep- Periods of 

• i» 1 - 1 r 1 11 1 - ••• " minor instif- 

sia, which, tor the greater part, represent, m all probabih: symptom- fideacy. 

groupings of various maxima of localization, of the same general, congenital, 
constitutional and structural defect (see "Congenital Astheni 

* In opposition to the views of Prof. Stiller relative to the asserted immunity of this 
type of individual to organic heart disease, the author believes that the females of the 
asthenic group furnish the greater number at least of those cases of the pure funnel type, 
mitral stenosis, of the youthful non-rheumatic and non-infectious form described by Duro- 
15 a special form of that ailment. Every example of these peculiarly long-enduring 
cases seen by the author during the last decade have shown distinctively the stigma of 
congenital asthenia. 



6>2 



MEDICAL DIAGNOSIS 



Responsive to 
treatment. 



Lost oppor- 
tunities. 



6. Adaptation vs. "Perfect Compensation." — Though patients with 
organic heart lesions may go for years without serious symptoms after adapt- 
ive hypertrophy is established, the pathologic events in such cases make it 
evident that there is a constant, more or less gradual but progressive limita- 
tion of the field of cardiac response. Long before the onset of gross or 
emergent symptoms, periods of more or less decided minor insufficiency appear 
and recur from time to .time with increasing frequency. Appropriate 
therapeutic measures will then support and aid the embarrassed and labor- 
ing heart and prolong the life of its possessor. 

7. Causative Agents and Portals of Infection. — The recent studies of the 
causative agents and portals of infection in acute rheumatism, a better 
knowledge of the effects of prostrating acute infection, and chronic or recur- 
rent cryptogenetic sepsis upon the heart, the better understanding of the nature 
and means of detection of syphilitic infection and the introduction of new 
agencies and better methods for the early and efficient treatment of lues, 
indicate the possibility of limiting considerably the large group of myo- 
cardial, pericardial and valvular lesions of which they are the causative 
factors. 

8. The mere existence of a heart lesion is no justification for active 
treatment by the exhibition of drugs, though a fully compensating heart neither 
is damaged nor influenced by test doses of digitalis properly administered and 
controlled. 

Active treatment of any considerable duration is necessary and justifiable 
only when symptoms of cardio vascular insufficiency are clearly established 
and the use of heart stimulants should be limited if possible, (a) to test doses, 
which should be freely used,* (b) prophylactic small doses during con- 
valescence from acute prostrating ailments, (c) to the more or less prolonged 
periods or recurrent intervals of actual stress or genuine emergency. 

9. The importance of early diagnosis is emphasized by the fact that chronic 
heart disease, though incurable, is on the whole, wonderfully responsive to in- 
telligent and properly timed treatment, and always benefited by such proper 
supervision and control as may be indicated in the individual case and obtain- 
able only through early diagnosis, tactful disclosure and a judiciously tempered 
optimism. 

The "Abandoned" Heart Case. — An unfortunate tendency exists to the 
practical or actual abandonment of advanced or apparently hopeless cases 
of heart disease. 

Practical abandonment may take the form of a failure to establish such 
control of the patient's activities and such therapy as will, on the one hand, 
give the greatest possible amount of rest to the laboring heart muscle and, on 
the other, assist it directly, to regain in some important degree its waning 
tonus. 

Total abandonment is usually represented by an attitude of utter hope- 

* If one were to try the experiment of substituting them initially for the "tonic" or 
digestant," so universally used in obscure cases of "nervous debility" and "dyspepsia," 
he might be greatly surprised by the frequency of decided favorable effects. 



MYOCARDIAL OVERSTRAIN 



653 



lessness and a disinclination to do more than smooth the victim's pathway 
to the grave. 

In mitral cases, especially and, to a lesser degree, in other common cardio- 
vascular lesions, the patient may go to an apparent utter cardiac break- 
down with renal congestion, hepatic and pulmonary engorgement and general 
anasarca and still respond to treatment and live for years. 

Absolute rest is but too seldom enforced and rationally maintained. The 
patient is up and down, even though mostly down, and if improvement occurs 
is not held to a schedule demanding a gradual increase of activity, such as is 
needed in the generality of cases if improvement is to be had. 

In far too many instances in which absolute rest is enforced it is 
maintained for too long a period and almost immediately thereafter the 
patient is permitted to resume his or her activity. 

Too abrupt a transition from absolute rest to physical activity is often- 
times less effective and more dangerous than ambulant treatment. 

Above everything in cardiac therapy must be placed the element of time when 
one deals with its severer types or the cases of the nutritionally depressed asthenic 
type. These latter demand treatment which, as elsewhere stated, is practically 
identical with that of so-called "neurasthenia." 

The After Lifetime of the Cardiopath. — Cardiovascular disease greatly 
reduces the life expectancy of its "group" but the duration of life, in the case 
of any individual, involves a host of factors among which are the nature of 
the lesion, its cause, the constitutional peculiarities of the individual, his 
environment, habits, occupation and, above all, his own intelligence and 
common sense, and the same qualities in his physician. 

Futile Forecasts. — Despite adverse conditions and oftentimes despite the 
demands of an active, useful and even laborious life, certain individuals 
may and do carry the cardiac lesions of youth into a ripe old age and nothing 
can be more elusive and uncertain than prognosis in cardiovascular disease 
or more futile than the attempt on the part of the physician to set a date 
for the exitus of any patient not patently moribund at the time. 

With early recognition and prompt medical intervention in cases of actual 
insufficiencies, not only the life expectancy of the individual but that of cardio- 
paths as a group will be greatly extended. 

MYOCARDIAL OVERSTRAIN 
Acute Cardiac Overstrain 

Fundamental Factors. — Physical overstrain may affect the heart in 
different degrees dependent upon: (a) the congenital structural peculiarities 
or deficiencies of the individual; (b) his age, general physical condition and the 
actual state of his heart and blood vessels at the time of exposure; (c) the severity, 
abruptness and duration of the strain imposed; (d) the habituation or non- 
habituation of the individual both to physical exertion of the degree attempted, 
and to such specific coordination of certain neuro-muscular units as is involved 



Keep fighting. 



Abundant time 
indispensable. 



Greatly 
shortens life. 



Individualiza- 
tion of cases 
imperative. 



Wonderful 
individual 
resistance. 



Futility of 
prophecy. 



Promise of 
added days. 



Basic factors. 



^54 



MEDICAL DIACN 



M.;1t i Z.Zl 

: i i ■ s 



in the partic. >ut forth, and, finally and chiefly, the question of 

toxemia 7 proximate, actually present, or recurrent. 

Physical Fitness and Habituation. — Physical fitness is an important 
factor, one of the commonest causes of acute overstrain being the attempted 
performance of tasks suited only to the trained athlete or the frontiersman 
by individuals who are distinctly out of condition, actually convalescing 
from an illness, or congenitally unfit.* 

The author has encountered it repeatedly in well-fed men, outwardly 
appearing to possess a powerful build, but proving to be of asthenic stock 
and to carry inherited deficiencies, especially such as involve the heart, 
blood vessels and lungs. Also in individuals possessing a past replete with 
athletic prowess, but at the time distinctly out of condition and unfit. 

In the well-conditioned athlete the heart is actually slightly smaller after 
or during some endurance test than at its beginning, being fully able to meet 
the demand by a combination of increased rate and driving power, this being 
in direct contrast to the condition of dilatation produced in untrained or 
structurally deficient individuals.! 

: riei summary of a typical case oat of the great number encountered by the author 
would read thus: Male. Sedentary occupation and habit, aet. forty-seven, weight 200, 
complains of indigestion (as most of them do) chiefly manifested by dull pain over pit of 
stomach. Pain usually late in day {after day's activities), sometimes seems to follow 
I exertion. Can't do his work as easily as he did formerly. Gets tired quickly when out 
Is often drowsy during the latter part of the day. This often passes off after 
X: definite relation of pain to meal hours, but is always worse when he is con- 
stipated or has "gas on the stomach." This patient's heart was found to measure 16 cm. 
in total transverse diameter and a soft systolic murmur was present, limited to the apex; 
pulmonary second sound about equal to the aortic tone. All findings negative save as to 
--.iz~.. 

His pain had begun three years previously while duck hunting, but he had not related 
to us the events because of the misleading epigastric localization. On that day he had 
shot both morning and evening standing in the water and deep mud of a shallow North 
Dakota slough lake. Shooting was good and when darkness fell and he waded about 
---Q-.:r"- :jie iter zli-ring ~.:l :: richer — = - :^ — e :^:::.:::: .: :: :: iirry 

rl : e : :■- long wade to shore he felt " all in." Had a great deal of pain in the chest, struggled 
to shore, felt faint, vomited, and lost consciousness. Finally struggled to his feet and 
went to camp to lie down, leaving ducks, shells and game behind him. "Felt pretty 
well" next day but now recalled the fact that his "indigestion" had dated from that day. 
(Judex treatment the pain iisappeared iofly in three or four days. He remained under 
for four — eeks The cardiac outline shrank to 13 cm. and the murmur wholly 



::e: 
-5: 



He has now remained pexfectb ell during five years. 

This represented an acute dilatation occurring in a particularly well-built robust but 
middle-aged man, leading a sedentary life and wholly out of tr aining . Anyone who has 
-::::::-: \i-z: : .z.z exzeriez.-r k-:~ s —ell :he e~::e~e ef ::: rezuirei. _- ie: :he ;:.:::: _li: 
conditions present. His not at all unlikely that some transient antecedent infection may 
have played a part. The "drop" hearts or those of individuals in poor health dilate far more 
easily and with less dran 1 :: c ~y~z : : ms in ma st instances 

J The author has been struck by the frequency with which he has encountered cases of 
distinct physical impairment in men of athletic records who have suddenly been translated 
to sedentary pursuits but still seek to pursue sporadically and fitfully athletic pursuits of an 
extremelv strenuous sort. 



DIAL OVERS TRAIN 



655 



The Commonest Cause of Minor Heart Strain. — The placid state of 
physicaPunpreparedness'' represented by middle age. a sedentary occupation, Middle age. 
and a daily life in which the accustomed exercise is represented at best by a 
round of golf and a walk to the orhce. is often disturbed by an abrupt autumnal indUn summer 



overstrains. 




Fig. 349. — Plate made nineteen days after acute dilatation of a supposedly norma 
heart. Fibrillation was present during eighteen hours after attack. Some precordial 
distress still present when exposure was made. Total transverse diameter of heart 
12.5 cm. (See also Figs. 350 and 351.) 

rejuvenescence taking the form of a tendency to play tennis with mistaken 
strenuosity and perseverance; to climb mountains; take an oar or a paddle 
'"to show them."' or hunt the deer over heavy going; all these plunges being 
taken without sensible moderation or previous preparation. Such unwisdom 
results in a host of cardiac overstrains, for the most part, spontaneously 



6 5 6 



MEDICAL DIAGNOSIS 



readjusted, but in some instances working great damage if undetected and 
unaided. 

The Asthenic Heart. — Considerable attention has already been paid to 
the peculiar heart of the congenital asthenic ("drop" heart) and one need only 




Fig. 350. — Same case of acute dilatation as is shown in Fig. 349. Patient, when 

apparently fully recovered, slipped and fell on the ice severely wrenching himself. A 

second attack of acute dilatation followed. Heart is still dilated from second seizure. 

[ Total transverse diameter 14. 1 cm. Both right and left borders are extended outward. 

(See Fig. 351.) 

repeat in this connection, that such hearts are among the commonest of clinical 
findings. They are peculiarly prone to transient or persistent loss of tonus or 
actual minor dilatation, and, to the production of subjective expressions of 
insufficiency, often remote from the heart itself. 

As stated previously, such hearts, even when both overstrained and decidedly 



MYOCARDIAL OVERSTRAIN 



657 



overlooked. 



dilated are, at present, almost universally disregarded, because of the fact that 

even when greatly enlarged (hey need not equal in transverse diameter the area constantly 

of the normal heart of a non-asthenic individual and further because of their 

unfortunate tendency to present the clinical features of so-called ''neurasthenia" 

or the equally dubious syndrome "nervous dyspepsia." 



w 


mmw^ 


^ 






Ei^B| 




1 


- 


pi 


jgfr 






ifl 










j 






■ » 


IP 


i 


■ 




W 


! 




w 




,-«-... 


w 


1*1 '+ o.i-W 


.ct\« 






XlW **n 







Fig. 351. — Same case. Acute dilatation of the heart. Plate taken nine days 
later, showing shrinkage of the heart after second attack of dilatation. Heart is 
still dilated as compared with Fig. 349. 



toxemia. 



A Common Cause of Overstrain. — One of the commonest sources of acute 
or sustained cardiac overstrain lies in the too early resumption of exercise alter Myocardial 
an exhausting surgical operation or prostrating illness, or even in hasty uncon- 
sidered exertion during the actual illness. 

We too often forget that for one case of recognized acute myocardial 
disease there must be a multitude in which a similar though less pronounced 
and advanced process is present, but undiscovered and undiscoverable save 



6 5 8 



MEDICAL DIAGNOSIS 



Hurried 
convalescence. 



during periods of impaired tonicity and overstrain. In all severe acute pros- 
trating infections, even though of short duration, the heart is peculiarly liable 
to suffer from myocardial toxemia of varying degrees and in acute rheumatism 
affecting the already damaged heart, as also in true influenza, we are pecul- 
iarly likely to have larval and obscure or definite and recognizable insuffi- 
ciency. The former type is almost universally overlooked at the present 
time during and following such an illness. 



Mr. M.fl fl&ZI 



Rr IOO 




BMW! it> 



Mr.M.A. Ufa /* , 




"Wl 



*X^ s ^v^«~^^ 



U^kN>WvKKk^NNJVAv 



LR 



B 



Fig. 352. — Mr. M. A. (A) 11-6-21. Temporary fibrillation of the auricles following 
acute overstrain, and a readily demonstrable dilatation in a supposedly normal "drop" 
heart. (B) 11-10-21. Record taken four days later showing a normal sinus rhythm. 
Clinically the normal sinus rhythm was reestablished in 24 hours. LR = Left radial. 
RJ = right jugular. 



Subjective Weakness. — In the absence of frankly objective cardiac 
symptoms the best guide often proves to be the therapeutic test, which 
unmasks a slight dilatation or loss of tonus, and the evident or merely sub- 
jective weakness of the patient. It may be demonstrated easily in many in- 
stances that despite a striking loss in endurance and in the capacity for 
symptomless performance of the day's work or ordinary physical activities 
the strength of the skeletal muscles is well preserved. 

Many patients themselves date a persistent myocardial weakness and 
dilatation from an illness during which neither myocarditis nor endocarditis 
was recognized, but following which there was a forced resumption of activity 
in the face of a persistent bodily weakness. 



MYOCARDIAL OVERSTR \1\ 



^59 



Patients should be guarded with special care during and after prostrating 
tonsillitis, acute rheumatism, influenza, diphtheria, scarlet fever and typhoid; important 
and their own sensations, properly interpreted, as a rule constitute the best 



v * w » 9 » ■ » r » ^ » V » » » » T »r»» ■ r 9 



7,621 



Radial 



R*te ' 4& 




Joflu'or f 








~N/V J 


./<? 


^oj*^ 




* m yJ K 


lott'ol 




B 




-~> — - 


»»»»» wm 9 9 




Mrs. WH 


BtdZl 





'Radial 




Fig. 353. — Airs. W. H. Variability in myocardial strength as indicated by polygraphic 
records. {A) 7-6-21. Record taken before operation showing high radial thrust and 
indicative of good myocardial strength and tone. (B) 7-26-21. Record taken 6 days 
after laparotomy under local anesthesia for supravaginal hysterectomy with removal of 
both appendages. Xote marked flattening of radial as compared with that in (A), indi- 
cating a decided loss of myocardial tone and strength after operation. (C) 8-13-2 1. 
Record taken 24 days after operation. Compare radial with that of (^4) and (B) and note 
that even then the record indicates that myocardial tone and strength have not yet been 
completely regained. Patient in hospital under ideal conditions. 



general guide for the physician, but do not replace a physical examination. 

Nor should they be allowed to drop out of sight wholly for months afterward, May initiate 

for both primary myocardial damage and actual endocarditis may delay tion. 



66o 



MEDICAL DIAGNOSIS 



Mr w FT (ftZt 





M«> n Gftzi 




fl.R 






21 


C 


Rate > >S( 




Mr. Pi bZOZI 





RoJ*ot 




Juguhr D V 



Fig. 354. — Mr. Fi. Series of four polygraphic records in a case of fibrillation during 
hospital regime, showing marked variation in myocardial strength and tone as indicated 
by the radial record. (A) Note the high radial thrust indicating good myocardial strength 
and tone. (B) and (C) show a progressive diminution of myocardial strength and tone, 
while (D) shows that myocardial strength is only partially regained. The myocardial 
weakening was due to a very slight cardiac overstrain as a result of a breach of instruction 
as to graduated exercise. RR = right radial. RJ = right jugular. 



MYOCARDIAL OVERSTRAIN 



66l 



Mr.H.F. IbaZi 




r'<S^4 




<i->-^->- 1 



w 



«5 



IOZT-t-1 



Mr. H-F 

Rata -~ BS 

B 



Mr. H.F. 




Ra+e = i.8 



-\ 



>S<P^ 



Fig. 355. — Mr. H. F. Three polygraphic records showing effect on myocardial tone 
and strength of a so-called •"simple" tonsillectomy. Patient in hospital under ideal 
conditions. Compensated myocardial defect. (.4) Record taken before operation. Xote 
height of radial thrust. 1 B) Record taken 7 hours after tonsillectomy. Compare height 
of radial with that of {A). (C) record taken 30 days later. Xote that height of radial 
thrust indicates that myocardial tone and strength have been regained. 

their manifestations for several weeks or months after apparent recovery from 
the primary disease.* 

* It is the failure to guard patients in convalescence and examine them at intervals 
afterward which makes our early recognition of certain chronic endocarditic valvular lesions 
so rare an achievement (mitral stenosis, aortic stenosis;. 

For the patient, early detection of his heart lesion is quite as desirable and necessary- as 
the early detection of pulmonary tuberculosis. Most of the tuberculous undergo a spon- 
taneous recovery- and the same is true of, and the same favorable issue attends, a host of 
instances of myocardial involvement during acute illness, yet in the case of both, early 
recognition and proper regimen, wise counsel and judiciously timed treatment are invalu- 
able, for in either disease the cases recognized and treated only when gross and obtrusive 
signs are present, represent almost hopeless conditions, though, in each, life may be greatly 
prolonged. 



662 



MEDICAL DIAGNOSIS 



Careful percussion by modern methods, having in mind the peculiarly small 
hearts of patients bearing the asthenic stigmata and the narroned normal limits 
represented by the table of Cohn* reveals the relative frequency of minor dila- 




Fig. 356. — Ready dilatability of the "drop" heart. This figure represents an exposure 
made during a period of continuing overstrain and shows a heart diameter of 13.0 
cm. This patient has passed through three attacks of acute dilatation, two of which 
threatened his life and were slowly recovered from. The third produced effects lasting 
acutely only a few hours although the dilatation was pronounced. The two attacks of 
massive dilatation were associated with major surgical operations; the third with simple 
physical overstrain. Compare this exposure with that shown in Fig. 357. 

tations following acute infections. The promptness of amelioration or dis- 
appearance of symptoms, and sometimes of gross border recession, under rest 
and full therapeutic test doses of digitalis is oftentimes astonishing. 



*See opening pa 



ges of heart section in this volume. 



MYOCARDIAL OVERSTRAIN 



66 3 



The Split Second Sound. — As previously stated, the author during several 
years has been studying a split second sound, audible only in the third left 
interspace, in its association with past or persisting cardiac overstrain and 
associated minor dilatation, often accompanied by more or less obscure and, 





*«m 




' sm9 






' il 


Hi ^i 






■ 




m 


H- 




'■'£ 






!To\ -. «i»-K^ 








^V*- *.*<\f 


lA .i\ 


'& 




»• 


- 







Fig. 357. — Same heart as shown in Fig. 356. Under treatment the cardiac diameter 
has become reduced to 10.9 cm., and all symptoms of decompensation have disappeared. 
Nevertheless this patient's reserve is definitely and permanently impaired although sufficient 
remains to enable him to carry on all of the necessary activities of a business life and a 
reasonable amount of recreational pursuits. 



oftentimes, referred symptoms of cardiac discomfort or primarily baffling sub- 
jective manifestations. It is usually present in middle-aged individuals, but 
is not uncommon in young people and, when persisting after the dilatation 
is relieved, usually assumes the form of a short diastolic, aortic murmur. 



A sign of 
interest. 



66 4 



MEDICAL DIAGNOSIS 



Habituation 
important. 



Deficient 

horse-po's-er, 



Seldom 
serious. 



Work alone 
rarely a cause 



It is almost invariably associated with a capillary pulse and, in its 
later stages* with an imperfect pulsus celer and increased pulse pressure. 

Signs of Acute Extreme Overstrain. — Extreme precordial oppression, 
marked dyspnea, pallor, dizziness, perhaps cyanosis and, not infrequently, 
severe or agonizing anginal pain and actual syncope are the symptoms observed 
in extreme cases. 

The heart is usually distinctly enlarged, the pulse rapid, weak and fre- 
quently irregular. Recovery may be extraordinarily prompt if the victim 
is in good physical trim and, in well-trained men, may pass off promptly 
and leave no visible effects behind. In others, and especially such as are 
already carrying recognized or unrecognized myocardial lesions, and in those 
structurally and nutritionally deficient or wholly out of training, the bad 
results may be prolonged or permanent or even promptly fatal. 

Preexistent Lesions. — The effect of acute overstrain upon the illy or 
even fully compensated heart carrying some preexistent lesion is such as will 
often initiate a fatal decompensatory process and this is especially true of 
instances in which the excessive effort is one lying outside of the habitual 
activities of the individual. The man with the double aortic and mitral 
lesion may perform the arduous duties of the locomotive fireman for years 
only to encounter his breakdown or actual exitus in the overexertion of a 
baseball game or the effort of cranking a refractory motor car. 

The diseased heart, even though fully compensating, is very susceptible to 
acute infections, notably to acute rheumatism and to influenza; many serious 
overstrains occurring during convalescence from such diseases. 

Overstrains of Adolescence. — Cases of acute cardiac overstrain are 
especially frequent in young boys at or about the age of puberty who are 
growing rapidly and seem in many instances to attain a body mass somewhat 
disproportionate to the strength and size of the heart, this being especially 
true of such as carry the congenital drop heart. 

/;/ many, if not ?nost, instances the initial impairment of compensation dates 
probably from some past infection and any such case demands a careful search 
for hidden septic foci. 

In some instances of this type coming under the author's observation 
dilatation and recurring overstrain have produced more or less frequent 
attacks of breathlessness, vertigo and syncope which in several instances have 
been interpreted and treated as petit mal. A short course of treatment 
directed to the heart, or the mere avoidance of overexertion, have resulted in 
prompt and permanent relief . and future growth and development balances 
the defect in most instances. 

The Heart in Laborious Occupations. — With better diagnostic methods, 
the use of the sphygmomanometer, improved case-taking and an apprecia- 
tion of the intimate relationship between the size of the heart and the body 
weight and musculature, no less than a wide knowledge of pathologic asso- 
ciations and etiologic factors, we must consign nearly all cases of cardiac 
disease, supposedly due to occupation itself, to the scrap heap. 

* As vet no cases have been watched for more than a decade. 



MYOCARDITIS 



665 



It is conceivable that certain occupations of an excessively laborious sort, other factors 

, . , 7 . „. always present. 

involving extreme fatigue and constantly recurring maximal physical effort, 
may cause disease of the heart in the case of those structurally unfit, of bad 
habits, or weakened by illness. 

On the other hand, it would seem proven that the effort involved in the most 
arduous occupations can be fully met by the normal heart which is habituated 
to its burdens. 

In the cases of congenital "drop" heart, temporary overstrain and chronic 
inadequacy often force its possessor to abandon heavy labor, but an aston- 
ishing response to demand is seen in most instances. 

In nearly all cases of heart overstrain fundamental defects of physical 
structure or in the habits of the individual are the more prominent factors 
and, in nearly every instance, past disease, chronic latent infections, or other 
similar conditions recognized as potent causes, play a chief part. 

ACUTE PARENCHYMATOUS MYOCARDIAL DEGENERATION 

Acute Myocarditis. — This, the common form of acute myocardial disease, 
in varying degrees is commonly associated with major acute infections and 
especially with true severe acute rheumatism, diphtheria, influenza, scarlet causative 
fever, pneumonia, typhoid or typhus, and smallpox,* but can and occasionally | 
does accompany or follow tonsillitis, severe measles and other acute infections 
including gonorrhea, and post-partum sepsis. One should bear in mind also 
the toxic effect of the excessive use of alcohol upon the myocardium and the 
special susceptibility of alcoholics to myocardial complications. 

Morbid Anatomy. — It is characterized by diffuse, cloudy swelling, and 
granular and oftentimes fatty degeneration or even hyaline or waxy and " 
calcareous changes of the muscle fibers, and the heart muscle is flabby, pale 
and easily torn. 

The degenerative process may proceed from the epicardial or endocardial 
surface into the interior or extend along the connective-tissue framework. 
Aschoff and Tawara believe that certain perivascular aggregations of 
nucleated round or oval basophile cells lying in the perivascular connective 
tissue are especially characteristic of or peculiar to rheumatic myocarditis. 
Such a process in an interstitial form would be peculiarly likely to affect 
conduction through the bundle of His. 

As will be seen readily, it is a composite process, as are all the myocardial 
degenerations, whatever the type.. 

Silent Transient or Permanent Forms. — These are doubtless extremely 
common and are usually and often unavoidably overlooked, much to the Masked cases, 
damage of the patient. They are not uncommon in a transient form in 
toxic "drop" hearts and afford most interesting near-replicas, in miniature, 
of the severe form in many such cases. 

* The order given is based upon the author's personal experience and is somewhat dif- 
ferent from that usually given. In the old pre-antitoxin days diphtheria would have 
largely exceeded all other causes of fatal myocarditis. 



heart.' 



666 



MEDICAL DIAGNOSIS 



Extremely 
important. 



Easily 
overlooked. 



Unsuspected 
fatal cases. 



Minor cases. 



Abnormalities 
of tone. 



The flabby myocardium of the asthenic seems peculiarly susceptible to, 
yet capable of recovery from, the toxemia of the commoner acute infections. 
Its endothelium has been considered to be relatively immune, but, as stated 
elsewhere, since he has had an opportunity to study the modifications of 
form assumed by the "drop" heart in the presence of endocardial and myo- 
cardial involvement the author believes such assumed immunity improbable. 

Septic Form of Myocarditis. — Septic emboli may block the terminal 
coronary branches and form miliary or pea-sized abscesses often yielding 
positive cultures of the causative organisms. Occasionally large abscesses 
form and rupture into the heart, or they may undergo absorption and 
inspissation leaving areas of scar tissue behind them. 

This is especially true of rheumatic, typhoidal, and influenzal cases in 
which the lymph spaces surrounding the vessels of this blocked area are 
filled with cells which in rheumatism and typhoid usually prove to be 
mononuclear. 

SYMPTOMS OF ACUTE SIMPLE MYOCARDITIS.— It must be re- 
membered that in all severe acute infections the heart muscle is likely to 
suffer in greater or less degree without producing obvious or obtrusive symp- 
toms or, of necessity, inducing permanent lesions. 

Subjective Weakness. — This sense of exhaustion the author regards as 
the most important early indication of myocardial toxemia, especially when 
coming on somewhat rapidly, and it is especially notable in influenza which in 
its true form attacks the heart muscle with peculiar severity and relative constancy. 

Subjective vs. Apparent Dyspnea. — Subjective dyspnea is also an early 
symptom of great importance, often disregarded or overlooked, and with it might 
be included certain vague sensations of precordial oppression or discomfort, 
frequently discovered only upon direct inquiry. An inability to hold the breath, 
a tendency to occasional sighing respirations or a visible air hunger, temporary 
or persistent, may be the only evidences of dyspnea. 

On the other hand, it may be decided or even extreme in frank, severe 
cases. 

Facies. — Marked pallor, pale lividity or moderate cyanosis may be present 
or appear abruptly and constitute signs of great value and significance in 
connection with other findings. 

Increase in Cardiac Area. — With a more general appreciation of the true 
normal heart boundaries and better methods of percussion many more acute 
myocardial lesions will be recognized and fewer instances encountered of a 
dramatic exitus, wholly unanticipated by the physician. 

Minor dilatation is not at all uncommon in the various everyday infections 
of a severe type and not infrequently becomes persistent and troublesome 
later if the patient is not protected against the too early resumption of 
physical activity. 

Massive Dilatation. — In severe cases the dilatation may be enormous and 
usually affects the left ventricle chiefly, but, to some degree, the right also. 

Heart Sounds. — To him who is accustomed to demand normal heart 
sounds and is therefore familiar with their qualities and variations, the weak- 



MYOCARDITIS 



667 



ness, impurities, soft murmurs, "murmurishness," sharp brevity, or associa- 
tion with soft murmurs, so frequent in myocardial degeneration and 
inflammation, will be apparent. 

Gross, distinct, dearly defined murmurs are often wholly absent even in the 
most serious cases as they may be in certain of the excessively weak and widely 
dilated hearts of terminal, chronic myocardial degeneration, and for the same 
reason. 

The pulse may be merely rapid, extremely fast, or, distinctly slowed from 
true heart block or vagus involvement and resulting excessive inhibition. 

The rhythm is often, though by no means always, more or less markedly 
disturbed and any form of arrhythmia may be present. Increase of rate, 
especially marked on slight exertion, is a common symptom and an impor- 
tant one according to its degree. So-called sinus arrhythmia is especially 
common during and following acute infections in the young. 

Gross Decompensation Signs. — Anv or all of the signs already described Any form may 
under cardiac insufficiency may appear m severe cases and these may be 
those of left or right heart type or both together. 

One has only to review the disastrous series of degenerative changes con- 
stituting the pathologic picture of myocarditis to realize the extraordinary 
ease with which dilatation and severe or extreme decompensation may be 
brought about by even slight exertion in acute myocarditis. Among the 
results are pulmonary or hepatic engorgement, reduction in the amount of 
urine, and other evidences of passive congestion, and multiple infarctions 
due to detached particles of clots, formed in the auricles or ventricles 
which may bombard the tissues supplied by the systemic and pulmonary 
arteries. 

Pain. — Acute pain is unusual though the most extreme angina has been 
present in a few of the author's cases. 

Epigastric Distress. — A subjective sense of distension, epigastric, precordial 
or distinctly substernal, or its opposite, a sense of constriction, may or may not An ominous 
be observed in various degrees of severity. Vomiting and excruciating epigastric 
pain may accompany any abrupt increase of dilatation and, as they tend to 
increase the heart weakness, these often prove forerunners of death. 

Vasomotor Symptoms.— These are frequently present in the form of cold low blood 
hands or feet, blueness of the extremities, nose, ears, and, usually, as a pressure * 
most suggestive associated sign, a markedly lowered blood pressure. 

Urinary Signs. — A sudden drop in quantity or a persistent undersecre- 
tion may be most significant though the febrile urine itself is scant and due 
allowance must be made if fever of any considerable degree is present. 

Vigilance Demanded. — One must never forget the danger attending exer- 
tion or excitement and the absolute necessity for close oversight. 

Cases presenting few symptoms and but slight dilatation may go into fatal 
collapse without warning, and dilatation of the most extreme type may occur 
with appalling rapidity. 

Although many cases are silent, general symptoms in others may be most 
severe and, in the septic case, strongly resemble those of malignant endocar- 



Abnipt 
diminution. 



668 



MEDICAL DIAGNOSIS 



Pancarditis. 



Care in 
convalescence. 



Bridges acute 
stages and 
chronic 
degeneration. 



Cardio- 
sclerosis. 



Softening of 
the heart. 



No charac- 
teristic 
symptoms. 



Conditions 
inviting fatty 
deposit. 



ditis, septic symptoms predominating and positive cultures being usually 
obtainable from the blood. 

It should also be remembered that a pancarditis may be present, especially 
in children, in which event the endo-, peri-, and myocarditis are practically 
coincident. 

If any decided evidence of acute myocarditis has been present in a given 
case, the utmost caution should be observed with respect to his resumption 
of activity. Many cases of chronic myocardial degeneration owe their incep- 
tion to the neglect of this rule and sudden death has occurred on many 
occasions. Especial care is necessary in convalescence from influenza, 
diphtheria, acute rheumatism and scarlet fever. 

THE CHRONIC MYOCARDIAL DEGENERATIONS 

CHRONIC RESIDUAL MYOCARDITIS.— A Transition Stage.— It is 

wholly rational to assume that after an attack of myocarditis or as the result 
of recurrent cryptogenetic sepsis, one often deals with a residual chronic 
myocarditis which still carries as its predominant characteristic the changes 
incident to the antecedent acute toxic process, but will be gradually trans- 
formed into one of the chronic degenerative forms of the disease. 

In this phase one still finds round-cell infiltration of tissue and parenchy- 
matous degeneration of the muscle fibers. 

Sclerotic Changes. — Coincidently there will be a tendency to diffuse 
sclerotic changes foreshadowing the probable future dominance of a 
myofibrosis, or cardiosclerosis, the commonest type of chronic myocardial 
degeneration. 

Myomalacia Cordis. — Should the local embolic processes have been espe- 
cially marked, replacement of muscle fibers by scar tissue will be evident and 
if extensive may yield the picture of myomalacia cordis and subject the patient 
to the risk of cardiac aneurysms, rupture and sudden death. 

In certain cases, all active inflammatory changes may subside; in others, 
there is a tendency to renewed infection and myocarditic activity, perhaps 
many times repeated. On the other hand, it usually takes on one of the 
other forms of extremely gradual chronic degeneration associated with a 
more or less effective (adaptive and defensive) hypertrophy. 

Diagnosis. — There are no specific symptoms of actual "chronic myocar- 
ditis " aside from those of cardiac insufficiency and its presence is merely an 
assumption based upon probabilities having special reference to known acute 
infection in the past. 

FATTY OVERGROWTH.— An Important Distinction.— Even though 
in many cases the two conditions are associated, "fatty heart," signifying 
fatty overgrowth and infiltration, as a specific pathologic process, should be 
sharply distinguished from "fatty degeneration" of the heart, a far more serious 
condition. 

Obesity and Sedentary Pursuits. — Fatty infiltration or overgrowth of 
various degrees is of especially frequent occurrence in obese individuals who 



MYOCARDIAL DEGENERATIONS 



669 



are heavy eaters., heavy consumers of alcohol, or both, and who lead an indo- 
lent or sedentary life. 

Pathology. — At rirst it is merely an exaggeration of the normal epicardial 
fat, such as is present normally in varying degrees beneath the endothelial 
layer of the visceral pericardium within the sulci, and it may so remain; but 
in certain persons the deposit becomes greatly increased and spreads over 
and even invades the underlying myocardium, much as does the connective 
tissue in a case of "interfascicular fibrosis. " 

The amount thus accumulated may be enormous, may envelop the whole 
heart and even equal or exceed the weight of that organ. 

In itself it seldom exercises any fatal degree of adverse influence, but it 
does superadd a certain amount of interference with the integrity and func- 
tional adequacy of the cardiac musculature, favors the increase of any co- 
existing degeneration of the myocardium, and, to some extent, mechanically 
embarrasses the heart's action and affects the intrinsic circulation. Its 
adverse effect, though usually relatively slight, is intensified by any concur- 
rent obesity and general muscular flabbiness existing in its possessor. 

Obesity and Cardiac Overstrain. — In this connection the adverse in- 
fluence of an overplus of body fat, when allied to relative or absolute muscular 
weakness should be strongly emphasized. 

The individual, who in the course of a few months or years adds 75 
or 100 pounds or more to his weight, owes it to his heart to keep his muscles 
in trim for, however well "packed" the adipose tissue may be, he is, never- 
theless, carrying constantly a heavy load and, if his muscles are not coin- 
cidently strengthened, this must of necessity constitute a chronic overload 
most evident under physical stress. His longevity in great measure depends, 
therefore, upon a direct reduction of this burden by any proper means or j 
such exercise and outdoor living as will serve to keep him in training for the 
inevitable persistent increase of physical effort required. 

Insurability. — Life insurance companies justly fear the flabby-muscled, 
big-bellied man whose weight exceeds, to any marked degree, the tabular 
figures and this fear is intensified if a history of rheumatism or other severe 
infections in the past, sedentary habits, overeating and indulgence in 
alcoholics, are also, in evidence. 

Common Associated Pathologic Conditions. — There are three conditions, 
aside from actual fatty degeneration, which more or less commonly may be 
found associated with disabling cases of fatty overgrowth of the heart. 

The most interesting of these is an atrophy which may be wholly obscured 
by an increase in the apparent size of the organ due to fatty deposit and dilatation. 
The second and most important is sclerosis of the coronary arteries; the third, 
cardiosclerosis. 

Other forms of degeneration may of course exist and almost any one of 
them may constitute the most potent factor in any major cardiac insufficiency 
present in the individual case. 

u Fatty hearts" rarely hypertrophy to any considerable degree and the obstacles 
which the fattv bond offers to that full freedom of diastolic relaxation and 



Pathologic 
exaggeration 
of the norma] 
deposit. 



Effects. 



Ratio of heart 
strength to 
body weight 



Constant 
overload. 



Big-bellied 
overweights. 



Submerged 
atrophy. 



True hyper- 
trophyrare. 



670 



MEDICAL DIAGNOSIS 



Coronary 
deficit. 



High dia- 
phragm. 



Temporary 
exertion- 
dyspnea. 



General 
symptoms and 
signs. 



Secondary 
signs often 
extreme. 



Worse than 

primary 

degenerations. 



Peculiar 
combination. 



Tendency to 
right heart 
failure. 



attendant coronary flushing of the heart muscle which is so vital to myocardial 
nutrition, makes it easy to understand the handicaps ultimately imposed. 
It is a well-known fact that any obstruction to the descent of the diaphragm 
or persistent upward pressure upon it greatly embarrasses the work of the 
heart and Wenckebach has called attention to the high position of the heart 
frequently demonstrable in large-bellied individuals in the sitting posture 
and especially in those who wear tight belts or habitually adopt attitudes 
which brings upward pressure to bear. 

Symptoms and Physical Signs. — The shortness of breath on exertion so 
often observed in the obese does not necessarily mean a degenerative disease 
of the heart and often wholly disappears wheat circumstances lead to a proper 
amount of daily exercise on the part of the individual; yet it constitutes a factor 
of importance in connection with other symptoms or when persisting in a decided 
degree. 

A side from this the symptoms in most instances are merely those of cardiac 
insufficiency, modified by the type of the dominant pathologic myocardial lesion, 
and emphasized usually by its occurrence in persons who show a manifest dis- 
crepancy between body weight and heart mass, as inferred from their general 
contour contrasted with their skeletal musculature and its tonus. 

The Cardiac Outline. — The cardiac outline is often decidedly misleading, 
the heart being apparently enlarged to right and left even though dilatation 
is not present. The heart sounds and any murmurs of relative insufficiency 
may be relatively indistinct, the apex-beat faint or absent and the 
superficial cardiac dulness usually less flat in tone because of the under- 
lying fat.* 

Obscure Advanced Cases. — Cases of this type - associated with atrophy 
or a silent dilatation are frequently encountered in the stage of decided incom- 
pensation made evident by hepatic engorgement, moderate edema of the feet 
and ankles, decided dyspnea on exertion, signs of passive pulmonary conges- 
tion and renal stasis. 

The combination of these frank symptoms with an almost silent heart 
forms a striking, and, to the uninitiated, a puzzling combination. 

Prognosis. — The disease is usually manifested during or after the fourth 
decade of life and only slight symptoms of cardiac weakness may be present for 
years, but if gross decompensation is present, the outlook is distinctly worse even 
than in primary, uncomplicated, degenerative, myocardial lesions. 

Many cases are associated with an interstitial nephritis and arterial 
hypertension which makes a peculiarly unfortunate combination. 

Furthermore, if cardiac atrophy or any marked degree of true fatty degen- 
eration is present, the cases are peculiarly unresponsive to treatment and 
especially so to large initial test doses of digitalis or its congeners. 

Such cases usually lose weight as the terminal stages approach and present 
a peculiar combination of anemia, flaccid muscles and weak heart. Curiously 
enough failure is earlier and more marked in the right heart. 

* In the absence of distinct signs of emphysema the presence of such a modification of 
. cardiac flatness in a stout individual is distinctly suggestive of decided fatty overgrowth. 



MYOCARDIAL DEGKNE R ATK >NS 



6 7 I 



THE CARDIAC INSUFFICIENCY OF THE GLUTTON AND THE 
SOT. — In general this condition is merely that of "fatty heart" or a greatly 
disturbed ratio of body weight to heart mass and vigor plus a myocardium 
weakened by alcohol and the toxic products of an abused metabolism, 
occurring in notorious gluttons and habitually heavy drinkers or drunkards. 

Special mention should be made of the so-called " hypertrophic beer 
heart," encountered in large numbers in Munich) Bavaria, but by no means 
infrequent in other parts of the world. 

Brewery Drivers and Ice Cart Men. — In America it is more frequently 
seen in persons who combine an excessive consumption of beer and resulting 
plethora, with an excessively laborious occupation. It is best exemplified 
in ice cart men and drivers of brewery wagons, both of whom often combine 
lifting and the carrying of heavy burdens with frequent potations.* In 
these cases it is supposed that the large amount of fluid introduced, by cre- 
ating hypertension, plays a considerable part in the cardiac decompensation. 

Human Vats. — In Munich it is said to occur ^in relatively young persons 
who drink beer in prodigious quantities "day in, day .out," with only relatively 
short pauses. 

The author's patients have almost wholly been in the "forties." The 
decompensatory signs have been especially those of right heart weakness, 
though the left show r s marked hypertrophy and dilatation. 

Extreme dilatation with frank symptoms of tricuspid insufficiency constitute 
the common finding and the patients show, as a rule, a decided and relatively 
prompt response to a diversion of the flooding tides of beer, rest and cardiac 
stimulants. On the other hand, relapses are common and prompt unless the 
occupation and the habits alike are changed. 

FATTY DEGENERATION.— This serious pathologic change, though often 
concurrent with fatty heart in the extreme forms of that lesion, is of itself absolutely 
and entirely different from fatty overgrowth or infiltration. It is associated in 
some degree with almost every form of myocardial degeneration and, when the 
dominant degenerative process, constitutes one of the most serious and intractable 
of myocardial lesions. 

It is an actual destructive fatty degeneration of the muscle fibers affected, 
which wider go finally complete loss of structure and function. 

It is especially common in association with various forms of severe chronic 
anemia, primary, secondary, or post-hemorrhagic, constitutes one of the 
characteristic features of acute phosphorous poisoning, and is a not uncom- 
mon post-mortem finding in deaths from exhausting chronic disease. 

Symptoms. — As a dominant process, it is especially common in middle 
age and its symptoms and physical signs in no wise differ from those described 
under the later stages of fatty infiltration, being merely those of chronic, progres- 
sive, and relatively intractable cardiac insufficiency occurring, however, in fat 



Jeer-heart. 



Excessive 
drinking and 
laborious 
occupation. 



Victims of 
interested 
hospitality. 



Common 

pathologic 

type. 



Relapses 
common. 



Serious if 
dominant. 



True fiber 
destroyer. 



* Ice cart drivers are so frequently " treated " to beer, on their rounds, not only in saloons 
but in private kitchens as well, as to make them heavy drinkers in many instances. The 
head of a large corporation informed the author that a thorough investigation of the 
habits of his own men revealed the fact that 80 per cent, were steady drinkers. 



672 



MEDICAL DIAGNOSIS 



an d thin alike, and, not infrequently, associated with a sallow countenance and 
a special resistance to and intolerance for drugs of the digitalis group. 

ENDOCARDIAL LESIONS 

ENDOCARDITIS.— Definition.— An inflammation of the endocardium, 
which may be acute, subacute, or chronic; is always secondary, and may 
assume a benign, malignantly septic, or septically recurrent form. 

It affects by preference the left heart and, chiefly, the opposed surfaces 
of the valves; more rarely, and oftenest in the malignant, septic and chronic 




Fig. 358. — Acute vegetative mitral endocarditis. The right side of the photograph 
shows the cauliflower-like mass of vegetations almost replacing the valve and running up 
on^the endocardium- of the left auricle. (Yiridans type.) Case of woman, age 2&, who 
"never had rheumatism "(?). At 22 had jaundice and enlargement of liver. Married at 
23. After birth of child was never well. About 2 years before death had right-sided hemi- 
plegia. Slowly recovered for a year and then had left hemiplegia. Infarcts of both brain 
and kidneys were found at post-mortem. {Courtesy of H. E. Robertson.) 

recurrent (" streptococcus viridans") cases, the adjacent mural endocardium. 
It tends to produce either transient or permanent vegetations or deformities, 
is overwhelmingly chief in the production of chronic valvular lesions of 
children and young adults; in its acute and recurrent malignant types is al- 



ENDOCARDITIS 



673 



most invariably fatal, and in any of its severer forms seriously affects valvular 
function. 

The degree of primary inflammation and the occurrence, depth and sub- 
sequent behavior of the necrotic process depends upon the condition of the 
myocardium, the virulence of the causative organism and the resistance of 
the patient. 

In the non-malignant forms the primary effect may be slight and, prob- 
ably, transient as is shown in certain experimental work and suggested 
by clinical experiences. Ordinarily vegetations upon the valves result from 
the formation of bacterial emboli and a reactive fibrinous exudate. 




Fig. 359. 



Acute vegetative, mitral endocarditis. A ridge of soft reddish thrombi is 
located on the auricular surface of the line of closure. 



Etiology and Pathology. — No microorganism can be charged with the 
responsibility for acute endocarditis. The pneumococcus, staphylococcus, 
streptococcus, and more rarely the colon bacillus have been found in endo- 
cardial lesions. Acute rheumatism,* the acute forms of septic infection, and 
the toxins of various acute infectious diseases are associated with both the 
benign and ulcerative cases, and the true sclerotic forms are caused by the 
same factors that are active in arteriosclerosis. It is believed that an endo- 

* Acute rheumatism is responsible for about 90 per cent, of the chronic valvular 
lesions encountered in children and young adults. Valvular lesions of a pronounced type 
developing after the age of 30 are overwhelmingly syphilitic in origin, though rheumatism is 
even then a decided factor in those of the mitral type. 
43 



Valve emboli. 



Associated 
ailments. 



674 



MEDICAL DIAGNOSIS 



Acute 
rheumatism. 



carditis of some degree exists in nearly every severe case of acute rheuma- 
tism (its most common cause) and that many spontaneous recoveries from 
transient unrecognized lesions occur. This can be true when the inflam- 
mation is extremely slight and fleeting, and in mitral stenosis the classical 
symptoms of that lesion may be so long postponed as to cause over-hasty 
primary conclusions as to the patient's escape from valvular involvement. 

Children are especially liable to this acute complication of severe acute 
rheumatism, 60 to 80 per cent, of those cases occurring between the ages of 
ten and fifteen presenting demonstrable lesions, and an astonishing number 
a pancarditis. In adults the demonstrable percentage by careful methods is 
probably between 25 and 40 per cent., varying with age differences-, the young 
adults being the more often attacked and old age being almost immune. 
In choreic cases endocarditis is extremely frequent judged by post-mortem 
records, many murmurs are present which may prove ultimately to be func- 
tional or accidental. Endocarditis occasionally complicates other acute in- 
fections and, rarely, mild forms may occur in general sepsis, ulcerating inter- 
nal malignant growths, and tuberculosis* 

Any of the exanthemata and especially scarlatina and diphtheria may be 
complicated by it and gonorrhea in the adult is sometimes associated with 
the ulcerative form. 

Acute rheumatism and its recurrences doubtless account for from 65 to 
70 per cent, of all cases of acute endocarditis, and syphilis is now held account- 
able for the majority of the sclerotic cases developing in adult life and for 
long periods latent and undemonstrable. We now have excellent proof in 
the work of Poynton and Paine and E. C. Rosenow, especially, that acute 
rheumatism and the various forms of endocarditis are caused by various more 
or less specific strains of hemolytic streptococci which most frequently find 
their nidus in the tonsils, which when chronically infected offer an ideal point 
for incubation under the varied conditions of oxygen supply and nutrition 
which Rosenow found necessary to artificially reproduce in the test-tube in 
developing the different streptococcus strains. 

It is impossible to clearly separate the acute benign from the acute ulcera- 
tive form save on clinical grounds and chronic endocarditis of any type 
may follow an acute attack and in both the acute and chronic forms, and 
especially in children, associated myocardial changes always must be assumed 
to be present. 

The peculiar structure of the vegetations in verrucose endocarditis makes 
it possible in virulent cases for fragments to be swept away by the blood 
stream and produce emboli in the brain, lungs or other viscera, and this may 
occur in the acute and subacute forms though to a less degree than in the 
malignant types. 

In simple verrucose cases these do not appear often and the ultimate 
change is one of healing and transformation of the vegetations into connec- 
tive tissue with resultant deformity and disability of the valve affected. 

* A low white blood count is present usually in such cases, but is not wholly dis- 
tinctive, although leucocytosis is the rule in acute and malignant cases. 



ENDOCARDITIS 



675 



A point 
of value. 



Varieties. — In general there are three classes of chronic endocarditis: 

1. Verrucose, in which the valves are the seat of transformed 
vegetations. 

2. The ulcerative form, characterized by superaddition and predomi- 
nance of a rapidly extending necrotic process, present only to a slight 
degree in the verrucose form, the clinical symptoms of the former being 
largely those of acute or recurrent septic intoxication, associated with a 
valvular lesion and myocardial insufficiency. 

3. The sclerotic form characterized by its slow development, its extreme 
chronicity and its tendency to deform gradually the valvular structures. 

The previous occurrence of tonsillitis may alone explain a mysterious 
endo-, myo-, peri-, or, pancarditis, in children especially, for in them the 
actual rheumatic manifestations may be very slight. The author has seen 
several cases of this kind in young children in which an actual malignant 
endocarditis followed a tonsillitis apparently after a period of seven to twelve 
days of apparent health. The joints in such cases may be no more than 
slightly tender and any history of acute arthritis lacking. 

Symptoms of Simple Endocarditis. — Early symptoms are likely to be 
almost wholly subjective, any change in the temperature being in most cases 
obscured by the febrile manifestations of the primary ailment. 

77 should be stated with emphasis that in the greater proportion of cases of 
endocarditis there is absolutely no complaint of cardiac symptoms on the part of 
the patient whose attention is wholly absorbed by the pain of arthritis or the dis- 
comfort of his sweats. 

His responses to the physician's inquiries usually furnish the only source 
of information with respect to the most important subjective manifestations of 
acute valvular involvement. 

Such patients, however, often exhibit increased pallor, cyanosis, subjective 
weakness, precordial oppression and subjective dyspnea, the last being sometimes important 
objective as well, but seldom marked. 

Acceleration and disturbances in cardiac rhythm occur as in myocarditis, 
and, perhaps, because of the concurrence of that lesion. Arrhythmia may 
be wholly absent or, if present, may vary from sinus irregularity of no clinical 
significance, to extrasystoles and varying degrees of heart block, as revealed 
by polygraphic or electrocardiographic tests. 

The importance of an acceleration out of correspondence with the degree of fever 
is only less important than the development of a definite arrhythmia. And even 
if no murmur is present, cases that show such signs should be followed with 
especial care through, and for several months after, convalescence. 

If the heart sounds have been carefully watched, an impurity, sharpness, or 
change of accent is usually detected, due probably more to the accompanying 
myocardial toxemia than to the valvular lesion itself, but nevertheless 
suggestive. Multiple systolic murmurs may be present over the heart 
which defy accurate classification, but usually prove to be temporary, 
this statement being almost wholly true of systolic murmurs maximal at 
the base. 



signs. 



Arrhythmia. 



Precordial 
oppression. 



676 



MEDICAL DIAGNOSIS 



Isolated aortic 
regurgitation. 



Silent cases. 



Delayed 
signs. 



In any event the sounds will have undergone a marked change since the last 
visit, in most instances, if in the meantime endocarditis has developed. 

According to the virulence of the infection, the intensity of the reactive 
changes and the valve involved, the occurrence of actual organic murmurs 
will be early or delayed. 

Mitral regurgitant lesions are by far the most common and easiest to 
recognize (80 per cent.). 

Aortic regurgitant bruits combined with a mitral come next in frequency 
and may be frank or, at first, but an apparent blurring or splitting of the 
second sound in the third left interspace, followed later by a short diastolic 
bruit or the typical long-drawn murmur. 

Aortic regurgitation occurring as an isolated lesion is relatively rare 
(3 per cent.) in acute endocarditis. It is usually a luetic lesion as ordinarily 
encountered in practice. 

Aortic stenosis is relatively rare as a result of acute endocarditis and diffi- 
cult to place during the febrile stage. 

Mitral stenosis usually affords no definite signs until long after the pri- 
mary and causative illness. 

If the mitral valve is the seat of the endocarditis, enlargement of the right 
ventricle is likely to be the primary change. This is by no means an absolute 
rule, however, both ventricles being affected in many instances, whatever 
the lesion. This is doubtless in a large measure due to generalized myo- 
cardial weakness. 

In many of the subacute or slowly developed cases, the change may first 
be noticeable when a resumption of activity is attempted in convalescence. 

The author . knows of no means of differentiating silent cases from acute or 
subacute myocarditis until their silence is broken. Indeed an accompanying 
myocardial toxemia of greater or less degree is present undoubtedly in every case 
and the reader should refer to the discussion of this subject on another page. 

Subacute Endocarditis. — This form presents few symptoms, other than 
a murmur, and fever may pass unnoticed unless it appear in an afebrile 
interval of the primary disease. Palpitation and inconstant symptoms of 
dyspnea, or more often a sense of precordial oppression, are usually present, 
though often overlooked. 

Common and Serious Error. — The frequency with which a chronic endo- 
carditis is found in patients whose condition is wholly unsuspected by the 
family physician is largely the result of three serious errors of omission. 

One is the failure to watch the heart during all acute infections, but especially 
tonsillitis and rheumatism; the second is the failure to guard the patient in con- 
valescence; the third, the almost universal neglect of the heart after such an illness 
is passed. 

Following every case of acute rheumatism the patient's heart should be 
watched and examined at intervals over a period of several months. Even 
a mitral or aortic regurgitation may not become clearly recognizable for six 
or eight weeks after recovery and mitral stenosis is rarely demonstrable at all 
or even suspected during the illness. The physician will add many years to 



MALIGNANT ENDOCARDITIS 



677 



the life of cardiopaths and save himself from legitimate criticism if he does his 
plain duty along these lines. Protection at the stages of early development 
may decidedly affect the after-course of the ailment by limiting or retarding 
the associated processes of myocardial degeneration. 

Recurrences of Acute Simple Endocarditis. — The liability to recurrence is 
decided, especially if, as is usual, these crippled hearts are not protected under 
proper and extended observation and judicious therapy, and the usual crypto- 
genetic foci {tonsils, peridental abscesses, chronically injected accessory sinuses 
and the like) are allowed to remain active. 

MALIGNANT ENDOCARDITIS.— In this form of endocarditis the 
symptoms are essentially those of (a) the typhoid state, or (b) of pyemia, and 
are usually definite, though masked and afebrile cases occur. 

Chills or chilliness, high or moderate, intermittent or markedly irregular, 
fever and sweats, associated with a valvular murmur, often considerably 
delayed in its appearance and changing from day to day as the emboli are 
thrown off the affected valves or new formation occurs, are the more charac- 
teristic features, but the disease may very closely simulate typhoid fever, 
malaria and meningitis, and cerebral emboli may further confuse the picture. 

Petechia? are usually present and of the utmost significance as represent- 
ing an embolic process; multiple abscess formation due to septic emboli are 
not uncommon; splenic tumefaction, often sudden, from infarct, may occur; 
gastrointestinal symptoms may be predominant, and, rarely, a septic arthri- 
tis develops. 

A systolic murmur in the tricuspid area is a prominent feature but is 
usually relative and secondary. Optic neuritis is a common finding in the 
later stages and in some instances retinal hemorrhages are demonstrable. 

Diagnosis. — The diagnosis depends largely upon the presence or the develop- 
ment oj the signs oj a valvular lesion, together with septic and usually embolic 
manifestations and the results of blood cultures, which are usually positive in 
this form. The disease in rare instances may run a prolonged fatal course with 
absolutely no fever. 

The blood culture is negative for typhoid and the blood smears equally 
so for malaria unless the latter disease co-exists, as may happen in certain 
districts. The Widal reaction fails unless the patient has had typhoid within 
six months or a year. The leukopenia of typhoid is absent and, usually, one 
finds a polymorphonuclear leucocytosis of varying degree. 

The pyemic form, especially when developing without a previous known 
infection, and in the absence of evidence of any preexisting valvular disease, 
is extremely difficult to differentiate from pyemia of the common type. 

Murmurs are less reliable guides in such instances than the early or even 
initial appearance of cardiac weakness and change in outline of the heart due 
to associated myocardial toxemia. The multiple cutaneous hemorrhages, due to 
the showers of superficial infarcts, are extremely helpful when present. 

Emboli may attack every portion of the body and vary from the tiniest 
of terminal artery plugs, to those sufficient to block a femoral artery. The 
skin emboli are characterized by a pale, yellow or white center and definitely 



Offers many 
difficulties. 



Septic 
phenomena. 



Petechias. 



Fundamental 
factors. 



678 



MEDICAL DIAGNOSIS 



Streptococcus 
viridans. 



Resembles 
malaria 



A common 
error. 



hemorrhagic border and sometimes appear as pemphigus-like or gangrenous 
areas. The embolic manifestations are limited only (a) by the boundaries 
of the systemic arterial distribution, being confined to the pulmonary cir- 
cuit in about 10 per cent, of all cases. 

Multiple abscess formation, if it occurs in either form of malignant endo- 
carditis, is usually the result of staphylococcic rather than the commoner 
streptococcic infection. 

RECURRENT -MALIGNANT SEPTIC ENDOCARDITIS.— This is 
essentially a chronic secondary recurrent injection of the septic type, caused by 
the streptococcus viridans (Schottmuller), and presents the symptoms 0} recurrent 
fever of variable intensity , but of a septic type, with signs of established valvu- 
litis and, usually, a preexisting hypertrophy and dilatation. 

It is often mistaken for malaria, the irregular estivo-autumnal forms of 
which it strongly resembles, both in the type of fever and in the ability of its 
possessor to keep about during the actual attacks, if these be mild. 

In other instances it is often mistaken for tuberculosis because of acci- 
dental concurrence or the peculiarities of the fever curve.* 

As contrasted clinically with the simple form this malignant type may be 
cryptogenetic and show no history of an acute antecedent illness. Three- 
fourths of the cases develop upon a preexisting valvular lesion and furnish 
good examples of the diminished resistance to infection associated with myo- 
cardial overstrain and diseased valves, the former undoubtedly playing the 
chief part. 

About 90 per cent, of the cases involve the left heart alone and limit their 
characteristic showers of septic emboli to the systemic arteries. 

It is probable that any aortic valve involvement is usually pneumococcic. 

Aside from the history of previous attacks, but four features of any importance 
can be emphasized as aiding differential diagnosis: 

1 . The presence of recognizable and usually ancient cardiac changes. 

2. A leucocytosis during febrile periods. 

3. The recovery of the streptococcus viridans from the blood cultures, of which 
several may be necessary. 

4. The transient, red, raised, painful, cutaneous nodes seen in many, if not 
in most cases, on the hands and feet, and almost pathognomonic. 

Prognosis. — Few cases recover but the intermittent febrile periods may 
continue during many months. 

MITRAL INSUFFICIENCY 
(Mitral Regurgitation or Incompetence) 
THE TYPICAL CASE.— The following summarizes the findings in typical 
endocarditic cases only (see "Rationale" for variations). . 

* In a case recently observed by the author the patient had a "cor bovis" with mitral 
and double aortic lesions, showed unmistakable physical signs at both apices, had recently 
returned from the tropics and carried the estivo-autumnal organisms. Blood cultures were 
positive, however, and he met his death within a few weeks. A diagnosis of tuberculosis 
(actually arrested) had first been made, then one of malaria, and finally the true one. 
His fever had been present at intervals for two years. 



MITRAL INSUFFICIENCY 



679 



THE MURMUR. Quality.— A blowing sound clearly heard but usually 
of only moderate intensity. 

Time.— Systolu \ i.e., coincident with, modifying, obscuring or entirely re- 
placing the first heart sound at the apex.* 

Maximum of Audibility. — At apex of heart. 




Fig. 360. — The normal heart in systole. The full ventricles are contracting, the blood 
flows freely from them into the pulmonary artery and aorta; the mitral and tricuspid 
valves are tightly closed; the auricles are refilling, mv. Mitral valve, tv. Tricuspid 
valve, av. Aortic valve, pv. Pulmonary valve. LA. Left auricle. RA. Right auricle. 
LV. Left ventricle. RV. Right ventricle. VCS. Vena cava superior. VCI. Vena cava 
inferior. PVn. Pulmonary veins. AO. Aorta. PA. Pulmonary artery. (Schematic 
Outline.) 

Areas of Maximum Transmission. — To and through the axilla; at the 
back, just within and somewhat above the inferior angle of scapula; usually 
not lost between these points. 

Cardiac Outline. — The relative cardiac dulness is increased both to left 
and right and the left border line rises somewhat upward and to the left and 
extends outward. 

The superficial cardiac area is significantly extended to the right and the 
apex-beat lies further to the left than normal and slightly or somewhat markedly 
lower, though never to the extent characterizing the aortic lesions. 

Pulse. — The pulse is not characteristic though usually soft, however forci- 
ble may be the apex-beat, and it for years may show no marked variation in 
force or rhythm. So many factors enter into its quality as affected by the 
many conditions with which mitral regurgitation is associated that no one 
type of pulse may be regarded as peculiar to the lesion. 

* Certain bruits closely follow the first sound and are called "postsystolic" and if 
further removed mesosystolic. 



Blowing 
systolic 
murmur. 



Right and left 

heart 

affected. 



68o 



MEDICALDIAGXOSIS 



On the other hand, one may encounter excessive pulse- weakness during 
periods of serious decompensation and any form of arrhythmia may be 
encountered. 

The auricles then show the same tendency to fibrillation or rarely flutter 
as is present in mitral stenosis, though in lesser degree. 




Fig. 361. — Mitral regurgitation. Four varieties of the murmur of mitral regurgitation 
are shown graphically, the first two of which represent the type. The heart in systole, 
mitral leakage evident. The contracting ventricles are forcing the blood through the open 
aortic and pulmonary valves; the tricuspid, tightly closed, prevents regurgitation into right 
auricle. The leaky mitral allows backflow into the left auricle already filling from the 
pulmonary veins above. Results. — A systolic murmur, dilatation of left auricle, pulmonary 
congestion, and consequent ultimate enlargement of right ventricle. 3iv. Mitral valve. 
tv. Tricuspid valve, av. Aortic valve, pv. Pulmonary valve. LA. Left auricle. RA. 
Right auricle. LV. Left ventricle. RV. Right ventricle. V.C.S. Vena cava superior. 
V.C.I. Vena cava inferior. P.Vn. Pulmonary veins. PA. Pulmonary artery. AO. Aorta. 
(Schematic outline.) 

Blood pressure varies slightly in the same manner but the tendency in 
compensated cases is toward a normal pressure. 

Associated Signs. — The pulmonary second sound in the second left inter- 
space is sharply accentuated, until the right heart weakens or actual tricuspid 
regurgitation is established. 



MITRAL INSUFFICIENCY 



68 1 



Thrill. — In about 20 per cent, of well-marked and established cndocarditic 
cases a systolic thrill may be palpated at the apex. 

Fundamental Differential Characteristics. — A murmur of maximal audi- 
bility at the apex, beginning accurately and exactly with or wholly replacing 
the first heart sound, is almost invariably due to mitral regurgitation. If the 




Fig. 362. — Mitral regurgitation. Note enlargement both to right and left. Measure- 
ments: M.R., 5.5; M.L., 9.5; total, 15 cm. Comparison with Fig. 308 is interesting. 
This picture lacks the excessive auricular bulge, although the median and inferior notches 
are filled out. Left ventricular hypertrophy with the mitral curve above is well shown 

lesion is solitary and long-established, the cardiac area is quite characteristic and 
of great value in confirmation of the diagnosis. 

RATIONALE. — Mitral insufficiency is at once the most common, most tract- 
able, and most elusive, of the commoner valvular deficiencies; easy of recognition 
in typical cases, but oftentimes extremely difficult to identify and properly place 
in others, because of the multitude of systolic murmurs of the so called 



682 



MEDICAL DIAGNOSIS 



Juvenile type. 



Degenerative. 



Relative in- 
sufficiency. 



Triple effect. 



Increased 
pulmonary 
pressure. 



Auricular 
dilatation and 
hypertrophy. 



"accidental" type and the great variations in intensity which even the endo- 
carditic regurgitant murmur displays. 

Etiology. — In the young, when typical, it is almost invariably (85 to 90 
per cent.) the result of endocarditis resulting from acute rheumatism and 
in such cases is usually typical in its manifestations. Many soft, poorly- 
transmitted systolic or post-systolic bruits maximal at the apex are asso- 
ciated with muscle-tonus deficiency and leakage. These are not without 
significance or importance, though the valves themselves may be wholly 
free from disease, and are discussed fully elsewhere. (See signs and 
symptoms of minor myocardial insufficiency.) In older persons it is more 
often a manifestation of sclerosis, the relative insufficiency of myocardial de- 
generations, or a leakage secondary to aortic defects (relative or secondary 
insufficiency), or, associated with a preexistent or coincident mitral 
stenosis. 

Secondary Effects. — In all these latter conditions it runs much less "true 
to form" in its symptomatic expression than in those originating in the acute 
infections of the first two or three decades of life, but in its typical forms it 
offers the simplest of problems both as to the mechanics and the secondary 
effects. 

The left ventricle has one inlet and one outlet and, when acting nor- 
mally, has but a single open orifice during each major phase of its cycle, one, 
the aortic, for outflow in its systole; one, the mitral, for inflow in its diastole. 

It is thus protected from overdistention and embarrassment, whether 
from currents from two sources in its diastole or failure to deliver its full 
load in its systole through the one proper channel. Normally this self -pro- 
tection of the ventricle itself is extended to the auricular reservoir which 
supplies it, and hence also to the entire pulmonary area, the right ventricle, 
right auricle, and the systemic circuit which these drain. 

It is obvious that in established gross mitral leakage the left ventricle 
fails to prevent backflow into the auricle during systole. As an immediate 
result, the left ventricle, left auricle, the entire pulmonary field and the 
right ventricle are affected. 

The left ventricle, by reason of the extraordinary and exhausting demands 
upon emergency reserve, almost invariably impaired by the causative toxemia 
or the antecedent effects of a primary myocardial degeneration or aortic valve 
lesion, must fail at first to deliver its full load to the aorta. 

The Left Auricle. — The auricle receives not only the flow of blood from 
the pulmonary veins, but also a concurrent abnormal backflow from the 
ventricle and must undergo primary dilatation. 

The effects of auricular engorgement are at once reflected in the pulmon- 
ary vascular field which it directly drains. 

Pulmonary Circuit. — It is evident that stasis of the pulmonary circulation 
threatens and that the right ventricle is called upon for extra work. 

Obviously, the most serious direct primary effect is that exerted upon 
that thin-walled reservoir, the left auricle, and this chamber must dilate 
and to the best of its limited ability hypertrophy; for, like the lungs, it is 



MITRAL REGURGITATION - 



68 3 



placed between two opposing forces, i.e., that of systolic regurgitation from Between two 
the left ventricle and that represented by an attempt at systolic compensatory 
overaction on the part of the right ventricle. A measure of relief must be 
found in an increase of rate and of cubic capacity (dilatation) on the part of 




Fig. 363. — Chronic vegetative mitral and aortic endocarditis with partial destruction 
of leaflets, thickening and retraction of margins and consequent insufficiency and involve- 
ment of the endocardium by vegetations and fibrous nodules over an area in the left ven- 
tricle below the aortic ring. The heart is hypertrophied and the cavities dilated. Case 
at University Hospital (Hosp. No. 3605) of man, age 33, who had rheumatism a few years 
before his attack of shortness of breath. Admitted because of edema of extremities and 
dyspnea. At autopsy heart weighed 640 grams. Infarctions of spleen and kidneys were 
present. (Dept. of Pathology, Univ. of Minn. Courtesy of H. E. Robertson.) 

the left ventricle, and this latter in turn must be limited and reenforced by 
hypertrophy of the musculature. 

Compensation. — Obviously the attainment of "compensation" in a typical 
case of free mitral regurgitation must represent (a) dilatation and hypertrophy 



68 4 



MEDICAL DIAGNOSIS 



Chief elements 
in compensa- 
tion. 



of the left auricle itself; (b) dilatation and hypertrophy of the left ventricle; and, 
(c), hypertrophy of the right ventricle, which, of the three chambers involved, is 
primarily least directly or violently afected because of the interposed arterio- 
capillary area of the lungs. 

Great Variation in Lesions. — The smaller the lesion and the more gradual 
its production or increase, the more insignificant will be the primary changes 
and, as a matter of fact, true regurgitation may be either temporary or 
permanent, so free as to abolish the murmur in weakened hearts when the 
stasis pressure within the left auricle may actually block the regurgitation 
mechanically, or so slight or fully met by slight adaptive hypertrophy as for 
long periods to add little to the burden of the chambers and present almost 
nothing in the way of physical signs save the murmur itself. 

Variations in Quality, Pitch and Duration of Murmur. — The quality, pitch 
and duration of the murmur will vary with the auricular vigor and capacity and 



I st Sd 



st Sd. 2 d 5d. 




Fig. 364. — Compare this area, obtained by flat-finger percussion, with the roentgenographir 
silhouettes, which represent very .closely the outlines obtainable by modern methods. 

yet more with right and left ventricular heart strength and intraventricular head 
of pressure. 

The size and shape of the opening, abnormalities of consistence and sur- 
face, the exact nature of the structures chiefly implicated in the valvular or 
myocardial disease-process, and the condition of the lungs are one and all 
important factors. 

A few general deductions are permissible if their limitation and fallibility 
are recognized and held in mind. 

If decided signs of stasis are absent and only the signs of a mitral leakage 
present, a short murmur usually indicates a small leakage; a long one a larger 
leakage though pitch is -also a factor. In general the greater the degree of 
left ventricular hypertrophy, the larger the leak. 

A decided heave over the epigastrium usually means a gross hyper- 



MITRAL REGURGITATION 



68 5 



trophy of the right chamber, hence a big mitral leak, a weak left heart, or 
both combined and its association with a pulmonary accentuation indicates 
good right ventricular strength. 

Variations in Time of Murmur. — Its time must obviously be systolic, and in 
typical cases, it must modify or even replace the first sound of the heart*, for it 
occurs at the moment when ventricular contraction "slams" shut the auricular- 
ventricular trapdoor and drives the blood through the open aortic orifice into the 
aorta itself. 

Murmurs of Relative Insufficiency. — In certain instances and especially 
those of relative insufficiency due to myocardial weakness and an unsupported 
septum and ring or to weakness of the papillary muscles, the mitral curtain 
seems to yield after primary closure or even late in systole and thus a proto- 
(early), meso- (midway), or post- (late) systolic murmur appears. These 
variations, especially the meso- and post-systolic variety, always suggest 
myocardial toxemia or an overstrained heart and demand careful inves- 
tigation and especially accurate localization. 

Such murmurs are likely to lack the 
definite transmission usually present in 
the case of true endocarditic mitral regur- 
gitation. 

Weakness or entire loss of the murmur 
may be evident in event of failure or de- 
cided weakness of the right ventricle and 
resulting extreme intra-auricular pressure 
or the pushing aside of the left apex by 
a dilated right heart; in the last instance 
it may, nevertheless, be heard over the 
back.f 

Extreme weakness of the left ventricle 
and an excessively large leak constitute 
obvious causes. 

Temporary Absences of Murmur. — The murmur sometimes varies greatly 
with the different heart beats. It must necessarily do so if produced at all 
by extrasystoles, the weaker beats of delirium cordis or those of decided 
alternation; and the same statement holds true during longer or shorter 
periods of actual paroxysmal tachycardia or auricular flutter (see " Arrhyth- 
mias"). 

Irregularly missing beats and murmurs occur in heart block when, by ! 
chance, the auricular and ventricular systoles coincide and regurgitation is 
minimized. 

Variation in Intensity. — It is usually a soft blowing murmur but may be 
faint, temporarily inaudible, a mere impurity or blurring of the first sound or 
loud, harsh, sibilant, musical or raucous. 

*At the apex, i. e., in the mitral area. 

t In several instances occurring in the author's series, it has been audible primarily at 
the back only. All have occured in slender, thin women. 




Fig. 365— Mitral regurgitation. 
Typical maximum intensity and 
transmission. (Arthur Sansom.) 



Proto-, meso- 
and post- 
systolic 
murmurs. 



686 



MEDICAL DIAGNOSIS 



Peculiarities 
of trans- 
mission. 



Papillary 

muscle 

transmission 



Apparent 
continuity of 
transmission. 



Transmission 
to back. 



Transmission of the Murmur. — Its transmission is peculiar and with 
respect to the apex area, to which it is too often limited and at which it is 
almost invariably maximal, to the author's mind is best explained by Hirsch- 
felder's suggestion* that the murmur as heard anteriorly is usually trans- 
mitted by the chordae tendineae along lines represented by the papillary muscle 
bases. It is brought thus directly to the chest wall at the point represented 
by the apex-beat, which is the tip of the left ventricle save in excessive right 
ventricular dilatation. The murmur is also heard at the back if the left 
auricle is greatly or even markedly dilated and usually in the axilla, and in 
the case of soft bruits the apparent continuity of transmission through the 
axillary region to the inferior scapular area, is doubtless due in part to the 
left ventricle (axillary transmission) and in part to a dilated left auricle 
(scapular transmission). The latter lies almost wholly posterior, but some- 
times transmits the mitral systolic bruit to the left second interspace. 

Loud murmurs are of course heard over wide areas but the maxima are as 
stated. 

Transmission may be markedly affected by excessive right heart dilatation 
which, as before stated, may actually displace the left ventricle and cut off 
the anterior field of transmission. 

Cardiac Area. — The changes in the cardiac area are quite characteristic 
and logical, the left border being carried outward, and the area of right heart 
d ulness increased. This is indicated especially by the extension of superficial 
and relative dulness to the right and only to be determined with any accuracy 
by the modern percussion methods and the X-ray. because of the peculiar 
relation of the right heart to the corresponding chest area and lung. 

Associated Signs. — The associated signs are of extreme interest and 
importance. 

Accentuation of the Pulmonary Second Sound. — That the pulmonic second 
sound should in most cases be louder than the aortic second or exceed its own 
normal intensity is self-evident, for the primary effect of the heightened 
pressure in the lesser (pulmonary) circulation must of course produce the 
conditions following: [a) Left auricular overload; (b) heightened pressure in 
the pulmonary veins, capillaries, and pulmonary artery; and (c) overaction of 
the right ventricle. These combine to produce an abnormally brisk and violent 
closure of the pulmonic valve. 

Precisely the same accentuation of the second pulmonic tone is evident 
in any other case of lung stasis or circulatory obstruction unless obscured by 
emphysema or adhesions, and, in such instances, failing accentuation may 
be of diagnostic and prognostic value exactly as in the case of the heart, 
indicating in acute congestion or pneumonia a failing right heart or a clearing 
up of the lung ("resolution"). 

' P ulmo nary Stasis. — In decided mitral insufficiency during decompensa- 
torv or incompensatory periods the tendency to actual passive congestion 
of the lungs is strong and often finds its extreme expression in chronic bron- 
chitis, transient congestion, hemoptysis, a blood-streaked sputum contain- 

* "Heart and Blood Vessels." 



Striking 

symptoms. 



MITRAL STENOSIS 



68 7 



ing heart disease cells or an actual hypostatic and circulatory pneumonia or 
terminal edema. 

In the tendency to pulmonary stasis, diminished oxygen and C0 2 ex- 
changes and asphyxiation of the respiratory center, we find the explanation 
of dyspnea on exertion, cough, cyanosis and even the spasmodic dyspnea, 
occasionally, though not often, present in mitral hearts. 

Diminished Pulmonary Accentuation. — The numerous instances in which 
this sharp accentuation fails are, in the main, easily understood in the light of 
the statement following, viz.: First, a roomy, hypertropkied, strongly acting left a good sign 
auricle and left ventricle will greatly diminish oxer long periods of time the tend- 
to stasis. Second, slight leakages, or those originally small and but slowly 
progressive, may for a long period cause little circulatory embarrassment and 
symptoms. Conceivably, overstrain of the capacity of the left heart is not 
always necessary to keep its chambers and those of its fell 'ou on the right reasonably a bad sign. 
clear and unobstructed. Third, obviously, a diminution of any preexistent accen- 
tuation of t)ie pulmonic secojid sound is likely to occur in the event of excessive 
ri^ht heart exhaustion, free tricuspid regurgitation or the rarer event, secondary 
pulmonary insufficiency. 

Subjective Symptoms.— With the slow advance of decompensatory 
changes and the gradual but inexorable and progressive limitation of the 
field of myocardial response, the extremely valuable, much-neglected and so 
often misinterpreted "subjective symptoms/' already described elsewhere, 
demand recognition. 

The second period of slight objective, plus more decided subjective, ex- 
pressions follows and finally, the transient periods of decided objective dys- 
pnea, pulmonary congestion, hepatic engorgement, renal congestion, and 
ankle edema arise and tend to become more and more frequently recurrent, 
resistant or persistent. 

The limitations of activity may then become more and more definitely 
defined until general anasarca, pulmonary edema, coma, cerebral embolus. 
mere cardiac overload, or, as happens frequently, some intercurrent com- 
plication terminates the case. 

It must never be forgotten that in the case of this lesion especially even the 
most severe sympto?ns may disappear under proper management. 

Prognosis. — In general, long-enduring, lasting sometimes for a lifetime and 
even then surrendering oftentimes the long-poised sword to some other execu- 
tioner, the tendency in mitral regurgitation is nevertheless toward a pro- shortens life 
gressive diminution of cardiac ''reserve" and a great reduction in the "life 
expectancy of its group. 

MITRAL STENOSIS 

A Lesion of Extraordinary Interest and Many Peculiarities. — This com- Young females 
mon valvular disease possesses many striking peculiarities relating to its affeVId. 
etiology, pathology, symptoms and course. It is predominatingly, though 
not exclusively, a lesion of the young and of the female sex, and it is almost Follows acute 
invariably due to a distinct endocarditis of infectious origin. 



Early signs of 
insufficiency. 



Definite 
evidence. 



Terminal 
symptoms. 



688 



MEDICAL DIAGNOSIS 



Usually due to 
rheumatism. 



Associated 

frregurgitation 

equent. 



Duroziez's 
disease. 



Rarely or 
never recogniz- 
able at onset. 



Decompensa- 
tion long 
delayed. 



Nearly or quite three-fourths of all cases follow acute rheumatic arthritis and 
the remainder are almost entirely chargeable to other acute infections, chiefly of 
the youthful types. The primary arteriosclerotic form is rare; the congenital 
case, a clinical curiosity. 

Associations. — The stenotic lesion is seldom unassociated with regurgita- 
tion but, when advanced, usually overshadows and dominates its associate, 
more or less completely, in symptoms and physical signs alike. 

Seldom Isolated. — Rarely it occurs as an isolated lesion and then chiefly 
in persons bearing the stigmata of "universal congenital asthenia,"* in whom 
its manifestations are so peculiar as apparently to have mislead Duroziez 
into describing it as a distinct ailment (Duroziez's disease). 




Fig. 366. — Normal heart at the beginning of diastole. 

Delayed Manifestations. — Existing alone it is seldom or never recogniz- 
able in its true form during the attack of endocarditis which causes it and, 
aside from marked irregularities in rhythm, as an isolated lesion its decom- 
pensatory manifestations may not appear in any marked degree until the 
valve has lost two-thirds of its normal caliber. Decided physical signs may 
be manifest at a much earlier period. 

In almost every case an associated mitral regurgitation or, much less com- 
monly, an aortic leakage hastens the decompensatory stages. 

Persistently Progressive. — Its unremitting course once established, stenosi 
of the mitral valve almost invariably is slowly but persistently and inexorably 

* According to the author's personal observations. 



MITRAL STENOSIS 



689 



progressive though its victims may live one, two or even three decades after its 
inception.* 

Anatomic Types. — Post-mortem, the disease presents two distinct types, 
\\z.\ First, the common " button-hole mitral" in which the cusps appear short, 1 1 
thick and adherent, and by reason of slowly progressive chronic inflammation 
and calcareous deposit, often form a solid mass surrounding the slit-like 



mitral. 




Fig. 367. — Graphic representation of three varieties of the murmur of mitral obstruc- 
tion. Heart at moment of auricular contraction immediately before systole (presystole) ; 
mitral obstruction evident; aortic and pulmonary valves closed; -tricuspid freely opened; 
right auricle nearly empty; right ventricle filled; left auricle but partly emptied; left ventricle 
barely half full. Result. — Presystolic or diastolic murmur, dilatation of left auricle, conges- 
tion of lungs, consecutive enlargement of right heart, mv. Mitral valve, tv. Tricuspid 
valve, av. Aortic valve, pv. Pulmonary valve. LA. Left auricle. RA. Right auricle. 
LV. Left ventricle. RV. Right ventricle. V.C.S. Vena cava superior. V.C.L Vena cava 
inferior. P.Vn. Pulmonary veins. P. A. Pulmonary artery. AO. Aorta. 

opening. Second, the " funnel form" which, resulting from less violent and The funnel 
destructive inflammation and less marked degenerative processes, shows adhe- 
sions of the valve segments at their borders, the body of the cusp remaining 

* It is quite possible that the radical treatment of concealed septic foci now so 
much in evidence may cause us to admit exceptions to the rule herein stated, with re- 
spect to the inexorable nature of the anatomic lesion itself. 
44 



690 



MEDICAL DIAGNOSIS 



comparatively unaffected. This results in a peculiar funnel-shaped opening 
and is preeminently the form encountered in cases of the type described by 
Duroziez. 

THE TYPICAL CASE.— Two distinct phases of this lesion are encoun- 
tered clinically and this fact necessitates a division of the murmurs commonly 
heard into two chief types. 

Murmurs. — First, the diastolic -presystolic bruit occurring exactly with or 
immediately following, the second sound of the heart, diminishing in intensity or 
entirely lost in mid-diastole, but recurring with increasing intensity just before 
Jie first sound of the heart, which seems to terminate it abruptly. 




Fig. 368. — Chronic mitral and tricuspid endocarditis viewed from the auricular sur- 
faces. The mitral opening on the left is further reduced by soft grayish-red vegetations. 
(Each opening measures 4.5 cm. in circumference, a reduction of about 59 per cent, in the 
case of the mitral and 64 per cent, in the case of the tricuspid.) Both valve curtains arc 
thickened, practically immobile and their chordae almost obliterated by shortening, the 
papillary muscles being attached almost directly to the margins. (Dept. of Pathology, 
Univ. of Minnesota. Courtesy of H. E. Robertson.) 

This represents the murmur as it is heard in cases possessing an auricle 
capable of presystolic contraction and is that commonly encountered in com- 
pensated mitral stenosis. 

Second, a pure diastolic form commonly associated with incompensated 
lesion and lacking wholly the presystolic crescendo of auricular systole by 
reason of established fibrillation of the muscle of the auricle. 

Quality of the Murmur. — It is described variously as "harsh," "blubber- 
ing" "rumbling," "purring" "thrilling" or "vibratory," the three latter terms 
applying best to the typical presystolic element associated with an actively con- 
tracting auricle. 



MITRAL STENOSIS 



691 



Characteristic First Sound at Apex. — The peculiar, loud, sharp, slamming 
quality of the first heart tone as heard over and near the apex is peculiarly char- 
acteristic and usually maintains its unique quality even if the auricle is in 
fibrillation and the typical presystolic murmur absent in consequence. 

This sound abruptly terminates any mitral, presystolic bruit and the apex 
beat yields to the palpating finger and sometimes to the eye, the same sharp, 
short impact that is revealed to the ear by auscultation. 




Fig. 369. — Chronic mitral endocarditis with recent vegetations on the line of closure. 
(The circumference of the narrowed opening measures 6.5 cm., a reduction of about 40 
per cent.) The thickened chordae tendinea? are not much shortened. The valve curtain 
is very thick and before section showed a "fish-mouth" opening. The muscle wall of the 
left ventricle and the papillary muscles are hypertrophied. Tricuspid valve irregularly 
thickened and insufficient. Case of (J. N. at University Hospital, No. 989) man, age 51, 
who had rheumatism and epilepsy at varying intervals over a period of 16 years. At post- 
mortem, heart weighed 573 grams. The aortic leaflets showed chronic changes and fresh 
vegetations. The right lung showed multiple infarctions. There was also infarction of 
left kidney. (Dept. of Pathology, Univ. of Minn. Courtesy of H. E. Robertson, Director.) 

Thrill. — A presystolic thrill (resembling that felt by the palpating fingers 
when laid upon the chest of a purring cat) when present at or near the heart apex 
is practically pathognomonic of mitral stenosis. 

It is most marked, and often of an exquisite quality and distinctness in 
most of the cases carrying a well-defined presystolic bruit, less perfect or 
wholly absent in the instances of auricular fibrillation, at times present when 
no bruit can be heard, and requiring for its best appreciation a somewhat 
delicate light palpation. 



A constant 
feature 



.Peculiar 
variation. 



692 



MEDICAL DIAGNOSIS 



Furthermore, it is extremely limited in its area of diffusion and easily 
overlooked. 

The Pulmonary Second Sound. — The second heart tone as heard in the 
second left intercostal space is markedly accentuated, but this increase of 
intensity may be diminished or absent if secondary dilatation of the right heart 
and associated myocardial weakness become extreme or a secondary or co- 
existent tricuspid leakage is present. 




Easily 
obliterated. 



Fig. 370. — Mitral stenosis with tricuspid involvement. Mural thrombus in right 
auricular appendage. The mass of adherent blood clot appears on the right side and op- 
posite the prominent fossa ovalis. The tricuspid valve curtain is irregularly thickened and 
increased in width. (Dept. of Pathology, Univ. of Minn. Courtesy of H. E. Robertson, 
Director.) 



Area of Maximum Audibility and Transmission. — Mitral stenosis mur- 
murs are heard and its thrills are palpable over only a small area the size of a 
silver dollar lying at, near, or. just within, the apex-beat of the heart in most 
instances. Transmission is quite as circumscribed save in rare instances 
when it may be diffused for a short distance into the axilla and very slightly 
to the right. 

Caution. — The utmost care must be observed in connection with the aus- 
cultation of this murmur to make no more pressure upon the chest than is 
necessary to secure complete contact of the rim of the stethoscopic chest 



MITRAL STENOSIS 



693 



piece. Even a typical murmur may be rendered atypical or wholly lost if 
heavy pressure be applied.* 

Effect of Posture and Exertion. — As a rule both the systolic and presys- 
tolic elements of this murmur are intensified when the patient assumes the 
sitting posture or undertakes some slight exertion, yet it is occasionally 
better marked in recumbency or, more frequently, in the left lateral 
decubitus and serves well to emphasize the importance and value of 
changes of posture in the elicitation of obscure baffling bruits. 

Changes in the Cardiac Outline. — Obviously, these must be chiefly those 
due to enlargement of the left auricle and consecutive increase in the size of 
the right ventricle and ultimately perhaps the right auricle as well. In 



Usetul 
maneuvers. 



Left auricle 
and right 
heart. 




4* 



Fig. 371. — Mitral stenosis. Flat-finger percussion area of pure mitral stenosis (type 
of Duroziez). The left ventricle is not enlarged, but the region of the pulmonary artery. 
conus and left auricle is extended outward and upward, and the right heart has undergone 
enlargement both to right and left, indicating a lesion of considerable duration. This is 
further shown by the enlarged hepatic area, which indicates more or less persistent decom- 
pensation. 



isolated mitral stenotic lesions the left ventricle either remains unaffected or 
undergoes a certain degree of atrophy. Increase of superficial percussion 
dulness over the right ventricle and especially the extension of this decided 
cardiac dulness well to the right of the left sternal border is the most marked 
characteristic, and if right auricular dilatation takes place, a marked enlarge- 
ment is manifest to the right of the sternum. A dilated left auricle may be 
detected by its shadow in a radiograph or by fluoroscopy but as its position 
is almost wholly posterior it yields ordinarily little evidence to percussion. 

* Disregard of this precaution is extremely common in the case of students, and unless 
one's ear is trained to an appreciation of the peculiar, characteristic, almost pathogno- 
monic quality of the first tone at the apex, also much modified by excessive pressure, 
he is likelv to miss manv mitral stenosis murmurs. 



6Q4 



MEDICAL DIAGNOSIS 



Associated Bruits. — Few cases of mitral stenosis are absolutely pure, an 
overwhelming majority representing combined mitral stenosis and regurgita- 
tion. In such instances either the systolic or diastolic murmur may dominate 
the auscultatory picture. Associated aortic lesions are far from uncommon. 



■pr ^ r*s 

f ■ 

1 


1 j -' ■ 


\| ■} "h~-huo 





Fig. 372. — Mitral stenosis. The heart of a girl of 19 carrying a pure mitral stenosis. 
The lesion probably dates from childhood and several periods of definite, moderate, de- 
compensation have been survived. Compensation good when plate was made. Evidence 
of great left auricular enlargement appears on the plate and in the relatively faint, yet dis- 
tinct, atypical transmission of a presystolic murmur to the back with one break at the posterior 
axillary line. The left ventricle is small as is the aorta. .The right is enlarged, yielding a 
M.R. semi-diameter of 5 cm. as against 6 only, for the M.L. semi-diameter. Total trans- 
verse measurement but n cm. The case is one illustrating mitral stenosis in a "drop" 
heart. Gastroptosis of moderate degree is present and signs of tuberculosis are visible in 
the original plate, although no activity is clinically manifest. 

RATIONALE.— The Murmur of Mitral Stenosis.— This is one of the most 
shifty and variable of heart bruits, being readily obliterated or obscured by stetho- 
scopic pressure and markedly affected by the patient's posture, capable of pre- 
senting three forms of murmur within the diastolic period and of shifting from 



MITRAL STENOSIS 



695 



one to another even during an examination because 0] variations in tlu contractile 
power 0} the left auricle. 

Both murmur end thrill are simulated closely by a rapidly beating "drop" 
heart. 

In slight lesions especially the presystolic element may be wholly absent 
even with no fibrillation present and the proto-diastolic extremely faint. 

Having the patient sit or stand or make almost any form of physical 
effort increases ventricular activity and increases that contraction of the 
papillary muscles and the sphincter muscle band which just precedes or 
really initiates ventr cular systole. This increase occurs at the time that 
the presystolic drive of the auricle propels the last of the blood through 
the mitral orifice and is probably responsible for the abrupt terminal 
crescendo of the presystolic murmur. 





Fig. 374. — Mitral Stenosis Upper 
shading. — Area of audibility of simu- 
lated doubling of second sound. Lower 
shading. — Unusual area of murmur 
transmission. See author's note under 
Fig. 308. {Sansom-Bramwell .) 



Fig ; 373. — Mitral Stenosis. Point • 
of maximum intensity and transmission 
in pure mitral stenosis. The murmurs 
may be heard quite clearly at the left 
back and outward from the apex beat 
into mid-axilla in certain unusual in- 
stances, if the murmur is loud and the 
left auricle greatly enlarged. Even 
these do not often carry completely 
through the axillary space but suffer loss 
of audibility at the posterior axilla. 
{Sansom-Bramwell.) 



The murmur is at times completely lacking, yet the presence of the lesion 
is often definitely suggested in silent cases by the peculiar accent and quality 
of the first mitral tone alone. 

It has been suggested that inhalations of nitrite of amyl may be used 
to develop a latent concealed bruit of mitral stenosis and the procedure 
is not without value if carefully applied. 

The mode of production, shifting quality and varying maximal phases of 
the murmur of mitral stenosis rest upon a simple and logical basis. 

With the second sound of the heart, initiating the period of diastole, the 
mitral valves open, and instantly the overfilled dilated auricle seeks relief 
from increasing intra-auricular pressure by pouring its blood through the 
opened gateway. 



696 



MEDICAL DIAGNOSIS 



Whenever a narrowed mitral opening sufficiently obstructs this current 
from auricle to ventricle, every phase of normally silent flow becomes vi- 
bratingly or blubberingly noisy from the whorls and eddies created by the 
unnatural barrier. 

Two chief periods of rapid flow appear, the one representing the initial 
acceleration due to the height of accumulated intra-auricular pressure 
diminishing as the initial pressure is lessened; the other late diastolic, active, 
expulsive and propulsive contraction of the auricle immediately before the 
next succeeding ventricular systolic contraction. 

The initial rate of flow maximal at its beginning, diminishes rapidly as 
urgent intra-auricular pressure is relieved, and in case the overload of the 
dilated auricle is excessive the overflow may remain relatively but diminish- 
ingly rapid until presystolic (late diastolic) auricular contraction again 
suddenly accelerates it and it is abruptly shut off by the sharp, instant 
closure of the mitral valve. 

Hence the diminuendo (first or diastolic phase of the bruit) which would be 
wholly absent only with failure of the right heart to drive an adequate 
amount of blood through the pulmonary circuit to the auricle or in cases 
where the contraction of the mitral orifice was insufficient to create audible 
eddies at the rate of flow initially achieved. Neither auricular paralysis nor 
fibrillation alone would completely obliterate it. 

The degree of stenosis, blood volume, and pressure in the auricle, would 
determine the maintenance or nonmaintenance of a rate of flow sufficient to 
carry the murmur uninterrupted, but diminuendo from the second sound (initial 
flow) to the period of abrupt presystolic crescendo, intensification. If the 
auricle is fibrillating it is incapable of presystolic contraction and that ele- 
ment of the murmur disappears. 

It is obvious that in relatively slight degrees of narrowing and with an 
actively functionating auricle, only the presystolic element may be audible. 

It is evident also that inasmuch as a thrill is a palpable vibration, usually 
audible as well, its occurrence is similarly conditioned. 

The speed of flow in proto-diastole is insufficient to produce the exquisite 
rapidly vibratory or purring sound of the typical presystolic element, but 
is sufficient ordinarily to yield a peculiar rumble or "blubber" whether the 
auricle is capable or incapable of contraction. 

The tendency to undersupply of the tissues and undue slowing of the blood 
stream is automatically met in part by a mild vasoconstriction, hence the 
pulse is usually small. 

Blood Pressure. — Sphygmomanometer readings may or may not show a 
diminished pulse pressure. 

In pure mitral stenosis it is likely to be low but as such. cases form 
the minority the pulse pressure is likely to be equalized by the mitral 
regurgitation and vasoconstriction. 

Thrill. — A peculiarly characteristic and indeed an almost pathognomonic 
purring presystolic thrill, peculiarly constant in cases of presystolic bruit and 
regular rhythm, and at times, to be felt in diastole even in the absence of the 



MITRAL STENOSIS 697 



typical murmur is one of the most valuable and interesting of physical signs 
and when present, permits an almost certain diagnosis to be made by pal- 
pation alone. 

We may anticipate the best thrills in cases showing the typical murmur, 
but it is conceivable that palpable vibration of a less typical sort may result 
from the proto- or even the meso-diastolic flow in fibrillation, provided that 
intra-auricular pressure is high, the auricle large and the stenosis decided 
yet not so extreme as to limit flow to the initial period, as may actually 
happen. 

Necessary Clinical Division. — Two divisions are necessary to a clear 
description of the physical signs of mitral stenosis inasmuch as these vary 
greatly according to whether the left auricle is definitely contracting or is in 
a condition of mere fibrillary flickering which indicates an entire failure of 
orderly effective auricular systoles. 

(A) Cases Lacking Excessive Pulse Rapidity and Extreme Irregularity. — 
/;/ these the pulse is either regular or, if irregular, is relatively slow or of moderate 
rate. 

MURMUR. — Quality and Character. — A vibratory, thrilling, rumbling 
bruit: distinctly crescendo in type and ending abruptly in a much exaggerated, 
slamming, shock-like, first mitral tone. 

This may also take the form of a murmur, continuous or showing a meso- 
systolic interval, almost filling the diastolic period, commencing as a proto- 
diastolic diminuendo murmur and in presystole changing to a crescendo and 
terminating as above described. 

Area of Maximum Audibility. — The entire area of audibility in mitral 
stenosis is usually characteristically limited to a sharply circumscribed area 
at, or slightly w T ithin, the apex-beat or left ventricular border, in the fourth 
or fifth interspace. 

The maximum intensity or area of clear definition is sometimes so contracted as 
to be covered by the bell of an ordinary stethoscope which may cause one to overlook 
it entirely on a casual or hasty examination, though the character of the first 
sound is usually suggestive. 

One occasionally hears the murmur over the epigastrium (right ventricular 
hypertrophy or dilatation) and sometimes, more or less distinctly, well into 
the axilla for some little distance; upward or outward over the left ventricular 
strip; or inward, for a variable distance, over the right ventricle but such 
transmission is seldom or never clear or distinct. 

(B) Cases Characterized by Fibrillation- or Flutter -Arrhythmia. — 
Auricular fibrillation is characterized by an utterly disorderly rhythm asso- 
ciated with irregularities in the force and spacing of individual beats and, 
usually, but not always, a tachycardia. Any suggestion of its presence may 
be strengthened by the absence of the normal presystolic jugular wave and 
the presence of direct systolic jugular pulsation. 

Some individuals may carry fibrillation for months or even several 
years. 

In such cases the auricle, though it is the seat of myriad flickering con- 



6g8 



MEDICAL DIAGNOSIS 



Thrown 
back, 



Strain on 
right heart 



tractions, is little more than a tidal estuary and the right chambers and left 
ventricle are carrying the entire burden of helpful activity. 

Murmur. — The typical presystolic thrilling vibratory murmur disappears 
and the blubbering diastolic murmurs may be present or the heart be silent 
save for the shock-like first sound. 

Owing to the varying length of diastolic period and the unequal force of the 
diastolic contraction characterizing the rhythm of fibrillation, such bruits, 
if present, may vary in quality and duration from one beat to another. 

A relative pulmonary insufficiency is doubtless more common than has 
been supposed and the rhythmic ebb and flow of a pulmonary capillary pulse 
has been actually demonstrated in several cases by fluoroscopic methods. 
Rarely, a mid-diastolic murmur only is present, crescendo in type but failing 
to extend to the first heart sound* 

In such cases, as Mackenzie has shown, there is a partial heart block or 
actual dissociation and the auricular systole is out of its proper sequence 
with the ventricle. In "dissociation" such a murmur would be only occa- 
sional in the succession of ventricular beats. 

Distribution of Overload. — Left auricular overload must be the first 
effect of mitral stenosis, but this is practically inseparable from pulmonary 
stasis and increased right ventricular output. 

The dependence of the auricle upon the right heart is peculiarly great by 
reason of the fact that an important left ventricular function, that of pre- 
venting passive congestion and increased vascular tension in the pulmonary 
field, is in abeyance because of the inability of the left auricle to supply the 
blood. The more powerful of the two pumping chambers is therefore wholly 
unaffected save that actual atrophy may result. 

Left auricular dilatation, fortunately slowly produced, prompt consecu- 
tive hypertrophy of its thin w^alls and right ventricular work-increase and 
hypertrophy, also gradually induced, are the only cardiac changes worthy of 
note in pure mitral stenosis until the indifferently effective compensation 
characterizing this lesion begins to wane. Even then the left auricle is the 
chief sufferer but the right heart also feels the strain and at the same period 
the auricle may be acting merely as a huge reservoir, f 

Paralysis of the left recurrent laryngeal nerve is observed occasionally 
in cases carrying extreme left auricular dilatation. 

* The protodiastolic gallop rhythm, often present at the apex, represents a third sound 
interpolated between the second sound and the succeeding first sound, at a point represented 
by a time interval about equal to that elapsing between the first and second sounds, i.e., it 
interrupts the long pause by a sound occurring in early diastole (proto-diastolic) . 

As has been stated elsewhere the proto-diastolic gallop or "canter" rhythm is not 
limited to mitral stenosis, but may also occur in persons carrying a slow pulse, but appar- 
ently sound, when they lie upon their left side. {Thayer.) 

In the presystolic gallop or canter rhythm, the interpolated sound falls, as the name 
suggests, just before systole, i.e., it is presystolic or post-diastolic whichever one may chose 
to call it. (See "Gallop Rhythm.") 

t Cases have been reported in which a left auricle was capable of containing 3000 c.c. of 
blood. 



MITRAL STENOSIS 



699 



The right ventricle is slowly yielding to strain, the pulmonary artery and 
contis dilatation increases, tricuspid regurgitation may follow, and even a 




Fig. 375. — Dominant mitral stenosis. Imperfectly compensated. Ambulant patient 
The profile shows clearly the change in the mid-convexity of the left border, due to the great 
enlargement of the left auricle. The enlargement of the right heart is obvious; but left 
ventricular change is manifest. The total transverse diameter in this case was 14. 75 cm. 
Although no mitral systolic murmur was audible, the presence of past incompetence of the 
valve is strongly suggested. The lungs have for years been the seat of persisting congestion 
intensified by the fact that cardiac reserve had been severely taxed for years by reason of 
the fact that the patient kept at work even when suffering from serious pulmonary symp- 
toms of decompensation. 

pulmonary leakage may add its diastolic murmur (maximal in the second 
left interspace) to symptoms of stasis in the systemic circulation. 



700 



MEDICAL DIAGNOSIS 



Changes in the Cardiac Outline. — The typical heart of pure compensated 
mitral stenosis is therefore relatively small, but when the right ventricle begins 
to fail and dilatation follows , it may completely overlap the unchanged or atrophic 
left ventricle and carry the area of superficial cardiac dulness to, or beyond the 
right border of the sternum. Relative (auricular*) dulness to the right may be- 
come excessive. Such typical hearts are unusual, and left ventricular hyper- 
trophy and dilatation usually are manifest because of coexistent mitral 
leakage. 




Fig. 376. — Greatly dilated right heart (auricle and ventricle). Cross-hatched area 
represents the right ventricle whose right border should be shown as extending obliquely 
downward to the right costoxiphoidal angle; black strip, the left ventricle; obliquely lined 
area, the right auricle. Xote that practically all of the surface accessible to percussion 
represents the right heart chambers. Even the small strip of left ventricle here shown may 
be lost. (After Mackenzie. Modified) 

Effect upon the Heart Sounds. — The diminished load of the left ventricle 
tends to reduce the second aortic tone and the increased load of the right 
ventricle together with its added force of projection results in a more forcible 
closure of the pulmonary valve and accentuation of its second sound in the 
second left interspace, this accentuation being retained until the right 

* In decided cases of the "drop" heart the right ventricle forms the lower right border. 



TRICUSPID INSUFFICIENCY 



70 [ 



heart fails, tricuspid leakage ensues or the pulmonary valve itself becomes 
affected. 

Secondary Systemic Effects. — These are the general subjective and objec- 
tive manifestations of cardiac insufficiency as already outlined, the first gross s 
effects being manifested by evidences of congestion in the pulmonary circuit 
and chiefly shown in dyspnea, varying grades of dusky red and, later, gray 
cyanosis together with a tendency to passive pulmonary congestion and 
bronchitis. 

Pain is sometimes a prominent symptom and, when the right heart weakens 
or the tricuspid valve yields, general stasis will occur throughout the systemic 
veins and involve the kidneys, liver, and gastrointestinal tract, thus leading 
to gravity-edema and a tendency to terminal transudations in the pleural or 
even in the pericardial sac. 

In this lesion of maximal auricular distention and relative stasis there 
exists a peculiar liability to the production of clot-fragment emboli leading infar 
to infarcts involving the various organs and not infrequently producing 
hemiplegia or even sudden death through cerebral lodgment. 

Not only should the lesion be recognized and some measure of control in- 
stituted before the more serious of the preterminal symptoms arise but, know- 
ing the frequency with which mitral lesions result from acute rheumatism, 
the physician is not wholly guiltless who does not so follow these cases during 
convalescence and for several months after recovery, so as to detect not 
only leakage but also stenosis at its inception. 

A little good advice in the beginning, and more than advice whenever the 
compensation weakens, would greatly prolong life. 

TRICUSPID INSUFFICIENCY 
(Tricuspid Regurgitation, Tricuspid Incompetence) 

Etiology. — Tricuspid regurgitation almost invariably represents a relative 
insufficiency, secondary to a chronic or acute obstruction of the pulmonary 
circulation, whether this arises from mitral lesions, by far the commonest 
cause, from any of the primary myocardial degenerations, from chronic inter- 
stitial pneumonia, marked kyphotic deformities, emphysema, acute lobar | Diseases of 
pneumonia, chronic adhesive pleuritis or chronic massive pleural effusions. 
It is far less common as a sequence of aortic stenosis or the cardiac hyper- 
trophy, dilatation and associated myocardial degeneration secondary to 1 
chronic interstitial nephritis, though by no means rare. 

Endocarditic Cases. — As an immediate and direct result of acute endocar- 
ditis, afecting two or more valves, it is rare; and, occurring as an isolated pri- 
marily endocarditic lesion, is a clinical curiosity. 

As might be expected from the general character of tricuspid reflux as a 
lesion secondary to left heart involvement and the obvious fact that both 
auricles must be severely punished, the greater number of cases show the „., . 

. . Fibrillation a 

" pulsus irregularis perpetuus" ("delirium cordis ") of auricular fibrillation, common ac- 

r companiment. 



Usually 
secondary. 



the lungs. 



702 



MEDICAL DIAGNOSIS 



Lower sternum 
and vicinity. 



Primary endocardial defects or those secondary to pulmonary disease may 
show no marked irregularity prior to the onset of fibrillation of the auricle, 
though extrasystolic intermittency may precede it by long periods. 

CHARACTERISTIC FEATURES OF THE TYPICAL CASE.— Pulse.— 
As commonly encountered in cases of marked or terminal decompensation, 
the pulse is usually markedly irregular, with an especial tendency to pulsus 
irregularis perpetuus. Lesions undoubtedly exist that show a perfectly regu- 
lar pulse and it is obvious from a consideration of the etiologic factors that one 
is usually dealing with the arrhythmias of the primary lesion or lesions to 
which tricuspid insufficiency is secondary. 



VC S 



VCI 



f»»V.'PV fl 



PA"*: 



\"A0 



Normal Heart 
Su stole. 



Fig. 377. — The normal heart in systole. The full ventricles are contracting, the blood 
flows freely from them into the pulmonary artery and aorta; the mitral and tricuspid 
valves are tightly closed; the auricles are refilled, mv. Mitral valve, tv. Tricuspid 
valve, av. Aortic valve, pv. Pulmonary valve. LA. Left auricle. RA. right auricle. 
LV. Left ventricle. RV. Right ventricle. VCS. Vena cava superior. VCI. Vena cava 
inferier. PVn. Pulmonary veins. AO. Aorta. PA. Pulmonary artery. {Schematic 
Outline.) 

MURMUR.— Quality.— Soft and usually blowing. 

Time. — Definitely systolic. Coincident with the right heart first sound 
which it tends to modify or displace. 

Area of Maximum Audibility. — It is sometimes best heard along the edge 
of the sternum or in the epigastrium. Slight murmurs are best heard, usually 
over the lower half of the sternum, but, inasmuch as the right heart presenta- 
tion includes practically the whole lower substernal and left thoracic areas 
of the precordium, it may yield when dilated a murmur over the entire right 



TRICUSPID INSUFFICIENCY 



7°3 



leakage. 



heart area. It is not well heard over the true heart apex, left ventricle or 
beyond as is the case in mitral regurgitation. 

In very advanced cases with profound decompensation, extreme ven- snent 
tricular weakness, and a large leak, no murmur may be audible. 

Associated Signs. — (a) Diminution or loss of the second pulmonary tone, 
(b) Enlargement of the right heart area especially to the right of the sternum 
(auricle K* (c) Cyanosis, (d) Dyspnea, (e) Direct, systolic pulsation, and 



to 


^ / c//r> /-PV.n 


vcYV^- 


mS 1 V 


RV> 


7^- L» • 


PA sM/ / — - - -^*^^ ^"^ ^ — .^ i^ /\U. 


Mitral and Tricuspid 
ftecjursitat ion. 



Fig. 378 — Mitral and tricuspid regurgitation. Heart in systole. Mitral and tricus- 
pid valves both incompetent. Result. — Double systolic murmur, enlargement of both 
right and left chambers, pulsating jugulars, general venous congestion, edema, anasarca. 
etc. mv. Mitral valve. TV. Tricuspid valve, av. Aortic valve, pv. Pulmonary valve. 
LA. Left auricle. RA. Right auricle. LV. Left ventricle. RV. Right ventricle/ V.C.S. 
Vena cava superior. V.C.I. Vena cava inferior. P. Vn. Pulmonary veins. P. A. Pulmon- 
ary artery. AO. Aorta. Xote: — Dilatation of the right heart and tricuspid leakage are 
much more common than was formerly supposed. 

marked persistent engorgement of the external jugular vein are present in 
advanced cases and such persistent distention with little or no visible systolic 
jugular wave may be present in lesser lesions if the valves of the cervical veins are 
intact. Pulsation of the liver may occur, palpable or demonstrable only by instru- 
mental means. [/) Retarded circulation and a decided increase of pressure in 
the systemic veins leading to hepatic engorgement, edema, ascites, renal conges- 
tion, (g) Asphyxia of the medullary center. 

* In marked or extreme types of "drop" heart, the right ventricle. 



704 



MEDICAL DIAGNOSIS 



Usual murmur 
variations. 



Conduction. 



RATIONALE OF TRICUSPID REGURGITATION.— The Murmur.— 

This is usually soft and blowing for reasons already given, but, in rare 
instances, may be harsh and vibrant and associated with a thrill, or, for 
reasons stated above, may be represented by a mere "muffling" or impurity 




Fig. 379. — An enormous C19.8 cm.) silent heart of the combined mitral and tricuspid 
type. Disproportion between Ml. (11 .3 cm.) and Mr. (8.5 cm.) is very marked. Ambu- 
lant patient. Dyspnea on exertion. Decided edema of the legs at the end of the day. 
Engorged firm liver. Persistent rales at lung bases. All four chambers enlarged. When 
the left ventricle yields in terminal decompensation, the triangular area of universal de- 
compensation will be manifest. Heart lesion had been wholly disregarded and left un- 
treated. Dorso-ventral aspect. 

of the first tone. " Murmur is h" sounds or extremely short bruits may occur 
in this as in any other valvular lesion. 

Obviously its best conduction to the surface would be over the substernal 
portion of the right ventricle to which it is conducted by the chordce tendinea and 
papillary muscles; but logically it should be heard clearly or even maximally 



TRICUSPID INSUFFICD N< \ 



705 



at times to the right of the sternum over the right auricle which receives the 
impact of the regurgitant current. 

The Second Pulmonary Tone. — It is evident that the pressure within 
the ventricle during each systole is reduced and that the load driven into 
the pulmonary arterv will ordinarily be less in amount than is required and Effect of leak- 
lacking in force of projection. As a result the pulmonary second sound ened n rignt 
(valvular closure) will be greatly diminished or even inaudible in the event 
of any free leakage unless this be associated with a strongly overacting 
right ventricle. 

A markedly diminished second pulmonary tone at once suggests a failing 
right heart and tricuspid leakage, or a pulmonary insufficiency or stenosis, 






1st 



Sd. 




st 5d. Z d 5d. 



Fig. 380. — Mitral and tricuspid regurgitation. Decompensation marked. Such a 
heart has repeatedly been aspirated for supposed pericardial effusion, though this error is 
more likely to occur in a similar universal enlargement without murmurs. Bruits may or 
may not be very obscure in such cases as this if the valvular lesions are wholly the result 
of degenerative changes. (Flat-finger percussion.) 



the last being excessively rare lesions, usually congenital, associated with char- 
acteristic and well-defined murmurs. 

The right auricle must greatly dilate and hypertrophy in tricuspid regur- 
gitation though to a somewhat less degree than is the case with the left Throwing the 
auricle in mitral stenosis, in that the incoming systemic venous currents lack 
the persistent and primarily inexorable drive maintained by the right ven- 
tricle against the crippled left auricle in the case of mitral lesions and also 
because the right auricular overload, in a considerable measure and quite 
readily, is passed backward to the great veins (superior and inferior vena 
cava), thus raising and rendering strikingly intermittent the venous pressure viscsrai stasis, 
and flow and engorging the viscera of the systemic circuit. 

Venous Stasis. — From this partial circulatory block on the venous side 
results the chronic passive congestion of the kidneys and the engorgement and 
45 



load 
backwards. 



706 



MEDICAL DIAGNOSIS 



Lungs, kidneys 
and.liver. 



Stomach and 
intestines. 



Anasarca. 



Cerebral 
symptoms. 



Paradoxical 

rhythmic 

retraction. 



Combined type 



enlargement of the liver, often associated with a feeling of excessive epigastric 
fullness, tension or actual pain because of the stretching of its capsule. 

G astro-intestinal disorders of like causation are common; edema, ascites 
and in terminal cases, effusions of liquid transudate into the pleural or peri- 
cardial sacs occur and the patient's general nutrition suffers greatly. 

The brain likewise feels the stasis, and drowsiness, somnolence, stupor, 
or a terminal coma may be manifest. 

A Vicious Circle. — One of the most 
vicious of circles arises from asphyxia of 
the vasomotor center which raises pressure 
in the systemic arteries, adds to the bur- 
den of the left heart and greatly increases 
the weakness of the general circulation. 

Furthermore, there is a constant short- 
age in the blood supply throughout the 
nutritional and ventilation areas repre- 
sented by the systemic and pulmonary 
capillary deltas respectively. 

Dyspnea and cyanosis are alike marked 
and the former tends to assume one of its 
most extreme forms in terminal decom- 
pensation associated with this lesion. 

Epigastric pulsation due to an enlarged 
right ventricle is often evident, and at such 
times especially, the murmur may be 
clearly audible over that area. Such a 
rhythmic rise and fall of the epigastrium 
may be confused with true expansile pulsa- 
tion of the liver, if mere anterior palpation 
is employed and the antero-posterior 
bimanual method neglected. 

The epigastric pulsation is usually 
somewhat wavy and less determinate than 
the heave of a greatly enlarged left 
ventricle, as seen over the left thorax in 
aortic lesions. . 

Variations in hepatic outline corresponding to the degrees of stasis are 
extremely marked, jaundice is common and nutmeg liver is often encountered. 

Systolic retraction of the lower interspaces to the left of the sternum is usually 
a marked feature, attributable to the systolic retraction of the anterior 4 wall 
of the enlarged right ventricle, and in mitral stenosis especially, or cases of 
primary right ventricular hypertrophy and dilatation, the true systolic 
visible apex impulse of the left ventricle may be submerged, owing to the 
inability of the left chamber to reach the thoracic wall. 

In such instances the wavy, diffused indeterminate right ventricular 
impulse is characteristic. In combined mitral tricuspid and aortic lesions a 




Diastole. Systole. 

Fig. 381. — Phantom-pulse in pul- 
monary veins. This fluoroscopic 
phenomenon is occasionally demon- 
strable, under a special technic, in 
mitral cases with tricuspid insuffi- 
ciency, showing the positive (systolic) 
jugular pulse, of which this hilus flow 
and ebb is the pulmonary counter- 
part. {Schematic; after Schwarz.) j 



AORTIC INSUFFICIENCY 



707 



curious combination of presystolic undulations over the right ventricle and 
systolic heave over the left may be encountered. 

Slight or Silent Leakages. — It must be remembered that slight leakages 
may be evident in the murmur only, all secondary signs failing, and that either 
slight or large leakages may be wholly silent for the reasons hitherto assigned. 

Only a small percentage of the total tricuspid insufficiencies present 
during life are recognized either ante- or post-mortem, though a more careful 
study of the venous pulse and second pulmonary tone would uncover many 
at present overlooked. 

In cases of long standing this lesion is associated with a significant and 
characteristic permanent dilatation of the cervical veins. 

Direct Expansile Hepatic Pulsation. — The direct systolic pulse is, of 
course, registered over the internal jugular and the bulb and over the en- 
larged liver, which may be often felt to expand following each systole when 
firmly compressed front and rear by the two hands. 

In well-established cases, moreover, i the liver be forcibly compressed 
when so held, marked jugular distention and increase of cyanosis are usually 
demonstrable. 

Significance of the Systolic Jugular Pulse. — A direct systolic venous pulse 
indicates one of four conditions, viz.: ventricular extr asystoles, tricuspid regurgi- 
tation, auricular fibrillation, or, certain cases of dissociated rhythm in complete 
heart block, in which there is an accidental concurrence of certain auricular and 
ventricular contractions. 

Important Deduction. — If decided enlargement of the veins co-exists with a 
marked systolic pulsation, a lesion of the tricuspid valve is distinctly indicated, 
whatever the rhythm of the heart, and in cases presenting either auricular 
fibrillation or ventricular extr asystoles, a diminished second pulmonary tone 
or one disproportionate to any existing pathologic conditions adequate to 
produce marked stasis in the pulmonary circuit, indicates a leakage of the 
tricuspid valve. 

In marked instances, moreover, the systolic tricuspid jugular pulse is 
more like an arterial pulse than the gentle filling and collapse or the flowing 
wave of its simulators and engorgement or enlargement of the cervical veins 
is associated usually with general and decided venous stasis. 

In advanced cases carrying this lesion a persistent distention of the veins 
and their prompt refilling when compressed above and stripped of blood is 
marked and characteristic. 

Extreme Examples. — In some cases of especially free regurgitation the 
systolic venous distention may be visible not only in the neck but in the arms, 
back of the hands and even in any existing varicosities of the veins of the thigh 
or leg (D. Gerhardt). 

In these cases the pulsation represents an actual systolic rhythmic recession 
and advance of the venous flow as may be readily demonstrated by compression* 

Over the jugular bulb and crural space when the valves are still intact, 

* In all marked cases the degree of venous pressure increase is marked. Gerhardt 
reports a case in which a weight of 300 gm. was upborne by the veins. 



Jugular pulse. 



Four chief 
causes. 



Diffused ven- 
ous pulsation. 



Systolic 
venous tone 
or bruit. 



708 



MEDICAL DIAGNOSIS 



one may sometimes hear a distinct thud in systole and over the same areas, 
when the valves have yielded, a distinct systolic bruit. 

In the excessively rare instances of isolated primary endocarditic tricuspid 
regurgitation, the left ventricle may remain normal or may undergo actual 
atrophy (Stadler). 

AORTIC INSUFFICIENCY 

("Aortic Regurgitation," ' 'Aortic Incompetence") 

Characteristic Signs in Cases, Commonly Encountered. — The following 
summary applies to the usual cases only (see "Rationale" for chief variants). 

The Murmur. — Quality. — A blowing, hissing, or rasping sound, of ex- 
tremely variable intensity, loudest at its beginning and waning with the con- 



VCS 
RA„. 



r*S D\/n 



RV'T 



±$m 



Normal Heart. 
Diastole. 



Fig. 38 2. —Normal heart at beginning of diastole. 

tinuance of the diastole, i.e., a diminuendo murmur. It may be very clear and 
distinct, as soft as the faintest pulmonary vesicular murmur, or wholly absent. 

Time.— Distinctly diastolic; beginning at the exact time that the second sound 
ends, with no detectable break, yet often tending, apparently, to obscure, modify, 
or displace the second sound of the heart in the aortic area, first right interspace, 
right half of the manubrium stemi and the carotid artery, if this second sound 
be shortened, diminished, or, wholly lost, by reason of the peculiarities of 
valvular defects. 

It is usually accompanied by a systolic murmur, maximal in the second 



AORTIC INSUFFICIENCY 



70Q 



right interspace near the sternum or one interspace higher, and transmitted 
upward into the carotids. In the case of loud murmurs this makes the two 
sounds resemble more or less closely the "to-and-fro" sound of the wood 
saw ("see-saw" murmur'). 

Alternative Areas of Maximal Audibility. — These lie along a line joining the 
chief points of maximal " murmur transmission," viz., (a) the second right inter- 




Fig. 383. — Graphic representation of murmur. Two varieties of .aortic diastolic mur- 
mur. (With sphygmogram.) The heart is shown in diastole, aortic leakage being 
evident. The blood has just been projected into the aorta and pulmonary artery 
by the ventricular contraction. The pulmonary valve tightly closed maintains the 
blood column, but through the leaky aortic valve a regurgitant current meets the 
stream descending from above through the open mitral valve. Results. — A diastolic 
murmur, dilatation and hypertrophy of left ventricle, a slapping, low-tension pulse. 
irv. Mitral valve, tv. Tricuspid valve, av. Aortic valve, pv. Pulmonary valve. LA. 
Left auricle. RA. Right auricle. LV. Left ventricle. RV. Right ventricle. VCS. 
Vena cava superior. VCI. Vena cava inferior. PVn. Pulmonary veins. PA Pulmonary 
artery. AO. Aorta. 

space at the edge of the sternum; (b) the third left interspace- or, (c) midway on a 
line joining these points; (d) at the ensiform cartilage. 

The point of maximal audibility is found, therefore, usually, over or along 
the line of the regurgitant stream whose eddies and whorls generate the 
sound, a wholly logical and simple distribution. 

The point of preference is usually the third left interspace at or just to the 



710 



MEDICAL DIAGNOSIS 



Connects areas 
of maximum 
audibility. 



Increased to 
left and 
downward. 



Visible pulsus 
celer. 



Corrigan pulse. 



Capillary 
pulse. 



" Pistol-shot' 
sound. 



left of the sternal margin; not over the valve above or in the second right 
interspace, which with the first right interspace constitute the points of 
election for the auscultation of the second sound itself. 

Area of Maximal Transmission. — These are the points mentioned above, 
the intermediate area, and along the left edge of the sternum to the ensiform. 

It is often especially marked along left sternal border. Oftentimes it is 
faintly or distinctly heard in the carotid and subclavian arteries and at the apex 
of the heart, though audible faintly, or not at all, over the intermediate right 
ventricular area, save in the case of loud and widely distributed murmurs. 

In rare instances the murmur may be audible or even maximal in the left 
axilla. (R. Cole). 

Cardiac Outline. — 77 is that of left ventricular dilatation in recent endocar- 
ditic cases, but as encountered commonly, represents combined hypertrophy and 
dilatation of the left ventricle. The left border is extended, therefore, outward 
and sharply downward. (See "Roentgenography.") 

The apex beat is lifting or heaving in all free and long established cases, the 
force and sustained strength of the left ventricle varying with the dominance and 
degree of hypertrophy as affected by the tendency to gradually induced ascendency 
of dilatation, and the latter is often rendered obvious by the less determinate 
character of the prominently visible impulse. 

Slight dulness may be noted over the second right interspace if, as commonly 
happens in old cases, the aortic arch is more or less decidedly dilated. 

Associated Signs. — (a) Visible, jerking, throbbing, pulsation of the arteries 
of the superficies, especially marked in the carotids, brachials, radials and tem- 
porals, but extending to the lesser branches. 

(b) A radial pulse of unsustained initial 
high pressure, sharp and shock-like, the 
11 Corrigan" or "water-hammer pulse.'" 

(c) A visible or demonstrable "to-and- 
fro," "ebbing and flowing" wave of color, 
"the capillary pulse," which represents the 
rhythmic alternation of high and low arterial 
pressure in the relaxed vessels. It is visible 
on the lips and nails or over and at the edges 
of a fading erythema or any flushed area, 
whether natural or artificially induced for 
the purpose of examination. 

(d) A "pistol-shot sound" in the f em- 
orals, i.e., a sharp, shock-like sound and 
palpable impact, sometimes double, often associated with a systolic bruit, and 
sometimes with a double {" to-and-fro") . murmur (" Alvarenga-Duroziez") 
under moderate stethoscopic pressure. 

The Heart Tones. — The character of the aortic second sound itself varies 
under the influence of many factors — such as the freedom of regurgitation, the 
strength of the ventricle, the character of the valvular lesion, the deformity of the 
valves and the presence or absence of aortic stenosis (see "Rationale"). 




Fig. 384. — Usual maxima of audi- 
bility and lines of transmission of 
bruit of aortic regurgitation. 



AORTIC INSUFFICIENCY 



711 



RATIONALE.— The Mental Picture.— 77/ 1 second sound of the heart 
represents the closure of the aortic and pulmonic valves and thus marks, clinically, 
the end of systole ami the beginning of diastole. 

As regards the left heart* the term diastole at once brings before the 
mind's eye the picture of an aorta overdistended by, and exerting compression 
upon the blood which, having been forced at this instant into it by the 
ventricular systole and shut off from the heart by the closure of the aortic 
valve, must seek normally the one open pathway represented by the systemic 
arteries. 

One sees also the left ventricle relaxed in diastole and the now opened 
mitral orifice through which the blood is rushing in from the left auricle above 
to reload the pumping chamber for its next systolic discharge. 



Semilunar 
closure. 




Fig. 385. — Configuration of heart and aorta in compensated aortic insufficiency. The 
apex is so blunt in this case as to suggest masked stenosis. Compare with normal heart 
outline and similar figures under mitral lesions. (Schwarz. modified.) 

Essentials of Valvular Efficiency. — Accurate closure of the aortic valve is The normal 

" ventricle. 

absolutely essential to the maintenance of normal conditions of ventricular 
refilling and the proper distribution of the force of the ventricular drive 
(pressure energy) . This, in fractional part, (one per cent.) is required imme- 
diately to maintain the blood flow and, in far greater measure, to store poten- 
tial energy in the distended elastic aorta, and stabilize pressure and flow alike 
until the next systolic discharge. This manifestly demands perfect freedom 
of movement and entire integrity of both the surface and outline of the three Normal valves 

- t and ring 

cusps of the valve itself, together with adequate strength and consistence of essential, 
the muscular ring which forms their base and determines their areas of 
contact. 

* One need only substitute the words "tricuspid" "pulmonary" and "pulmonary 
artery" respectively for "mitral," "aortic" and "aorta" to get the coincident concurrent 
phases in the right heart and pulmonic circulation. 



712 



MEDICAL DIAGNOSIS 



It is evident that calcareous plaques, vegetations, nodulations, or the 
deformities due to a sclerosis, no less than a yielding of the aortic ring itself, 
must, and inevitably will, prevent accurate approximation of the aortic 



I st 5d. 2 d 5d.^/ k^l st 5d. 2 d Sd. 




Fig. 386. — Aortic regurgitation. Flat-finger percussion area. Much more accurate 

delineation now possible. 




Fig. 387, — Aortic and mitral lesions. Decompensation of right chambers, past or present, 

suggested by hepatic outline. 

cusps and establish a leak and abnormal backflow into the ventricle which 
thus receives blood from two sources at the same time and must perforce 
enlarge its cavity. 



AORTIC INSUFFICIENCY 



713 



If we assume the sudden production of aortic leakage, the normal pic- 
ture is "at once changed and we visualize the instantaneous fall in that 
aortic blood pressure so necessary to a sustained and equalized circulation 
and the instant dilatation of the overladen ventricle which, pending hyper- 
trophy, must at once automatically draw upon its full reserve, markedly 




Fig. 388. — Type of aortic insufficiency with dilatation of the aorta. 

increase the rate of its contractions, and so expand its cavity as to enable 
it to pump rhythmically into the aorta the amount of blood necessary to 
maintain an adequate blood supply for the body tissues and brain centers, 
in addition to that which is lost through the abnormal diastolic backflow from 



Sharp drop in 
pressure. 

Ventricular 
dilatation. 



Ventricular 
cavity must 
enlarge. 



7H 



MEDICAL DIAGNOSIS 



Varied 

pathologic 
cases. 



that vessel into the ventricle. By a forced increase of tonus it must prevent 
also a progressive stasis in, and fatal dilatation of, its own cavity. 

In this simple picture are all of the essential clinical elements of aortic 
insufficiency. 




Fig. 389. — Chronic aortic endocarditis with insufficiency. There is thickening and 
retraction of leaflets and vegetative thrombi adherent both to the central portions of 
leaflets and the ventricular endocardium. The left ventricle is markedly dilated and heart 
is hypertrophied. Case is that of man, age, 39, who was admitted to hospital because of 
cough, weakness and orthopnea. Clinical examination showed dilated heart and a Corrigan 
pulse in right radial but absent in the left. At autopsy, heart weighed 675 grams. There 
was also thrombosis of right auricular appendage, embolism of left radial artery at elbow, 
and both recent and old infarction of spleen and kidneys. {Dept. of Pathology, University 
of Minnesota. Courtesy of H. E. Robertson, Director.) • 

The lesion may represent the effects of endocarditis, acute, chronic, 
simple or malignant; sclerosis of the cusps, cardiosclerosis, acute physical 
overstrain or myocarditis, myasthenia and myocardial degeneration of any 
type. 



AORTIC INSUFFICIENCY 



7*5 



The results are the same in each instance if the integrity of the valve 
structure itself or of its base is affected seriously. 

Obviously, Five Cardinal Symptoms Simultaneously Appear. — i. A 
diastolic murmur due to a rhythmically recurrent backflow ("regurgitation") 
of a part of the blood projected into the aorta by the heart's systole. 

2. An obligatory increase in the size of the left ventricle, which is inex- 
orably determined by the abnormal increase of content due to rhythmic backflow 
from the aorta in each diastole. 

3. The establishment of high "pulse pressure," through rhythmic alterna- 
tions of abnormally high "systolic" with abnormally low "diastolic" arterial 
pressure, in place of the normal alterations of level. 

4. The "water-hammer pulse" reflecting these abnormal pressure variations 
and intensified by an automatic defensive vasodilatation adapted to a partial 
stabilization of rate of flow and variants of pressure in the capillary deltas. 

5. The "capillary pulse," which is merely a visible expression of the ab- 
normalities of flow associated with this lesion and permits a systolic — diastolic 
advance and recession, How and ebb, of the arteriocapillary blood stream. 

THE MURMUR OF AORTIC INSUFFICIENCY.— The eddies and whorls 
of the regurgitant stream cause a murmur which in time, quality, duration, 
pitch and transmission follows logically the physiologic, anatomic and pathologic 
conditions present in this lesion. 

Time of Murmur. — Produced in diastole by the backflow of blood from an 
overdistended, elastic, or, relatively rigid aorta, through the damaged aortic 
valve at the instant of its attempted complete closure, the murmur must 
necessarily be diastolic in time and seem to modify, obliterate, or, more 
rarely, in the case of lesser defects, closely follow the second heart sound and 
tend to show a prolonged diminuendo quality, its intensity diminishing as 
the high initial aortic pressure falls. 

Quality of Murmur. — Under ordinary conditions it is a blowing or hissing 
murmur but, obviously, its pitch, quality, loudness, and duration must 
depend chiefly upon : (a) the strength of the ventricle and the volume of the load 
discharged by it during the preceding systole; (b) the resulting head of pressure 
in the aorta and the elasticity of its walls; (c) the size and shape of the valvular 
deficiency; and (d) the consistence of the valve segments and the degree and 
character of any roughening or irregularity of the edges of the leaking orifice. 

The Many Variants. — Hence, though we find the murmur ordinarily a blowing 
or hissing sound of moderate pitch and intensity, clearly audible over certain well- 
defined areas, we may find it high-pitched, whistling or even distinctly musical. 

It may be so loud as to be audible over the entire heart or thorax, may 
be auto-audible and a constant torment to the patient, or, so intense as to 
be distinctly heard by the unaided ear at short distances from the chest. 

On the other hand, it may be so soft or faint as to be heard with difficulty 
over only a single small area, often only after exertion or with the patient 
in recumbency, may be absent in the erect or sitting posture, and is almost 
always more distinct in recumbency and increased by moderate stethoscopic 
pressure. In some instances a murmur disappearing or very faint in the 



Why diastolic. 



Why 
diminuendo. 



Hissing or 

blowing 

murmur. 



Factors 
determining 
quality and 
intensity. 



Auto-audible 
murmurs. 



Faint 
murmurs. 



Effect of 
posture. 



716 



MEDICAL DIAGNOSIS 



Silent cases. 



The split 
2d tone. 



Usually long, 
rarely short. 



sitting or erect posture may be revived or intensified by having the patient 
raise both arms above the head. 

In cases of extreme cardiac weakness or excessive size of the leak, with or 
without coincident aortic or mitral stenosis or insufficiency and high-grade 
sclerosis of the aorta, it may be entirely absent. 

An Important Sign. — In very slight insufficiencies, usually due to physical 
overstrain, myasthenia or secondary dilatation of the aortic ring, but from 
whatever cause, leakage may be manifest primarily only in a split second sound 
heard only over the third left interspace, or a very short murmur, which may 
alternate with it or stand alone, prove transient, recurrent over long periods of 
time, or, become a permanent aortic regurgitant murmur of the classical type. * 

Duration of Murmur. — So also as to duration one finds usually the pro- 
longed diminuendo murmur starting with the first sound, but, as in the last 
instance, it may be extremely short and in rare, unexplained and always 
dubious, instances, definitely post-diastolic.f 

Maxima of Audibility. — The maximum of audibility is for the most part 
wholly in accord with anatomic relationship and the laws of sound conduction. 

The murmur is loudest, normally {not over the valve itself, but over the regurgi- 
tant stream which produces it by its whorls and eddies) , at the third left inter- 
space, at the sternal margin, or over the sternum itself, midway on a line joining 
these points, i.e., in the immediate vicinity of the aortic valve. It may be maximal 
over the aorta itself at the second right interspace, which is the point of elec- 
tion for the auscultation of the second heart sound itself, but this is a less fre- 
quent maximal localization- than was formerly supposed. Occasionally the 
sound is so intensified by unusual relationships and sternal reinforcement of 
vibration as to be maximal at the ensiform and sometimes, probably because 
of the predominating involvement of the posterior cusp or an accidental 
diversion of the main point of impact of the stream, the bruit may be maximal 
at or beyond the apex by reason of the maximal, direct, left ventricular 
transmission thus produced. 

Transmission of the Murmur. — The transmission of the murmur is also 
easily explainable. The right heart occupies nearly all of the anterior cardiac 
area,! below the level of the third interspace and tends, to diminish or wholly 



The usual 
tripod. 



Occasional 
variations. 



Rare 
exception. 



* The author has reported on various occasions the apparent frequency and clinical 
significance of this split second sound as heard over the third left interspace in association 
with moderate dilatation of the left ventricle, a distinct capillary pulse, marked variations in 
arterial pressure, and almost invariably a history of some hitherto forgotten cardiac over- 
strain or exhausting illness. The sound appears often in alternation with the short dias- 
tolic murmur which may become fully established and gradually increase during succeeding 
months or years to a typical bruit or in rarer instances wholly disappear. 

The first cases observed occurred after extreme overstrain associated with marked 
collapse and have now been watched for several years. 

t Such cases are often due to mitral or, very rarely, to tricuspid stenosis, with fibrillating 
auricles. 

t In the normal heart, the right border is wholly that of the right auricle which may give 
place to the right ventricle at the right edge of, or more commonly, the middle of the ster- 
num. Only a strip of the left ventricle is normally accessible. The "drop heart" right 
border is that of the right ventricle alone, the auricle lying above. 



AORTIC INSUFFICIENCY 



717 



suppress the conduction of any murmur of left heart origin throughout that 
region. 

Hence the murmur of aortic insufficiency is best conducted from the valve Angle of 
and the adjacent cardiac area involved in its production and in the direct impact 
of the regurgitant jet, along lines connecting the basal areas of maximum audi- 
bility (third left to second right 'niters pace and down the sternum to the ensiform, 
the sternum serving as a sounding board), and is heard with some constancy in 
the carotids and first right interspace, especially in clearly defined lesions with 
associated diffuse dilatation of the first portion of the aorta. 

As stated previously with reference to maxima of audibility, loud murmurs 
are often widely generously conducted, and in rare instances may be heard 
faintly over the entire torso. On the other hand, certain cases show them 
only at a single maximal intensity area or even at the apex only, though, as 
already stated, the latter is far more likely to be a mitral stenosis with the 




Fig. 390. — Configuration of heart in combined aortic and mitral disease. Compare 
two mid-curves of left border of silhouette with the normal and with those of aortic 
stenosis and aortic regurgitation with normal heart outline and those of aortic regurgita- 
tion and stenosis. (Roentgenoscopic.) {Schwarz, modified.) 

auricle in fibrillation and should be diagnosed as aortic only when the associated 
signs of aortic regurgitation are present. 

One must keep in mind also the possibility of interpreting the diastolic 
murmur of pulmonary regurgitation as an aortic reflux. Such a murmur 
due to over-distention of the pulmonary orifice and conus arteriosus may 
occur in association with chronic mitral disease (Graham-Steele murmur). 
Error is avoided readily by noting the absence of typical transmission and 
associated arterial phenomena of the aortic lesion. 

Increase of Cardiac Area. — As stated hitherto, ventricular overload is a 
marked and immediate result of this lesion and, when rapidly or suddenly pro- 
duced, obviously must result in a rapid left auricular dilatation. In acute 



conduction. 



Carotid 
conduction. 



Wide 
audibility. 



Caution. 



Dilatation and 
hypertrophy. 



7 i8 



MEDICAL DIAGNOSIS 



Cardiac 
reserve. 



Reveals 
enlargement 



Cor bavis 



May lack 

marked 

enlargement. 



Key to signs 
and symptoms. 



Pulse 
pressure. 

Water- 
hammer pulse. 



Technic. 



Arterio- 
sclerosis. 



Pistol-shot 
sound. 



cases, this enforces at least maximal physical rest on the part of the patient 
and demands in such cases the full emergency heart muscle reserve or that 
amount of it which antecedent toxemia may have spared, to tide over the 
period, fortunately a short one in favorable cases, until hypertrophy shall 
dominate, limit the dilatation, and establish a larger field of response.* 

Left Border and Apex. — The enlarged left ventricular cavity must reveal 
itself in widening and downward projection of the left heart area and, when 
combined with hypertrophy of the wall of that chamber the persistence of a 
forcible heaving apex-beat to the left and well below the normal site is a 
striking clinical symptom. 

Aortic Dilatation. — If the aorta itself becomes markedly dilated, some 
increase of dulness may be made out in the second right interspace near the 
sternum and if, as often happens, co-existent or secondary mitral disease is 
evident, an increase in the right heart area is superadded and in advanced 
cases produces the enormous "ox heart" (cor bovis). 

The presence of predominant dilatation is more or less clearly shown in the 
substitution of an indeterminate "mixed" apex beat, already described, for the 
sturdy heave and lift of dominant hypertrophy. 

Hearts with Small Leaks. — One should remember that true small aortic 
leakages, secondary or from overstrain, may exist without decided, or at 
least, excessive, left ventricular changes and with little objective or subjective 
evidence of myocardial overstrain. 

The Alternation of High and Low Pressures. — Unsustained blood pressure 
and flow constitute the key to nearly every important objective and subjective 
subsidiary symptom of aortic leakage. The unsupported blood column leaps 
and falls back, as it were, throughout the arteries and capillaries, the "pulse 
pressure" \ being double or even treble that of health in cases of free regurgitation. 
Corrigan Pulse. — The unsustained pulse (pulsus celer) is peculiarly char- 
acteristic, though not wholly pathognomonic of the disease and the jerking, 
throbbing, superficial arteries are no less striking to the eye than to the finger 
which feels the shock-like systolic impact as a tiny but definite blow or tap. 
Over the radial artery this is best felt if the wrist be actually grasped and the 
arm raised high up, the palmar surface of the base of the first phalanx of the 
examining hand being apposed to the radial artery. 

As the disease progresses, or as an associated or possibly antecedent con- 
dition, arteriosclerosis may exist, and while more or less modifying the 
intensity and sharpness of pulse impact, renders even more obvious to the 
eye the arteries of the superficies or superadds to their jerky, throbbing beat 
the vermicular, rhythmic shortening and lengthening of the serpentine curves 
induced by extreme arterial rigidity. 

Arterial Tones. — If the stethoscope be placed over the femoral artery, 
a sharp, shock-like, systolic pressure tone, "the pistol-shot sound," may be 

* Cases of sudden free aortic insufficiency due to valve rupture from overstrain and 
antecedent disease produce profound shock. 

J Pulse pressure is the sum obtained by subtracting the diastolic from the systolic 
readings of arterial pressure. 



AORTIC INSUFFICIENCY 



719 



manifest, and, if pressure be increased, a "to-and-fro" murmur (the sign of 
Alvarenga and Duroziez) may become audible. Such signs may be present 
in other arteries and the systolic pressure tone may be present even in the 
palmar arch. 

The Capillary Pulse. — Closely related to the Corrigan or water-hammer 
pulse (pulsus celer) is capillary pulse (of Quincke), not pathognomonic, but 
one of the most delicate and exquisite of clinical signs. 

This is a capillary manifestation of the abrupt ebb and flow of pressure 
which takes the form of an alternate flushing and paling of the beds of the 
nails, the mucous membrane of the lip, the margin of color in a flushed cheek 
or ear, or in areas of artificial erythema induced by friction. 

Technic. — The simplest test for the capillary pulse, if it is not apparent 
on close inspection, consists in slightly blanching or deliberately reddening by 
friction the area under observation and watching for the rhythmic recession 
and advance of the border of color or the flushing and paling of the red area. 

Pressure upon the tip of the finger-nail, or that of a clear tumbler or wine- 
glass, upon the everted lip, or brisk friction of the forehead, are simple and 
successful methods. 

In areas of erythema thus produced, the sign is even better marked 
when the initial redness begins to fade and, over all, a glass slide applied 
with moderate pressure will intensify and render clearer the rhythmic 
paling and flushing, recession and advance. 

The appearance in the nail often suggests rhythmic winking or blinking. 

This phenomenon may be demonstrated beautifully in a dark room or 
even by daylight if transillumination of the fingers is secured by grasping an 
electric hand light or bulb, or by the use of any similar means of illumination. 

Sight Diagnosis. — The jerking arteries, especially, make recognition of 
this ailment at sight or touch often easy though not always certain. 

The jerking foot when one knee is crossed over the other, the rhythmic 
nodding of the head ("Musset's sign"), the beat of the pulse felt when shak- 
ing hands, or the rhythmic waxing and waning of an outdoor flush, may make 
"snap diagnosis" reasonably easy even in the "market place." 

Modifications of the Heart Sounds. — Additional modifications of the 
heart sounds may be present though inconstant. One readily understands 
the occasional tendency to a more or less complete absence or obscuration of 
the aortic second sound in cases of extreme valvular defect or cusp immobiliza- 
tion, despite the powerful drive of an overloaded hypertrophied ventricular 
and increased aortic distention and recoil. In many, if not most instances, 
however, it is actually increased, and when markedly diminished, one must 
assume as a probability that the commonly associated aortic systolic murmur 
is due to an actual co-existing stenosis rather than to mere sclerosis of the 
aorta. 

So also the first sound at the apex representing mitral closure is dull, 
even though it be loud, and is often impure or markedly diminished, be- 
cause of the incomplete emptying of the ventricle and lack of the usual radius 
of excursion of the cusps, or, this combined with marked weakness of the 



Alvarenga- 
Duroziez sign. 



Pressure ebb 
and flow. 



"Street car 
diagnosis." 



Musset's sign. 



Aortic 2nd 
tone. 



Mitral zst 
tone. 



720 



MEDICAL DIAGNOSIS 



Pseudo-mitral 
stenosis. 



Pseudo-aortic 
stenosis. 



True asso- 
ciated aortic. 



A vasomotor 
paradox. 



Mental state. 



heart muscle, by reason of which one or both elements which enter into the 
formation of the mitral systolic tone may be diminished. 

The Flint Murmur. — A presystolic rumble or blubbering sound, arising 
probably from the pressure of overmuch blood, and the resulting intra- 
ventricular pressure, in late diastole, is sometimes heard in aortic insufficiency, 
and it is quite possible that in such cases the mitral segments are nearly 
approximated at the time of the presystolic auricular contraction, thus causing 
a false stenosis. 

According to present opinion the so-called " Flint murmur" is an extremely 
rare phenomenon and the presence of a presystolic rumble due to any condition 
other than mitral stenosis is unqualifiedly denied by many eminent European 
clinicians.* 

Careful measurements in the autopsy room indicate that the lesser degrees 
of mitral stenosis are more common in connection with aortic regurgitation 
than was formerly believed. 

The addition of a direct systolic aortic murmur, having all the qualities of 
aortic stenosis except obscuration of the second sound and, slight delay in the 
bruit is very common. This is especially true if marked sclerosis and dilatation 
of. the aorta are present or if general arteriosclerosis or the high pressure of 
primary, secondary, or associated, interstitial nephritis is evident. 

An actual stenosis of the aortic valve with diminished or absent aortic second 
tone and a greatly modified Corrigan pulse is of course a relatively common finding. 

When present the two murmurs often closely simulate the sound produced by 
sawing wood. {The "see-saw" murmur.) 

General Symptoms. — As in all chronic lesions, so also in this, a patient 
may for years show and feel little or no effects from the disease; yet no eardiac 
ailment is more troublesome when decompensation gets the upper hand and 
periods of incompensation occur. 

Pallor. — Such individuals show superficial pallor though internally vaso- 
motor relaxation is present to a marked degree and seems to represent 
an effort of nature to slow the capillary current for the sake of the tissue 
exchanges so vital to the processes of repair and waste and the integrity of 
cerebro-spinal function. 

Nutrition and Temperament. — Such patients are usually thin, pale, even 
though anemia is absent or only moderate, high-strung and nervous, and 
with marked decompensation, irritability, insomnia and a more or less marked 
psychasthenic state or even one resembling a severe hypochondria or actual 
melancholia may develop. 

Subjective noises such as thumping, roaring in the ears, tinnitus aurium, 
vertigo, throbbing headaches and even syncopal attacks are not uncommon 
and are subjects of constant complaint and additional sources of persistent 
nervous irritability in many instances. 

Pain. — It is almost inevitable that the coronary arteries should suffer a 

* There is no doubt in the author's mind relative to the occasional occurrence of the 
Flint murmur, but quite as little to its rarity. Nearly all such cases prove at autopsy to 
be due to an associated organic mitral stenosis. 



\ORTIC STENOSIS 



721 



loss of equal calibration and normal elasticity which, together with myocardial Minor and 
degeneration and the unstable nervous balance, leads to various types of major angina - 
arrhythmia and superadds the various painful expressions of angina minor 
or major so valuable in diagnosis. 

Dyspnea. — Dyspnea, though usually and for long periods less manifest Dyspnea, 
than in mitral lesions, is often extreme or even paroxysmal if the myocardial 
weakness is marked or the coronary changes decided. 

Sources of Danger. — The nervous system being extremely labile, fear, . 
anger, joy and sorrow, the excessive use of tea, coffee, tobacco, or stimulants, 




Fig. 391. — Chronic aortic endocarditis with extreme stenosis. Lumen reduced to 
three slit-like openings meeting in the center. Estimated reduction in lumen, 75 per cent. 
There was marked hypertrophy of the left ventricle. Case of man, age 80, who died 
of apoplexy. Kidneys showed advanced stage of chronic diffuse nephritis. 

sexual excess, and mental as well as physical overstrain of any kind, may 
prove not only potent factors in the excitation of symptoms, but, in the case 
of the major factors, the cause of fatal decompensation or sudden death. 

It is evident that aortic insufficiency must constitute one of the commoner MaykiU 
causes of sudden death and in this, as in every other case of heart disease, suddenl y- 
the relatives should understand the possibility of a dramatically tragic exitus. 

AORTIC STENOSIS 

Etiology. — True aortic stenosis is a relatively uncommon lesion, affecting 
the adult male almost exclusively, and, as an isolated lesion, constitutes a clinical 
46 



722 



MEDICAL DIAGNOSIS 



rarity. In the greater number of cases it is associated with a more or less 
free regurgitation.* 

As stated, to a large degree its causes are identical with those of the aortic 
regurgitations originating after the age of thirty, but it occurs also as a result 
of acute vegetative endocarditis. It is essentially a lesion of the adult and 
of advanced age, of lues and of sclerosis, rather than one of the juvenile 
infectious type as formerly supposed. As the result of chronic inflammation, 
adhesion and calcareous deposit, the aortic valves become fused into a more 
or less pouch-like membrane, projected into the aortic lumen and possessing 
a central circular or slit-like opening. The margins of the opening may be 




Fig. 392. — Normal heart in systole. 

such as will permit a small valvular excursion or it may be merely a rigid 
diaphragm with a central aperture which, in extreme cases, may barely admit 
a knitting needle, post-mortem.^ 

Physical Signs and Symptoms. — As might be expected, the signs are 
extremely frank and definite in advanced cases. 

* Save as it constitutes a general rule subject to exceptions, the author's personal expe- 
rience has not confirmed the perfectly reasonable and logical statements of Bamberger, 
Romberg, D. Gerhardt and others that mild grades of stenosis are associated with regurgi- 
tation and the extreme grades are not. In several of his cases representing the maximal 
degrees of obstruction the regurgitation has been plainly manifest. This in fact was the 
case in the most extreme aortic stenosis which he has seen at autopsy. 

t Its marked predominance in the male strongly suggests that lues is a more potent 
factor than we have been led to believe in times past. 



AORTIC STENOSIS 



723 



The Murmur. — Time. — Systolic, but actually following the first sound sughtiy 
by a fractional interval representing the presphygmic period which in this 
lesion is slightly prolonged. 

Quality. — A loud harsh bruit usually of a " hissing " or " sawing " character Usually loud 

... . , . r i i • 1 it and harsh. 

which in association with aortic regurgitation frequently results in the see- 




Fig. 393. — Aortic stenosis. A sphygmographic tracing is shown, and three varieties 
of the aortic systolic murmur are represented graphically. Diagrammatic representation of 
the heart in systole, stenosis of the aortic valve being present; the mitral and tricuspid 
valves have closed; the right ventricle is nearly empty; the left ventricle is still more than 
half full of blood, because of the obstruction present at the aortic orifice. Result. — A sys- 
tolic murmur in the aortic area; enlargement of left ventricle, etc. hv. Mitral valve. TV. 
Tricuspid valve, av. Aortic valve, pv. Pulmonary valve. LA. Left auricle. RA. Right 
auricle. LV. Left ventricle. RV. Right ventricle. VCS. Vena cava superior. V.C.I. 
Vena cava inferior. P. Vn. Pulmonary veins. P. A. Pulmonary artery. AO. Aorta. 

saw" murmur, quite accurately reproducing the double sound of a wood saw 
in action. 

Maximum Intensity and Transmission. — The murmur possesses few 
vagaries, is heard best in the second right interspace (aortic second sound Few vagaries, 
area) and transmitted to the carotids and subclavian arteries. 

It may also be heard down the sternum and its left edge, faintly at the wholly logical 
apex, or, more distinctly, at the back in the region of the second, third, and i 



724 



MEDICAL DIAGNOSIS 



fourth dorsal spines to the right and left the latter representing the general 
surface area opposite the point of posterior aortic contact. 

Loud Murmurs. — The murmur may be extremely loud, harsh or musical 
and in such cases its conduction may cover the entire thorax and extend down 
the vertebral column even to the sacral region. It may, moreover, be auto- 



Widely heard. 



Auto-audible 
bruits. 




Fig. 394. — Configuration of heart in compensated aortic stenosis (advanced). Note 
blunt apex and lack of aortic enlargement. Compare with aortic regurgitation outline 
and that of combined aortic and mitral lesions. (Schwarz, modified.) 



I st 5d. 2 d Sd 



II 



5t 5d. 2 d Sd. 




Fig. 395. — Flat-finger percussion area in aortic stenosis (strikingly misleading). 

audible, and in quite numerous instances is detectable by the unaided ear at a 
distance of several inches, or, in rare cases, several feet. 

Thrill. — In the case of loud murmurs a distinct systolic thrill is almost 
invariably present in and about the second right interspace. 



AORTIC STENOSIS 



725 



Aortic Second Sound. — The aortic second sound is usually, but not invar- 
iably, absent or faint and is seldom audible in the first interspace or carotids if 
the lesion is advanced. 

This constitutes a sign of great differential value in relation to the various 
pseudo-stenotic systolic murmurs associated with aortic insufficiency, aneurysm 
and simple dilatation of the aorta, as well as the accidental murmurs, and those 
of certain of the congenital lesions presenting a harsh systolic murmur at the 
base of the heart. Occasionally, even in true stenosis, plaques and sclerotic 
areas maintain a second sound of normal or increased intensity and one is 
forced to depend upon the slightly delayed murmur, the altered pulse, or a pulse 
tracing for differentiation. 

Cardiac Outline. — Of all the valvular lesions aortic stenosis furnishes us 
with our best example of dominating hypertrophy of a single chamber, in 
this case the left ventricle. The left border extends outward and the apex 
markedly downward. 

For long periods astonishingly little change may be manifest to percussion 
and, in the presence of other signs, demonstrable enlargement of the left ventricle 
is not indispensable to early diagnosis. 

The Apex-beat. — The apex-beat in established cases is that of dominating 
hypertrophy, heaving, lifting, forcible, low in position, and more or Jess 
removed to the left when the lesion is fully established. 

Hypertrophy itself may at first be moderate and over periods of years 

decided dilatation of the ventricle may be 
lacking. Hence a surprisingly small area 
of increased dulness may be associated with 
other definite signs of true aortic stenosis. 

Late in the disease dilatation occurs, but 
even under broken compensation the beat 
seldom shows the indeterminate quality of 
dilatation to such a degree as is observed in 
other lesions under the like conditions. 

The Pulse. — The pulse constitutes at times 
a most important criterion in that it is slow 
and deliberate, often distinctly small, is pal- 
pably long-sustained, slow to rise and slow to 
fall {pulsus durus) . 

Even in cases showing a dominant 
associated aortic insufficiency, an associated stenosis will oftentimes strik- 
ingly modify, without wholly destroying, the characteristics of the pulsus 
celer. 

RATIONALE. — Aortic stenosis represents a persistently increasing 
tendency to shortage of blood in the systemic circuit and is the most inde- 
pendent and self-sustaining of all the valvular lesions of the heart; yet 
there would seem to be a tendency to overrate this quality, for in some of 
the cases caused by syphilis the duration is surprisingly short. 

A slight stenosis of the aortic outlet is readily overcome by moderate 




Fig. 396. — Maximum of audibil- 
ity and chief lines of transmission 
in aortic stenosis. 



Valuable 

differential 

point. 



A puzzling 
variation. 



Little changed 
for long 
periods. 



Typical of 
hypertrophy. 



Pulsus durus. 
Valuable aid. 



Symptoms 
slow to appear. 



726 



MEDICAL DIAGNOSIS 



Long enduring. 



Often remains 
undiscoTered. 



Heart block 
and fibrillation 



concentric hypertrophy but, like mitral stenosis, it is at all times distinctly 
a progressive lesion, though very gradually contracting the valve lumen and 
making its slowly increasing demands upon ventricular strength. Most of 
the cases ultimately reach a point at which ventricular stasis and dilatation 
become established and persistent and, in part, throw their burdens back 
upon the mitral valve, left auricle and right heart. 

It is nevertheless quite true that in many instances the lesion never becomes 
really troublesome or obtrusive and may not be discovered before death from inter- 
current disease and then only in event of autopsy. 

Arrhythmia. — Arrhythmias are very frequent in aortic stenosis, but only 
when compensation begins to fail, and take commonly the form of extrasystoles. 

Heart block of various degrees is not uncommon and fibrillation may occur 
in the late stages when, secondarily, the right heart and left auricle are 
markedly affected. 

The interesting tables of Lewy show the effect of this lesion in increasing 
the work of the heart. 

Table i. — Slow Pulse and Prolonged Systole 

Heart's work per hour 

Rest Moderate exercise 

Ostium normal 813 mkg. 3,400 mkg. 

Reduced % 835 mkg. 4,068 mkg. 

Reduced Ko 991 mkg. 8,864 mkg. 

Reduced %o 2,112 mkg. 43,578 mkg. 

Reduced x %o 6,386 mkg. 175,426 mkg. 

Reduced 4 % Q 20,000 mkg. 

The strong normal heart can exert maximally, in emergency, thir teen-fold 
the effort required in rest, i.e., 13,008 mkg.* 

The importance of rest and moderate exercise and of a slow regular rhythm 
in cases of heart disease is emphasized by these figures, as is the reason for 
the marked difference in longevity observed in afflicted persons of differing 
temperament and occupation. 

Widespread arteriosclerosis is a common complication and several of the 
author's patients have suffered most intense angina and repeated syncopal 
attacks terminating in sudden death. 

TRICUSPID STENOSIS 

Excessively Rare. — Tricuspid stenosis is one of the rarest of cardiac lesions 
and, occurring alone, is a medical curiosity. It is usually the result of an 
antecedent acute endocarditis affecting other valves as well. In a large pro- 
portion of the cases it is associated with tricuspid incompetence and occa- 
sionally forms a part of a complex congenital defect. 

* According to Lewy's statement, if the aortic ostium is reduced by more than J-fo 
its possessor cannot perform ordinary day labor, whatever may be the grade of hypertrophy, 

As a matter of fact the author has seen at autopsy a heart which showed a reduction of 
the aortic ostium by % whose possessor had served as a Turkish bath "rubber" for days 
at a time up to his last brief illness. He could not perform unusual movements, however, 
without producing distressing symptoms, nor work continuously at his calling. 



TRICUSPID STENOSIS 727 



MURMUR. — Time. — In most instances the murmur is presystolic and of 
a quality almost precisely similar to that of mitral stenosis; less frequently it 
is distinctly diastolic (auricular fibrillation) and usually lacks the smooth 
even quality of an aortic diastolic murmur. 

Thrill. — In certain instances a presystolic thrill may be felt to the right 
of the sternum or along its edge or even in the region of the ensiform cartilage, 
as in the case reported by Robert H. Babcock. 

Maximum of Audibility. — The bruit is usually' audible over or at some 
point near the right border of the lower half of the sternum. Occasionally it 
is maximal in mid-sternum. 

Transmission. — It may be sometimes heard over the entire lower half 
of the sternum and the lateral area immediately adjacent. 

Percussion Area. — There is no percussion area pathognomonic of tricuspid 
stenosis but, as would be assumed, the right border is greatly displaced to the 
right by reason of right auricular hypertrophy and dilatation. 

Subsidiary Signs. — Distention of the external jugulars, an exaggerated 
presystolic jugular pulsation and an occasionally demonstrable presys- 
tolic venous pulsation of the liver are the most characteristic associated 
signs. Obviously, the pulmonary second sound will be relatively faint and 
the ordinary accentuation attending a mitral regurgitation or stenosis, if 
this lesion be present in the case, is likely to be diminished or absent. 

Effect upon Preexisting Hypertrophy of the Right and Left Ventricles. — 
It has been taught always that with the oncoming of this lesion any pre- 
existing hypertrophy of the right or left ventricle due to mitral lesions would 
undergo a recession and it is probable that this is true in some cases but not 
of the majority, according to most recent reports of autopsy findings. 

Seldom Recognized Intra Vitam. — Only in the rarest instances have 
reported cases of this lesion been recognized during the life of the patient. 
This is explained doubtless by the extraordinary rarity of tricuspid stenosis 
as an isolated lesion, which fact tends to allow the more striking and obvious 
symptoms of the other lesions to obscure a condition so rare as seldom 
to be recalled to mind, even as a possibility. It is wholly probable that 
in the future more accurate diagnoses will be made during life. 

RATIONALE. — The factors underlying the symptoms are extremely 
simple. Obviously the two chief conditions resulting from this lesion are: 
First, a failure on the part of the right auricle to convey to the ventricle the 
blood poured into it by the great systemic veins, the result being marked 
dilatation and a certain amount of early hypertrophy of the thin-walled 
atrium and, second, a transference of the overload and venous stasis to the 
systemic veins and viscera. This explains the extraordinary degrees of 
general edema and of engorgement of the kidneys and of the viscera tributary 
to the portal system encountered. It also accounts for the marked pre- 
systolic pulsation observed in the veins of the neck which is often audible 
together with sharp presystolic clack which would seem to be of sufficiently 
frequent occurrence to give it value from a diagnostic standpoint. The 
presystolic pulsation of the liver is attributable to the same mechanism. 



728 MEDICAL DIAGNOSIS 



The effect upon the lungs and primarily at least upon the left heart 
chambers is the precise opposite of that just described. A condition of 
relative anemia or, more properly, deficient blood supply, must inevitably 
be produced, according to the grade of the lesion and, however much the 
conditions of relative ischemia present in the lungs may contribute to tubercu- 
lous infection, it is evident that all of the pulmonary phenomena associated 
with the stasis of mitral lesions will be lacking in tricuspid stenosis. Further- 
more, while theoretically we should find an extremely low blood pressure 
and radial pulse, in practice it appears that the blood pressure is maintained 
at a normal height in most instances and the pulse, though small, is not exces- 
sively soft save in terminal lesions. This seeming paradox, of course, is due 
to the compensating vasoconstriction automatically induced by the conditions 
present, and no doubt referable in some measure to the continuous asphyxia 
of the respiratory center in the medulla. 

Effect of Long -continued Lesions upon the Normal Left Ventricle. — It 
has been stated that eventually left ventricular hypertrophy follows tricuspid 
stenosis of long duration. The actual reports on record would seem to indi- 
cate that this development is unusual rather than inevitable, but more infor- 
mation is needed upon this specific point. Babcock has shown by citation 
of an extremely interesting case that in this ailment a complicating 
interstitial nephritis may raise systolic blood pressure to 250 mm. of mercury 
and produce decided hypertrophy of the left heart. 

Prognosis. — It has been asserted that this lesion is one permitting a 
relatively long life in cases where it exists alone and that it does not greatly 
shorten life as a complicating accident. At the present time such statements 
cannot be accepted as true of recognizable grades, and it is doubtful whether 
individuals so afflicted often live beyond the age of thirty and probable that 
in most instances the lesion endures but a few years. Possibly, however, it 
is one of excessively slow development and may for long periods fail to attain 
a grade which materially increases the work, of the left auricle. 

PULMONARY INSUFFICIENCY 
(Pulmonary Regurgitation, Pulmonary Incompetence) 

Etiology. — This lesion, extremely rare as a primary endocarditic affection 1 
and, as an isolated lesion, a clinical curiosity, is perhaps only relatively so 
in its secondary form; yet undeniably, it is rarely recognized ante-mortem. 
This secondary insufficiency represents a dilatation of the valvular ring such 
as may result from an antecedent mitral stenosis or regurgitation, chronic 
diseases of the lung or xiphotic spinal deformity. 

It occurs in association with a congenital stenosis of the conus arteriosus, 
and, in rare instances, in connection with conditions such as chronic kypho- 
scoliosis, chronic pleural adhesions, emphysema, and fibroid phthisis which 
tend to block the pulmonary circulation. 

Endocarditic cases seldom or never occur primarily save as a part of 



PULMONARY INSUFFICIENCY 



72Q 



extensive, coincident, right and left heart involvement in an acute endo- 
carditis affecting the mitral, aortic and tricuspid valves. 

The pulmonary valve is distinctly weak as compared with its aortic 
counterpart and the supporting ring is likewise less stable than its fellow. 

Tkis lesion is, of course, a lesser, right heart replica of aortic regurgitation Arepttca. 
with no opportunity to duplicate the striking external vascular expressions oj 
that lesion. 

CLINICAL SIGNS AND SYMPTOMS. MURMUR.— Time.— Diastolic, 
seeming to modify, obscure or even replace the second pulmonary tone. 

Quality. — .4 blowing, rasping or hissing murmur, capable of any and all 
of the usual variations in quality, pitch, and intensity, tending to be prolonged 
throughout diastole, but usually faint, soft and perhaps short, these qualities 
being more or less characteristic of the lesser relative insufficiencies which 
constitute a large majority of the few cases clinically recognized. 

It is usually harsher and more superficial than the aortic diastolic murmur 
and may be greatly intensified if the breath is held after a forced expiration. 

Maximum Audibility and Transmission. — The murmur is best heard over \ • 
the pulmonary area (second left interspace) ; is audible also in the third; and, 
if loud, is transmitted to the left; also, but less distinctly, over. the right ventricle; 
and, somewhat more distinctly, downward over the lower sternum. If carried 
at all into the neck, it is heard over the left carotid more distinctly than over the 
right. 

The murmur is distinctly one of downward transmission and, usually, 
the aortic tone may be distinctly differentiated, if not lost through coincident 
or antecedent disease of its own tissue, by auscultation over the first right 
interspace or deep stethoscopic over the arch of aorta itself in the hollow 
of the neck above the manubrium. 

The second pulmonary tone is usually decreased but, as in the case of 
its aortic prototype, may be either increased or diminished; the former if variable, 
the lesion is slight, or associated with sclerosis,* or marked dilatation of the 
pulmonary artery; diminished, if marked deformity is present or actual 
stenosis of the valve exists. 

Alternations of Pulmonary Pressure. — As in aortic insufficiency, abrupt 
rhythmic changes in arterial pressure are inevitable, but in this lesion are Hidden pulsus 
hidden in the area of the pulmonary circulation. They may nevertheless 
be manifested by a systolic intensification of the breath sounds in forced 
deep inspiration as heard over lung areas even though far distant from the Rhythmic 
heart. The presence of an audible double tone over the lungs, analogous to breath sounds, 
that heard over the crural artery in aortic insufficiency is well marked some- 
times in this lesion. 

The marked rhythmic waves of cardiac respiratory pressure may also 
be registered at the nostrils by a suitable apparatus if the breath is held. 

Thrill. — A thrill is not uncommon in the endocarditic lesions and is 
usually most intense in the second left interspace. 

* There is probably no definite rule and no less an authority than D. Gerhardt declares 
that intensification always exists unless stenosis is also present. 



/o l 



MEDICAL DIAGNOSIS 



Pulmonary 
area. 



A weak valve. 



One still 
weaker. 



A damaging 
effect. 



Variants of 
accentuation. 



Oxygen deficit. 



Cardiac Area. — The rigid heart area is markedly increased both to right 

and left and the apex-beat itself may be formed by the right ventricle. Systolic 
retractions over the chamber itself li'ould be present in most instances. 

There may be increased dulness in the pulmonary area; sometimes a 
marked pulsation in the second and third left interspaces; and evidences of a 
dilated conus arteriosus, not only in the form of a decided pulsation, but mani- 
fest in radiographs and to percussion in the shape of an extension of the left 
upper border several centimeters to the left of the sternum in the second 
interspace. 

The Pulse and Blood Pressure. — Unless aortic regurgitation co-exists, 
the pulse is small and the blood pressure without special features; a state of 
affairs sufficient in itself to indicate the true origin of any isolated diastolic 
murmur, maximal at the base of the heart, which lacks the water-hammer 
quality and the increased "pulse pressure'' of aortic regurgitation. 

RATIONALE. — The pulmonary valve, its ring and its artery are alike 
relatively weak as compared with their aortic fellows, and the valve has 
been shown (by the late G. W. Gibson) to 'show leakage under relatively 
slight excess of pressure. It is theoretically possible, therefore, that, as the 
result of persistent obstruction of high grade in the pulmonary circuit, 
whether this be due to disease of the lungs, mitral disease, or chronic myo- 
cardial degeneration, the pulmonary artery may dilate and the supporting 
ring of the valve yield and produce insufficiencies which may be slight or 
decided, temporary or permanent.* 

The effect of pulmonary insufficiency is to throw an added burden upon 
the right ventricle and tricuspid valve, such as would ultimately cause a 
consecutive insufficiency of that, the weakest of the heart's valves, or, in 
any event a dilatation of the right ventricle, and marked or extreme stasis 
throughout the systemic venous circuit. 

The pressure within the lungs is lessened to a disastrous degree, and is no 
longer stabilized; high systolic and low diastolic pressures alternating rhyth- 
mically throughout the pulmonary circuit precisely as they occur in the 
systemic arteries and capillary deltas in aortic regurgitation. Left ven- 
tricular shortage of load results and the blood pressure might be expected 
to fall but is usually sustained through adaptive vasoconstriction. 

It is evident that the first sound at the apex should usually become 
weakened and somewhat sharp from underload, though it would remain 
clear, and that the pulmonic second might or might not be weakened or lost 
according to the actual condition of the valve itself, the strength of the right 
ventricle and the presence or absence of tricuspid insufficiency. 

Deficient oxygen and an increased C0 2 content must inevitably result 
and both dyspnea and cyanosis are marked, and are usually paroxysmally 
intensified. 

As with the systemic arteries and capillaries in aortic leakage, so with 

*The author feels that clinical evidence is strongly opposed to such an assumption, 
save as it applies to rare and exceptional instances, for though the pulmonary valve 
is weak, the tricuspid is still weaker and should act as a safety valve in large measure. 



rriMONARY STENOSIS 



731 



Difficult in 
practice. 



those of the pulmonary area in this lesion great damage to the walls must 
gradually result. 

There must also arise therefore a tendency to bronchitis and capillary Sputum 
oozing which is made evident by blood-stained sputum. 

The cyanosis may be extreme but is of the gray pallid type, by reason of 
the systemic, arterial anemia. 

Pain. — There are no painful sensations characteristic of this rare ailment, 
unless it be the paroxysms of angina occasionally reported, which are 
quite similar to those of angina pectoris as encountered in aortic lesions, 
primary degenerative myocardial lesions and, less often, in mitral disease, are 
said to be more commonly referred to the right shoulder and arm. The same 
thing occurs, however, in left heart lesions, though infrequently, and bilateral 
referred pain is very common in major angina pectoris from any cause. 

Otherwise, the discomfort or pain experienced differs in no material 
respect from that of other incompensated heart lesions. 

Differential Diagnosis. — Theoretically, this is simple; but, practically, 
it seems to offer much difficulty, though many more cases will be recognized 
from now on, because of a better understanding of the symptomatology and 
a more careful scrutiny of the pulmonary area in decompensatory degenera- 
tive and valvular lesions. 

Cheif Differential Points. — (a) A diastolic murmur maximal in the second 
left interspace, with transmission downward along the sternum; or, if upward, 
wholly or chiefly to the left. 

(b) A clear aortic second sound in the first interspace or, if aortic incom- 
petence be present, a second diastolic murmur, never maximal in the second right 
interspace nor, if transmitted upward, following both carotids and subclavians. 

(c) An entire absence of the water-hammer pulse unless aortic involvement 
is coincident. 

(d) Increased intensity of the diastolic murmur when the breath is held 
after full expiration and during the act itself. 

(e) Profound pallid cyanosis, if decompensation has begun, which differs 
from that which might accompany a confusing proto-diastolic mitral stenosis 
murmur in its relatively slight or negative response to rest and digitalis. The 
apex localization of such a mitral lesion is quite distinctive and confusion rarely, 
or never, should occur. 

(/) A thrill in the second left interspace and limited to that area is most 
suggestive but rarely present. 

{g) Sharp pulsation and marked dulness over the conus arteriosus {second 
left interspace) is suggestive. 

(h) The decided increase of right heart dulness is a valuable sign, both 
corroborative and differential . 

The X-ray picture and fluoroscopic screen may greatly assist diagnosis if 
available. 

As a factor in congenital heart disease it rarely can be more than assumed 
and, finally, no one need feel humiliated if he fails to make the diagnosis, for 
the very elect of our diagnosticians usually make it post-mortem. 



732 



MEDICAL DIAGNOSIS 



PULMONARY STENOSIS AND ATRESIA 

Etiology. — Pulmonary stenosis or atresia is essentially a congenital lesion, 
Septal defects is almost invariably associated with patent interventricular septum, is frequently 
accompanied by other developmental defects and has its inception, usually 
during the second month of fetal life. 

Most Frequent of Congenital Lesions. — It constitutes or forms a part of 
70 per cent, of the congenital heart lesions; an even greater proportion 





1 






"J 











Fig. 307. — Pulmonary stenosis, probably ersdocarditic. in a child three years of 
age. Right ventricular hypertrophy beautifully shown. Left ventricle unaffected. 
(See Fig. 398.) 

(80 to 85 per cent.) of those whose possessors have passed the age of twelve 
years, and is important, not only because of its relative frequency, but also 
because of its pronounced cyanosis, its associated congenital defects, and the 
relatively prolonged tolerance shown by its victims. 



PULMON \u\ STENOSIS 



733 



Fetal Endocarditis Rare. A few cases seem to be caused by fetal endo- 
carditis, but more commonly it results from arrest of development at the 
tonus below the valves, or, without the valves, in the pulmonary artery itself, 

where the trunk is in close relation to the aorta. 

Indeed) tlie obi iterative pressure of an aneurysmal sac may produce all of 
the clinical evidence of pulmonary stenosis in non-congenital cases. 




Fig. 398. — (E 78")- Pulmonary stenosis in child three years of age. Same case as 
Fig- 397- — (E 78). but auricular enlargement was present at the time this exposure was 
made. Note extension outwards of right heart border. Cyanosis was slight and clubbing 
of the finger-tips lacking in this case. 

Extraordinary Combinations. — It is evident that, if pulmonary stenosis 
and a defective ventricular septum co-exist, the blood, for- the most part, 
will pass directly from both ventricles to the aorta, and it would seem that 
septum defects and an open ductus arteriosus (ductus Botalli) both, would Open ductus 
be necessary to life, as without them only a minimal amount, or, in high- 
grade stenosis or actual atresia, no blood at all could pass to the lungs. As 
a matter of fact, however, though present in 90 per cent, of the cases, ven~ 



Botalli. 






MEDICAL DIAGNOSIS 



Patent foramen 
orale. 



trkular septum defects are more often lacking in actual atresia complete 
closure) than in stenosis. 

such instances the lungs are taken care of by a remarkable series of 
anastomoses. 

In nearlv all of such cases the "foramen ovale" is broadlv defective but 
in rare instances this also is closed. 

The ductus arteriosus is nearly always open in atresia but closed in 
stenosis, but it may be impermeable in either, in rare ins tan 



absent. 



MirkeiiT 




^^ 


^^ 


j^mir 


^TZ /^ 


■ = 


g 


^ 


fc=^ . j 


w 


1 



Fig. 309. — Pulmonary stenosis in 
adults. (Sansom.) Shaded area repre- 
sents field of Tnavimiim intensity. 



Fig. 400 . — Pulmonary stenosis. 
Maximum point and direction of 
transmission. 



MURMUR. — Time, systolic, representing right ventricular systole and 
closure of tricuspid valve. 

Quality. — Extremely harsh T blowing and superficial. 

Thrill. — Systolic, and present and distinct in the pulmonary area (left 
2d interspace) 20 per cent, of all cases, absent in nearly all of those presenting 
ventricular septum defect with a closed foramen ovale, and most frequent, 
relatively, in those with both the auricular and ventricular septum intact.* 

Maximum Audibility. — Second left intercostal space near edge of sternum. 
May be widely heard by reason of its intensity, but is transmitted obliquely 
upward to the left clavicle, and downward, over the sternum. 

It is not conducted into the carotids or heard along the right subcla 
isiE the use in aortic stenosis. 

Pulmonary Second Sound. — L:s: ;: t.~:: emery faint in the region of the 
heart base in most instances though cases are reported in which it was ap- 
parently increased. The sign is not absolutely dependable. 

In complete atresia with an excessively wide septal defect no murmurs 
may be audible. 

Cardiac Area. — The heart is markedly enlarged as to its right ventricle and 

mately its right auricle. The epigastric heave is usually striking, the chest 
is usually bulging and the shock of systole may shake the whole body of the child. 



Abbott. Her admirable article, in Osier's "Modern Medicine 1 

v Etudes:. 



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401 Miss \. i» 1 Lectrocardiographic record in the case of pulmonary stenosis 
in thrn- > tar old child. I ULggeration oi P-wa\ e show a overaction o! auricles. 6 wave in 
Lead 111 shows continued action of auricles. Right ventricular preponderance indicated 
by deep S wave in Lead I and R wave in Lead ill rhe deep S wave in Lead 11 indicates 
a .marked asynchronism of the ventricles. (See X-ray, Figs (39 and 



736 



MEDICAL DIAGNOSIS 



Blue babies. 



Increased 
viscosity. 



Cyanosis. — Extreme in grade and universally distributed over the cold 
clammy skin of these patients, cyanosis constitutes the most striking single 
symptom. In the endocdrditic cases reported by Rissema and by Rosenthal, 
decided cyanosis was absent. 

The congenital heart cases give us most of the "blue babies" and in 
them the deep dusky blue color is either persistent or appears and becomes 
a purple or even purplish black, upon exertion, crying, or in attacks of 
spasmodic dyspnea, which may be associated with convulsions. 

Clubbing of the fingers is usually marked in degree. 

Secondary Erythremia. — Cyanosis so profound must lead to erythremia 
and one may find an erythrocyte count exceeding 9,000,000; increased 
hemoglobin (120 to 160 per cent.).; increased viscosity, and high specific 
gravity of the blood. Counts of 6,500,000 or 7,000,000 are common. 

Differential Diagnosis. — The age of the patient is most suggestive. No 
other cardiac lesions produce so high a grade of cyanosis as do those of the 
congenital type and especially this particular disease. Endocarditis is rare 
in infants. The localization and intensity of the bruit are usually fairly 
characteristic though curious variations occur. Finally the combination 
of youth, profound cyanosis and the physical activity so often maintained is 
most striking and suggestive. 

On the other hand, one must remember that accidental murmurs are 
peculiarly common in the pulmonary area and that in profound anemia, 
especially if this be suddenly induced by a massive hemorrhage, both an 
intense murmur and palpable thrill may occur. 

In one of the author's cases such a post-hemorrhagic murmur of pul- 
monary site was audible to the unaided ear at a distance of 2 feet from the 
chest. 

Comment. — If, as so generally happens, there is an associated ventricular 
septum defect both the thrill and murmur may be more intense over the 
third and fourth left interspaces and lower sternum. 

If the ductus arteriosus is patent, the murmur is more likely to be sharply 
transmitted to the back (third and fourth dorsal) and show marked inspira- 
tory accession and expiratory recession of intensity. 

An open foramen ovale may yield a presystolic murmur. 

Compression of the pulmonary artery or its branches jnay accurately 
simulate the congenital lesion and this may occur, not only through aortic 
aneurysmal pressure, but from mediastinal disease (adhesions, tuberculosis, 
malignant disease, Hodgkin's disease, indurative mediastinitis or massive 
pericardial effusion). 

In all these conditions, however, the pulmonary second tone is accentuated and 
it may he said with emphasis that diagnosis in the terms of "a congenital heart 
lesion" is usually simple and easy; its absolute analysis, difficult and often 
impossible. 

Prognosis. — Cases of pulmonary atresia with closed ventricular septum 
die during the first six or seven months of life, With a defective ventricular 
septum and a closed foramen ovale a few may live ten or twelve years. With 



PULMONARY STKNOSIS 



737 



open foramen ovale and defective ventricular septum practically all die 
within the first year. 

In mere stenosis without septal defect, a majority may reach the third 



^Xw^Jt^v^-^^r^ 



Fig. 402. — Lead i. 




Fig. 403. — Lead ii. 




Fig. 404. — Lead iii. 

Figs. 402, 403, 404. — Congenital heart; mitral "P"s; delayed conduction from auricle 
to ventricle (partial heart block). Lead i shows the typical split (toothed) "P" of mitral 
stenosis; the less clearly indicated mitral "P" in the form of a square summit; the (rela- 
tively) small "R" in lead i and deep S in lead ii suggestive of a congenital element; a 
"P-R" interval of 0.3 sec. as contrasted with the normal "P-R" of 0.12-0. 18 sec. (R. 
Edwin Morris.) 

decade of life. With defective ventricular septum few survive the first 
seven years and fewer still reach the end of the second decade. 

With ventricular septum and foramen ovale alike patent, all die during 
the first two decades.* Trivial foramina! defects are relatively common. 
* Maude Abbot: loc. cit. 
47 



738 



MEDICAL DIAGNOSIS 



PATENT FORAMEN OVALE.— Ordinarily this is silent and escapes 
diagnosis, for even cyanosis may be absent and very slight patency is a rela- 




Fig. 405. 




Fig. 406. — ii. 




Fig. 



407. — 111. 



Figs. 338, 339, 340. — Congenital heart. Fatal case coming to autopsy. The condi- 
tion is indicated graphically by the (a) small "R" (almost zero) in lead i; (b) deep "S" in 
leads i and ii. Right ventricular hypertrophy is indicated by the inversions of the "T" 
summit in leads ii and iii. Small "R" and deep "S" in i. Large "R" and small "S" 
in iii. Inversion of "T" in leads ii and iii is thought to indicate a bad prognosis. (R. 
Edwin Morris.) 

Note. — In congenital transposition of the heart ("situs inversus") all summits in the 
first lead are inverted. 

tively common condition (Vierordt), but as it may be combined with mitral 
or pulmonary lesions or with both, a most bewildering variety of murmurs 
is rendered possible. 



PULMONARY STENOSIS 739 



If pulmonary stenosis, extreme emphysema or fibroid phthisis be present, 
the increased right auricular pressure may result in a systolic, presystolic, or 
presystolic-systolic foraminal bruit and an exaggerated presystolic wave in the 
jugular. Occasionally the varying intensity of the murmur may be suggestive. 

If mitral regurgitation is present, a marked systolic foraminal murmur 
may result from left auricular hypertension due to the regurgitant mitral 
current and resultant auricular overload, and this may even produce an 
exaggerated systolic jugular pulse without obliterating the presystolic ele- 
ment, together with a degree of cyanosis far exceeding that ordinarily asso- 
ciated with the mitral lesion alone. 

In all such cases the foraminal murmur is most intense over the base though 
perhaps audible at the apex, and paroxysmal cyanosis may occur. 

Paradoxic Embolus. — It is in defects of the auricular septum that one 
meets occasionally with the curious and significant formation of emboli in 
the systemic arteries which evidently arise from thrombi in the systemic veins. 
The diagnostic importance of such a decided abnormality of route with 
respect to septum defe'cts is sufficiently apparent. 

PATENT DUCTUS BOTALLI {Patent Ductus arteriosus) —It becomes 
evident from a review of the congenital heart lesions that without great 
risk any medical poseur might add greatly to his kudos, if, when facing a 
dusky-blue baby, which on crying assumed a yet deeper color, presented to 
view a heaving chest and epigastrium, and to the ear, a bewildering medley 
of thrills and murmurs, he were to say "offhand" — "pulmonary stenosis, 
patency of the ventricular septum and foramen ovale, one, or both together, 
and a persistent and perhaps dilated ductus BotalliT 

Important Structure. — Certainly this last interesting developmental 
defect is an extremely common and almost indispensable associate of the 
most frequent of the congenital heart lesions of severity and symptoms. 

In fetal life the ductus arteriosus is a vitally important and prominent 
structure, being then greater than the aorta, nearly equal to the pulmonary 
trunk itself and a direct bond between the two great blood vessels. With the 
freeing of the pulmonary artery at birth, it almost invariably becomes a 
useless remnant. 

Value in Pulmonary or Aortic Atresia. — If during fetal development the 
pulmonary outlet becomes actually atresic, or if on the other hand, the aortic 
flow is blocked (coarctation, aortic obstruction or atresia) this vascular 
crossing between the greater and lesser vascular systems may be the chief 
means of circulatory salvation. 

In the first instance if the pulmonary block is complete, the left heart 
assumes the entire burden and pours all the blood into the aorta, the patent 
ductus Botalli playing the part of a pulmonary trunk. 

On the other hand, if the left heart overflow be blocked, the right heart 
and pulmonary artery take up the entire burden and the ductus arterious 
may receive and deliver the systemic supply. 

It is evident that an accommodating patency of the foramen ovale or 
ventricular septum or both must serve to switch the blood primarily from 



740 



MEDICAL DIAGNOSIS 



the blocked half of the heart to the open side or wide areas of anastomosis 
must be opened. 

The Murmur. — Obviously, the murmur will be a slightly delayed or 
definitely post-systolic murmur, " rumbling," "rushing," " humming," "churn- 



ing, 



harsh,' 



' "scraping," "musical 



or, rarely, "flowing," and should be 




Fig. 408. — Patient ductus Botalli in a man of 55 years of age. Xote the dilatation of the 
pulmonary artery and hypertrophy of the right ventricle. 

best heard in the first or second left interspace. It may or may not run over into 
the diastole, or be continuous. If aortic atresia exists, it may be heard plainly 
at the left back (third to fourth dorsal). 

It shows a distinct respiratory variation and is most intense in expiration. 
The pulse, on the other hand, is full in expiration and weak in inspiration 
{pulsus paradoxus). The condition is reversed if pulmonary atresia exists, or 



VARIOUS CONGENITAL LESIONS 741 



// patent ductus alone is present and the flow comes from the aorta through the 
ductus to the lungs. 

The murmur is then carried from the aorta and may be no longer heard 
at the back unless as a part of the general dissemination of a loud murmur 
by reason of the dilatation of the ductus itself and direct transmission from 
that structure. // is loudest in inspiration when the pulmonary current comes 
from the aorta . 

In cases where the aortic and pulmonary valves are competent and the 
patent ductus constitutes the only anomaly the double flow into the pul- 
monary artery increases the pressure in its circuit and a loud second sound is 
audible over the second left interspace. 

STENOSIS OR ATRESIA OF THE AORTA AND COARCTATION 

OF THE ARCH 

Sites. — Blocking of the aortic lumen may occur either within or just beyond 
the site of the ductus Botalli (ductus arteriosus). 

In the former 'case the systemic circulation will be carried on by the right 
heart through the aid of the ductus to whatever degree the severity of the 
lesion demands, for in such congenital lesions septal defects almost invariably 
permit the switching of the circulation within the heart. 

Coarctation. — In the second type the ductus Botalli is of no aid and the 
circulation must be carried on by anastomoses. 

In the first form a positive diagnosis is impossible. There are merely 
cyanosis and more or less indefinite single or double murmurs. 

In coarctation (blocking of the aortic isthmus), the diagnosis may be easy, 
extremely difficult, or impossible. Visible arterial pulsation of trunks in un- 
usual locations at once suggests it. There may be sharply defined differences 
between pulsation in the branches given off above the isthmus and those supplying 
the lower extremities through the arterial anastomoses. Pressure from medias- 
tinal tumor or aneurysm must be excluded. 

DEFECTIVE VENTRICULAR SEPTUM.— Though usually a part of a 
combined congenital lesion it may stand alone. Its manifestations must 
depend largely upon the question of the size of the defect and the relative 
strength of the right and left ventricles. 

If the normal left ventricular preponderance is present or increased, the 
escape current will flow during systole from the left to the right ventricle, 
distend and dilate the latter and produce right ventricular dilatation and 
hypertrophy which is indeed an almost invariable finding. If pulmonary 
stenosis or obliteration co-exists, the flow would be in the opposite direction 
but the right heart would still be chiefly affected (though the left would 
participate) because of continuous overloading. 

Murmur. — In either case a systolic murmur would result, most clearly 
audible over the base of the heart and, obviously, such a murmur might be 
less sharply related to the heart tones than would one of valvular origin. 

One would naturally assume that it woidd commence with the maximum 



742 MEDICAL DIAGNOSIS 



ventricular filling just before the first sound, that it would become suddenly intensi- 
fied in systole and somewhat overstep the second sound of aortic closure because 
of there being no valve to check it. 

Maximal Audibility and Transmission.— The bruit is usually maximal 
at the base of the heart, at mid-sternum, or in the second or third left inter- 
space, and diminished equally in all directions from its center of intensity. 

A striking thrill is often present over the same area and the murmur 
remains unchanged for years. 

It is obvious that with large septum defects there will be neither murmur 
nor thrill and that very marked changes in intensity must accompany condi- 
tions affecting the relative strength of contraction and the load of the 
ventricles. 

No cyanosis need be present in uncomplicated cases but as before stated 
the lesion is usually associated with pulmonary stenosis and a part of the 
clinical picture of ''morbus ceruleus." 

Transposition of the Arteries. — One should bear in mind the possibility 
of transposition of the arteries in situs inversus or dexiocardia. 

CONGENITAL HEART LESIONS IN GENERAL.— Congenital lesions, 
aside from the patent ductus Botalli and patent foramen ovale, have these things 
in common, viz.: (a) They are evident at birth or shortly after, (b) They kill 
for the most part within the first decade and to a remarkable degree in the first 
eighteen months of life, (c) They are characterized by marked enlargement of 
the heart, clubbed finger tips, bulging of the chest, and decided or profound cyano- 
sis, either persistent or easily induced, (d) They represent multiple lesions and 
are associated usually with well-marked murmurs and thrills. 

They may be, but seldom are, the result of fetal endocarditis, usually 
due to acute rheumatism in the mother; affect male children twice as often 
as the female and show a tendency to multiplicity of lesions which is more or 
less an adaptation of arrested development to the needs of the primary disease 
or deficiency. 

If, for example, the pulmonary artery be markedly stenotic or actually 
atresic, the ventricular septum may remain undeveloped, the blood be 
carried to the aorta in large part or in toto and the ductus arteriosus may 
remain open to insure a diversion of a part of the abnormal aortic stream to 
the pulmonary capillaries. In the same manner an open foramen ovale 
may relieve the auricular overdistention by equalizing the pressure in the 
two auricles. 

If the changes are in kind or degree insufficient to disturb the circulatory 
balance, they may remain innocuous for a lifetime. 

THE COMMONER COMBINED VALVULAR LESIONS 

Caution. — Certain basic principles should govern one who seeks accur- 
ately to determine and place the murmurs of multiple valvular lesions. 
With respect to systolic or imperfectly developed diastolic murmurs 

he should attempt ordinarily no more than a tentative partial diagnosis, limited to 
absolutely provable and obvious lesions, in the presence of: 



COMBINED VALVULAR LESlo.\s 



743 



(a) Excessive dilatation and extreme cardiac asthenia, 
{b) Excessive pressure upon the heart and consequent decided displacement, 
whether this be upward, downward or lateral. 

(c) Evidences of decided hyperthyroidism. 

(d) High fever and profound toxemia. 

(e) Extreme anemia and debility. 

(J) Excessive rapidity or extreme lability or arrhythmia of the heart. 
This caution does not mean that one may not make a provisional diagnosis 

but rather that anv final opinion be reserved. Under such conditions, the Misleading 

.... , i ... / .... .. N < pressure 

wise clinician names the murmurs by their time (systolic, diastolic, etc.); effects, 
places them as to their maxima of audibility and apparent transmission; 
expresses himself as to their apparent differences as to pitch and quality, 
associated thrills, pulse tracings, electrocardiograms, radiograms, and what 
not; carefully outlines whatever of the heart is percussable; searches for 
secondary decompensation signs and notes them and stops there until the 
conditions permit something in the way of a more complete specific diagnosis. 

Multiple Murmurs. — Under the conditions outlined above systolic murmurs 
may appear to arise at every orifice, yet ultimately be reduced to one or even to Primary 
zero. The chief need in such instances is that one should recognize and relieve 
the associated or resultant myocardial weakness, set aside any existing pres- 
sure, and thus lift the burden from the heart and blood vessels. 

Hair-splitting diagnosis under such adverse conditions is a fascinating diver- 
sion, wholly praiseworthy, but ultimately disciplinary, chastening and beset 
by thorns, largely represented by a more or less cold-blooded and critical patholo- a mine field. 
gist. The autopsy room is a veritable il mine-field" for the overconfident 
diagnostician. 

Essential Data in Differentiation. — To repeat all of the intrinsic charac- 
teristics and associated signs of the various valvular lesions would be but a 
waste of time. 

Pitch, quality, time, transmission, localized thrills and the like, in so far as 
they relate to specific individual lesions, are to be sought and made to serve the 
purpose of differentiation so far as possible. 

One is primarily concerned with murmurs originating in the left heart or its 
outlet, for these constitute literally at least 80 per cent, of the valvular murmurs. 

Any systolic murmur, therefore, is assumed to tentatively represent either: 
(a) mitral reflux, maximal at the apex; or, (b) aortic stenosis, maximal at the Recapitulation. 
base. The former, if endocarditic not " relative,'' or "accidental," is usually 
clear and distinct unless the ventricle is very weak or a mitral stenosis co-exists 
and dominates it or blocks the back flow of a weakened ventricle by the extreme 
volume pressure of afibrillating widely dilated paralytic auricle. 

Helpful Suggestions with Respect to Systolic Murmurs. — In the absence 
of evidence of concurrent mitral stenosis or excessive left auricular dilatation a 
relatively soft and low-pitched murmur, not typically transmitted, but maximal at 
the apex, is likely to be due to relative mitral insufficiency rather than to mitral 
endocarditic valvular disease. 

The true typical systolic murmur of aortic stenosis is transmitted above the 



744 



MEDICAL DIAGNOSIS 



Flint murmur. 



Extremely 
important 
lesion. 



right base of the heart to the vessels of the neck and usually associated with a 
relative diminution or total loss of the second aortic sound and a more or less 
characteristic pulse effect. 

Common Diastolic Bruits. — If the murmurs heard are diastolic in time, 
the assumption is that any homogeneous murmur, maximal at the third 
left interspace, ensiform, or the right second interspace, transmitted 
chiefly along the lines indicated, and, if loud, usually heard in the right 
carotid or in both is caused by aortic regurgitation. This assumption is 
confirmed if we find even a modified water-hammer pulse ("pulsus celer," 
"Corrigan pulse"), and a high "pulse pressure," in the absence of signs of 
marked hyperthyroidism (Parry's disease, Graves' disease, exophthalmic 
goiter) and, in the presence of the diastolic murmur, is a sound one to rest 
upon even if hyperthyroidism is present. 

If an audible diastolic murmur is maximal just within the apex-beat, begins 
just after the second heart sound, is blubbering or vibratory, and especially, 
if it shows a thrilling purring crescendo in presystole and ceases abruptly 
as if "shut off" by or actually terminating in a loud clapping or slamming 
first sound, we know that it is due to mitral stenosis unless aortic 
regurgitation is present. This suggests the possibility of the pseudo-mitral- 
stenosis bruit ("Flint murmur") caused, probably, by a false rhythmic 
stenosis due to the regurgitant blood from the aorta plus a large residual 
ventricular content which causes the valves to lift prematurely in late 
diastole and somewhat obstruct the flow from auricle to ventricle during 
the atrial systole. 

The Flint murmur is so rare as shown by autopsy that the wise man merely 
records it as a possibility if aortic regurgitation is proven and makes a 
tentative diagnosis of "associated mitral stenosis."* 

Tricuspid stenosis and pulmonary stenosis are excessively rare save 
as a part of the complicated and striking clinical pictures presented by 
congenital heart disease which cannot, and need not, be dealt with here, 
although the former probably occurs more frequently in connection with 
tricuspid regurgitation of the endocarditic type than is generally known. 

Tricuspid regurgitation is relatively rare as represented by a clean-cut 
sharply defined murmur of chronic endocarditis and offers little difficulty 
with respect to differentiation, whether from aortic stenosis or mitral 
regurgitation of the endocarditic type. 

It must always be borne in mind, nevertheless, as a murmur which repre- 
sents an important secondary (relative) insufficiency, in all cases associated 
with obstructed flow in the lung circuit whether from mitral disease, 
primary or secondary, or from excessively chronic pulmonary lesions. Un- 
less very slight it cannot exist without producing a decided or excessive exten- 
sion of the right border of the heart (right auricle) and diminution or loss of 
the second heart sound in the pulmonary area. 

It is usually associated with either persistent distention of the anterior 

* As previously stated its very existence as a clinical phenomenon is denied by some of 
the most eminent of foreign clinicians. 



COMBINED VALVULAR LESIONS 



745 



cervical veins or direct (systolic) jugular pulsation and is probably never 
maximal either in the mitral or aortic area, but over and about the lower 
sternum. 

Pulmonary insufficiency is dealt with fully elsewhere. It is excessively 
rare as a clinical finding, though, possibly, this represents the imperfection 
of clinical methods rather than such extreme rarity as our statistics would 
seem to prove. 

Thrills are usually accurately related to the classic auscultation points 
of the valves and when present are* extremely definite and helpful. Aortic 
stenosis very commonly shows one, mitral regurgitation only occasionally, 
aortic regurgitatioh quite frequently, and mitral stenosis quite constantly if 
the presystolic murmur is marked and, not infrequently, when only the 
diastolic bruit is present or even when no murmur is audible even to the 
lightest stethoscopic contact or upon changing the position of the patient. 

The presystolic thrill over the limited classical area of mitral stenosis murmur 
audibility a>id the systolic shock or sharp tap imparted to the finger as the purring 
tremor abruptly ends is as nearly a pathognomonic sign as any in medicine. 

Even in its absence the sharp, circumscribed tap usually remains palpable 
and often visible and justifies the experienced diagnostician in a tentative opinion 
even in the absence of a characteristic bruit. 

The Cardiac Outline. — This is of the utmost importance and by ortho- 
percussion, modified auscultatory percussion or, the radiogram, if the X- 
ray is available, one largely may confirm or correct previous inferences and 
oftentimes gain much additional information (see "Radiography"). 

77 should be remembered that, in general, aortic lesions, of themselves, cause 
left ventricular hypertrophy and dilatation resulting in an extension of the left 
border and apex-beat downward and outward; that mitral lesions affect chiefly 
the left auricle and to a less decided degree the left ventricle primarily; the right 
ventricle secondarily and, but only when the latter weakens or secondary 
tricuspid leakage ensues, the right auricle. 

All of these effects are shown upon the screen or by a radiograph and 
may usually be determined with considerable accuracy by modern percussion 
methods. 

Paradoxic Right Heart Pulsations. — It should be remembered also that the 
impulse {apex-beat) of a decidedly hypertrophied left ventricle is direct, deliberate 
and systolic both to the palpating hand and to the eye, whereas that of right 
ventricular hypertrophy or dilatation which may push aside the left ventricle 
and form the apex-beat in mitral lesions or primary right heart enlargement, may 
be diastolic to the sight, because of its withdrawal from the chest wall in 
systole and the resulting wave-like recession of the overlying tissues. 

If an hypertrophied left ventricle is only partially blocked off from the 
chest wall by an enlarged right heart the characteristic deliberate heaving 
impulse may be only shortened. 

In such cases the right heart systolic recession of interspaces may blend 
curiously with the left ventricular systolic thrust (" mixed" apex beat) to 
form a widely diffused undulant impulse. 



Important 
associations. 



Midway 
pulsations. 



746 



MEDICAL DIAGNOSIS 



Endocarditic 
sequelae. 



A crumb of 
comfort. 



If both ventricles are hypertrophied but weak and dilated, and yet the 
left ventricle can reach the wall, a curiously indeterminate breaking-wave 
effect may result especially marked in double mitral lesions. 

Any epigastric impulse or heave, systolic as timed by the carotid beat, and 
not transmitted from the aorta, is left ventricular in origin (Mackenzie). 

Any epigastric impulse or heave which is due to the right ventricle is systolic 
in its descent, as timed by the carotid. 

Actual systolic pulsation of the liver itself is expansile and involves the entire 
viscus. One hand in front and one at the back enclosing it, readily determines 
its expansion. 

Any diffuse impulse heave or apparent retraction of cardiac origin, 
maximal between the true apex and the left parasternal line or left edge of 
the sternum, is due to right ventricular hypertrophy, or if it be wavy and 
indeterminate, to right ventricular dilatation, which is usually confirmatory 
evidence of primary lesions situated in the left heart, of chronic .obstructive 
lung lesions, or of generalized extreme myocarditic weakness. 

Finally, massive hypertrophy of the right ventricle extends the superficial 
area of dulness chiefly to the left and outward tending to displace the left 
heart from the chest wall. It also carries it inward to the median line of the 
sternum. All increase of dulness to the right of the sternum, if of cardiac 
origin, is due to enlargement of the right auricle unless a "drop" heart 
exists. A dilated left auricle lies chiefly posterior but when dilated causes 
a radiographic projection shadow or area of percussion dulness in the left 
heart profile below the bend of the pulmonary artery. 

RATIONALE.— Multiple Lesions the Rule.— The nature of endo- 
carditic processes and the deformity and limited radius of excursion which 
the valves usually undergo makes it evident that single lesions must be the 
exception and multiple defects the rule. 

Whether the primary change be endocarditis or sclerosis, the tendency 
is toward relative fixation and more or less deformity of the valve segments 
and thickening and retraction of the chordae tendineae of the mitral or 
tricuspid leaflets. 

One, for example, can picture a rigid deformed stenotic mitral as ob- 
structing normal flow from the auricle to the ventricle, but it is difficult to 
see how such a valve can ever completely shut off a reflux from that 
chamber by absolute closure in ventricular systole. The same statement 
applies to the tricuspid and semilunar valves. 

Nevertheless, isolated stenosis, rarely, and pure regurgitation, commonly, 
do exist, as shown clinically and by autopsy. 

The frequency with which chief endocarditic valvular lesions lack signs 
! of other lesions coexistent cannot be stated accurately because of the wide 
! variations in all tabulations, but doubtless such cases are common, a bit of 
comfort for erring students and clinicians alike. 

Pure valve defects are rare at autopsy and relatively so when judged by 
clinical findings. 

Mitral stenosis and regurgitation are peculiarly changeable and all 



COMBINED VALVULAR LESIONS 



747 



clinicians have noticed the tendency to dominance of one element or the 
other, oftentimes to a degree which eliminates the lesser murmur. 

One can see with his mind's eye a residual mitral endocarditis which 
has thickened and deformed the valve and thus prevented its accurate 
closure and caused a typical mitral systolic murmur. If he follows the image 
further, he may see that the valve margins have become adherent and the 
opening narrowed, an event reflected perhaps only in a sharply increased first 
sound, due to relative rigidity, but if the process goes on, as mitral stenosis 
inexorably does, he finds that the contracting ring is actually reducing the 
volume of the regurgitant current and that a murmur diastolic-decrescendo 
and presystolic-crescendo, running into the loud snap and slam of the first 
sound, must wholly dominate, if the systole of the auricle is maintained. If 
the auricle fibrillates and its systole is lost, the clear presystolic-crescendo 
element of the mitral bruit disappears and the relatively stronger ventricle 
may carry into its original dominance the systolic bruit of the regurgitant 
stream. The intra-auricular distention-pressure ■ in fibrillation may be so 
great, however, as to actually block the backflow sufficiently to remove any 
preexisting murmur beyond the range of audibility, if the ventricle be weak 
and the aortic outlet unobstructed. Under rest and treatment the auricle 
may cease its futile flickering and again show tonus and systolic contraction 
and assume its dominant role. 

Aortic Stenosis and Regurgitation. — Somewhat similar changes occur 
in stenosis and incompetence of the aortic valve but are of a relatively simple 
sort and a tendency to progressive increase of the systolic (stenotic) murmur 
is likely to be noted as time progresses. 

Multiple lesions are demonstrable clinically in about one-half of all cases 
of chronic endocarditis. 

Bridging Gaps. — Even though an endocarditis may have spared the aortic 
valve and assailed the mitral primarily, it may bridge the short gap between 
the anterior mitral cusp and the aortic valve or vice versa. This occurs 
doubtless in cases in which, during the carefully observed acute disease- 
phases of, and in convalescence from, acute rheumatism, only one valve seems 
to be affected; yet when the patient is examined later, two valves are found 
defective with no history of intervening fresh infection to account for it. 

The interaction of multiple valvular defects combined with the variations 
in the relative strength of the heart chambers permits almost as many com- 
binations as a pack of playing cards. 

If an incompensated mitral stenosis and an aortic stenosis co-exist, 
for example, the ventricle receives little blood and less work is required to 
deliver it to the aorta. As a result of these peculiar conditions the left 
ventricular hypertrophy so characteristic of aortic stenosis may be wholly 
lacking throughout the entire (short) duration of the lesions. Neither would 
the pulse be the small "pulsus durus" of aortic obstruction (Romberg). 

If mitral and aortic regurgitation co-exist or aortic stenosis and regurgita- 
tion, the " water-hammer" pulse ("Corrigan," "pulsus celer") is diminished 
in its definition and intensity decidedly with progressive obstruction at the 



Shifting 

dominance. 



Genesis of 
stenosis bruit. 



The silenced 
murmur. 



Progressive 
lesion. 



Postponed 
secondary 
involvement. 



A clinical 
paradox. 



Modified 

•'Corrigan 

pulse." 



748 



MEDICAL DIAGNOSIS 



Illuminating 
discoveries. 



Anachronistic 
terms. 



Persistent liv- 
ing causative 
organism. 



Etiologic 
catholicity. 



Renal disease 
and apoplexies 



Tabes" and 
'paresis." 



A luetic lepto- 
meningitis. 



aortic outlet. Indeed a combination of the " pulsus celer" and u pulsus durus" 
may be manifest to the trained fingers. 

The effect of combined lesions in general is not conservative, however, 
but destructive, though this does not mean that the victim cannot endure 
them for decades, in some instances doing hard manual labor.* 

CARDIOVASCULAR SYPHILIS 

Recent Expansion of Our Knowledge.— But a short time ago our exact 
knowledge of cardiovascular syphilis might have been written upon a postal 
card. Today it boasts a tremendous literature and embraces important 
diseases seemingly wholly alien to their basic cause. 

The discovery of the Treponema pallidum, its fortuitous and roundabout 
but definitive articulation with complement-fixation, the specific allergic test of 
Noguchi, and our ability to demonstrate Treponema pallidum in the diseased 
tissues, have transformed etiologic assumption and suspicion into actuality, 
and made the terms "para"- or "meta" -syphilis, or even "luetic sequela" 
misnomers. 

We know now that from the time of the initial lesion to and through that of 
tertiary manifestations, even decades removed, we are dealing with actual syphilis 
— with the activities of the living causative microorganism. 

Enormous Cardiovascular Field. — Cardiovascular syphilis embraces a 
large part of toxemic, primarily degenerative arterio- or atheroscleroses, a yet 
greater and more important proportion of the cases of obliterative endarteritis, a 
large number of myocardial impairments, and nearly the whole of chronic pro- 
ductive mesaortitis and mesarteritis. 

Many cases of chronic hypertensive renal diseases must be added, to- 
gether with the specialized obliterative endarteritis of the basal cerebral vessels, 
so potent in precocious or fifth decade apoplexies. 

Recent investigations moreover add locomotor ataxia and general paresis, 
almost if not quite in toto, and in each, cardiovascular lues is evidently the basic 
factor. 

Cerebrospinal Syphilis. — In tabes dorsalis the primary change is a luetic 
leptomeningitis, with most extensive involvement of the arteries, marked 
infiltration, and a perivascular inflammation which follows the arterial 
pathways to the selective areas of attack. 

Paresis.— /w paretic dementia we find with astonishing frequency syphilitic 
mesaortitis oj some grade; basal, luetic, obliterative endarteritis and, constantly, 
in the cortex, a luetic endarteritis. 

In the case of both, the high percentage of positive Wassermann and luetin 
tests, and the repeated demonstration of Treponema pallidum in the tissues, 
have shown them to be the best representatives of the effects of selective 

* In one case observed by the author, a double aortic lesion and a free mitral regurgita- 
tion had apparently been carried from the age of fourteen to that of thirty-two although 
for fourteen years the patient had worked as a locomotive fireman. His compensation 
failed abruptly upon his receipt of a slight injury to the left chest and was never fully re- 
gained. Similar cases often arise. 



CARDIOVASCULAR SYPHILIS 



749 



endarteritic cardiovascular lues and the leading examples of cerebrospinal 

syphilis. 

To the list must be added: 

Myelitis 50 per cent. 

Congenital mental defect 50 per cent. 

Epilepsy 50 per cent. 

Paroxysmal hemoglobinuria 100 per cent. 

Primary optic atrophy 100 per cent. 

Disseminated sclerosis 30 per cent. 

Infantile cerebral palsy 50 per cent. plus. 

and several other conditions. 




Fig. 409. — Syphilitic mesaortitis. Aneurysm involving ascending and transverse portions 
of the'arch, coincident aortic regurgitation. Symptoms of aortic regurgitation and "neuras- 
thenia" only at time photograph was taken. Later those of the aneurysm present became 
evident. 

With respect to general paresis the stress of urban life and congenital Factors in 

... , , i -i- • i r localization. 

vascular inadequacy when imposed upon a syphilitic are the potent factors 
in localization. 

In Berlin between 30 and 40 per cent, of the male residents seeking hospital 
admission are said to be paretics, but it is rare among those coming from the 
country. 



75o 



MEDICAL DIAGNOSIS 



Mesaortitis. 



Great 
frequency. 



Denial of 
infection. 



Kraft-Ebing's etiologic reference of this ailment to " civilization and 
syphilization" is proven now to be more than a striking phrase. 

Importance of Luetic Aortitis. — The author will deal only with certain 
basic statistical facts and a brief discussion of the most anatomically character- 
istic and clinically complex cardiovascular expression of acquired syphilis, 
namely," "chronic productive luetic mesaortitis." 

To emphasize the importance of this condition one need but know the 
following facts: 

First. — Ninety per cent, of all persons dying of syphilis will show micro- 
scopic or macroscopic mesaortitis and in 50 per cent, or more it will be the actual 
cause oj death. 

Second. — Eighty per cent, of the symptomatically recognizable cases present 
aortic regurgitation. 

Third. — In all cases embraced in this subgroup, more or less decided im- 
pairment of the coronary flow results, although in but 10 per cent, is angina 
pectoris major present. 

Fourth. — About 90 per cent, of these cases become manifest by decided 
clinical signs between the ages of 30 and 60. (4th decade, 25 per cent.; $th 
decade, 50 per cent.; 6th decade, 15 per cent.). 

Fifth. — It kills in the very prime of life, is peculiarly intractable and pro- 
gressive once severe decompensation is established and constitutes, one of the most 
disabling, harrassing and painful of all lethal ailments and a not infrequent 
cause of sudden death. 

Sixth. — In no chronic disease is early diagnosis more desirable or less fre- 
quently attained. 

Some Astounding Figures. — It is asserted that the United States now 
contains approximately 2,700,000 adults carrying some grade of syphilitic 
aortitis; that of these, 2,160,000 are men, 540,000 women, a large proportion 
of the latter and a small number of the former being wholly unaware of past 
infection. Ninety per cent, are found to deny infection under routine case 
taking and one-half in the face of positive complement-fixation tests. 

The following are among the latest results reported: 

Hubert, 8652 consecutive admissions to a general hospital service. 
Result 8.8 per cent, positive Wassermanns. 

All admissions to Bellevue and Presbyterian Hospitals, New York. 
Result 20 per cent positives. 

Same procedure at Peter Bent Brigham Hospital, Boston. Result 15 
per cent, positives. 

An extended investigation by the United States War Department 
(Vedder) showed that nearly 17 per cent. (16.88) of accepted recruits were 
Wassermann positive, and upon the basis of results obtained at West Point, 
it is asserted as probable that 5 per cent, of college students are infected. 

From 3 to 6 per cent, of babes under one year are victims of hereditary 
syphilis. 

These figures, though startling, are quite in correspondence with those of 
other highly civilized and Christian countries. 



CARDIOVASCULAR SYPHILIS 



751 



Insurance 
experience. 



Concealed Identity. — Though almost unknown on certificates as a written 
cause of death, it is evident that sypliilis must kill annually an army of men in striking facta, 
the very prime of life, after a sneaking, insidious course, extending usually 
over many years. It is the slow poisoner and concealed assassin of many who 
have long thought themselves cured, and its cardiovascular types are more fatal 
than all other syphilitic lesions combined. 

Reduction of Life Expectancy. — The inadequacy of our therapeutic inadequate 
methods is demonstrated clearly by the experience of Life Insurance Com- 
panies. These have always exacted at least the evidence of effective, long- 
continued treatment and prolonged freedom from clinical symptoms, yet 
Deneke accurately asserts that a history of past syphilis means an increased 
death rate 68 per cent, in excess of the expected mortality. 

Recentlv published statistics show an astonishing selective distribution Selective 

, incidence. 

of the excessive death loss. 

The "Gotha," for example, finds that in insured syphilitics the following 
causes of death showed the tremendous increases set opposite them, namely: 

Per cent, over normal loss from that cause 

Malignant growths t 60 

Renal disease 64 

Gastro intestinal 84 

Cardiovascular 116 

Apoplexy 128 

Mental and nervous diseases 145 

Suicide 122 

Without further comment we pass to our main topic: 

CHRONIC PRODUCTIVE MESAORTITIS.— Mesarteritis vs. Athero- 
sclerosis. — One must distinguish the inflammatory or subinflammatory luetic 
mesarteritis from the degenerative arteriosclerosis or atherosclerosis which 
represents the commonest expression of vascular disease. 

Mesarteritis is not primarily degenerative, but irritative and destructive. 
Atherosclerosis as a type is degenerative from beginning to end. 

The former represents in all probability the direct activity and actual Basic factors 
presence of the pathogenic microorganisms ; the latter, a low grade of toxemia 
from any one of many sources one of the chief of which is syphilis. 

Nothing could be more striking than the degenerated rigid " pipestem ,} 
arteries of certain cases of congenital syphilis and lues can either itself 
initiate, or blend its endarteritic changes with, any type of toxemic degenerative 
arterial disease. 

Indeed in the earlier stages the luetic nature of its endarteritic types is 
usually readily demonstrable under the microscope. 

Lymph Channels and Veins. — In all of its irritative, inflammatory or 
subinflammatory forms the disease is as avid of lymphatics and veins as of 
arteries and exhibits a tendency to selective involvement, whether of certain 
regions, mere sections of an affected vessel, or an attack predominantly focal. 

Site of Preference. — In syphilitic productive mes aortitis, the site of elec- 
tion is the first portion of the aorta and the patchy involvement may be 
sharply delimited. If the arch itself is involved, only rarely does the 



Important 
distinction. 



Luetic 

degenerative 

changes. 



Sharp 
delimitation. 



752 



MEDICAL DIAGNOSIS 



Primary 
changes. 



Line of march. 



Macroscopic 
appearance. 



Long 
miscalled. 



Importance of 
location. 



Dilatation or 
aneurysm. 



process extend beyond its transverse portion though the terminal thoracic 
(supradiaphragmatic) segment is occasionally an initial site. 

Luetic mesaortitis is so steadfast in its seat of election as almost to exclude 
syphilis as the cause of such a lesion in other regions. 

Mesaortitis luetica may be said to be limited, practically, to the adventitia 
and media. 

Pathology. — The disease begins in the perivascular tissue and extends 
inward along the course of the nutrient vessels (vasa-yasorum) whose sheaths 
are seats of marked small-cell infiltration, consisting chiefly of lymphocytes 
and plasma cells. 

Within the infiltrated zones localized necrosis occurs, and in these areas 
groups of the Treponema may be demonstrable. 

In the media, areas of complete destruction and solution of fiber-con- 
tinuity may occur. 

In active cases the zones of necrosis, reparative fibro-plastic activity 
and actual fibrosis may co-exist. 

In the peripheral areas giant cells are found. 

The early involvement of the vaso-vasorum and the direct action of 
Treponema pallidum and its toxin. are the chief factors in the peculiar "line of 
march" of this process and the patchy distribution of its lesions. 

The intima may escape wholly the destructive process and merely show 
some late fibrosis and possibly an irregularly distributed subendothelial 
proliferation. 

These microscopic changes are more or less clearly reflected in the macro- 
scopic appearance of the inner surface of the affected portion of the aorta. 
Curious opaque, succulent, circular elevations, or tubercles, alternate with 
or are irregularly disseminated among sharply defined (punched out) de- 
pressions and pits, these often showing some translucency at their bases and 
a peculiar "silky crinkling" of the endothelial lining. 

Many investigators have found the Treponema pallidum in the affected 
tissues. 

The Francis Welch Aortitis. — Such is the luetic mesaortitis of Francis H. 
Welch, sometime Professor of Pathology at Netley, who first described its im- 
portant features, microscopic and macroscopic, in 1875 and asserted strongly its 
luetic origin. 

Long afterward, Dohle, Heller, Benda, Chiari, and many others, refined 
the investigations of Welch. Somewhat ungraciously, Continental, American 
and even certain British writers refer to this " chronic productive syphilitic 
aortitis of Francis Welch 11 as the " Dohle-Hellersche Aortitis." 

Inevitable Sequences. — It is manifest that both the symptoms and re- 
sults of this condition will vary greatly with the site of the lesion. The nearer 
the site of the inflammatory process to the aortic ring, the greater the damage 
and the more pronounced the symptoms. 

Obviously the weakened walls tend to yield, and upon the question of excessive 
focal activity, or a relatively extended di fusion of the destructive changes, de- 
pends the production of aneurysm on the one hand, or a mere diffuse dilatation, 



CARDIOVASCULAR SYPHILIS 



753 



insufficiency. 



pectoris. 



or a HuoroscopicaUy demonstrable increase of pulsatory excursion upon the 
other. 

It is evident that the commonest type of involvement, i.e., that of the Aortic 
first portion, must tend to weaken and enlarge the aortic ring. In 80 per 
cent, of the cases of luetic mesaortitis, such a secondary aortic insufficiency is 
established. 

The valves themselves are usually more or less wrinkled, thickened and Possible 
shortened, extension to the anterior mitral segment is not uncommon, and involvement, 
even a mitral stenosis may result. 

Inclusion of the sinuses of Valsalva and the coronary apertures is almost Angina 
inevitable in such cases, and the wonder is that in only 10 per cent, of the cases 
does major angina pectoris occur. The coronary orifices may be reduced to 
pin-point size in such instances. It is almost equally strange that in only 10 
per cent, do we find true aneurysm. 

Misleading Statements. — It is generally stated that in this disease blood 
pressure is normal, the heart but slightly affected, dilatation slight, hyper- 
trophy laggard, and compensation poorly achieved in the instances of aortic 
valve involvement. 

Such sweeping statements are most misleading. High systolic pressures and 
a greatly increased pulse pressure accompany all free aortic regurgitations and 
renal impermeability is, at least, a relatively common complication and may 
produce excessively high systolic and diastolic pressures, wjjich exercise a most 
disastrous effect upon a weakened artery or an inadequately nourished or defi- 
nitely toxic and degenerated myocardium. 

The assertion, oft repeated, that the heart is but slightly affected when the 
coronaries are free and aortic regurgitation absent must, of course, often be true, 
but frequency of exceptions must be asserted by the author on the basis of person- 
ally observed cases of aneurysm of the arch, no less than our growing knowledge 
of the relative frequency of early and late luetic myocardial involvement, although 
the former and indirectly, no doubt, the latter form in great measure are checked 
by the early institution of antiluetic treatment. 

The assertion of a famous German clinician that good compensation in An erroneous 

, . . . ...... . . assertion. 

an aortic regurgitant lesion proves it to be non-sypmlitic, is certainly errone- 
ous, for the author has seen several instances of excellently maintained 
cardiac reserve over long periods in men doing hard manual labor and 
carrying luetic aortic incompetence. 

Importance of Early Recognition. — // is strikingly true that once the break a striking fact. 
in compensation is permitted to occur under our present laggard diagnosis and 
therapy, its repair is extremely difficult and seldom more than partial and 
temporary. 

A s stated previously, early diagnosis and treatment are more essential in Early cases 
this than in any other cardiovascular ailment, and these hearts often prove as 
responsive to rest, with mercury or repeated fractional doses of salvarsan, as they 
are resistant to digitalis in their terminal stages. 

They are not especially resistant to this drug in the lesser myocardial decom- 
pensatory periods and this fact should be known and acted upon. 
48 



responsive. 



754 



MEDICAL DIAGNOSIS 



Laggard Hypertrophy. — With respect to retarded and sluggish hyper- 
trophy it is evident from the nature of the process that only in cases of 
involvement of the aortic valve is there with constancy any necessity for 
decided hypertrophy and equally obvious that the relatively gradual produc- 




Fig. 410. — Combined mitral and aortic insufficiency (typical). Marked dilatation of 
arch suggests syphilitic mesaortitis with extension from aortic to mitral valve. 

tion of free regurgitation would limit primary dilatation and slow the rate of 
hypertrophic changes. 

GENERAL SYMPTOMS.— Space permits but a brief review of the 
symptoms of this important condition. Fortunately, they for the greater 
part are those of simple aortic regurgitation and to a lesser degree those of 



CARDIOVASCULAR SYPHILIS 



755 



angina pectoris, diffuse dilatation of the arch, and aortic aneurysm, which are 
dealt with fully elsewhere. 

Luetic mesaortitis in its early phases is peculiarly a disease of subjec- 
tive expression and this assertion applies, measurably, even to the cases of 
the aortic regurgitant type. 

The first matter to be considered, therefore, is the proper evaluation of 
its subjective symptoms, upon which so much stress has been laid elsewhere 
in this volume. 

Pain and Discomfort. — The character and degree of pain encountered de- 
pends upon the presence of several factors, chief of which are: (a) The presence 
or absence of true aneurysm, (b) The actual degree of hyper distention or dis- 
tensibility and diminished aortic reserve, (c) Disease of the coronary arteries, 
and (d) myocardial weakness from any cause whatsoever. 

One must remember that the chief sources of pain in hollow automatic muscu- 
lar v-iscera are: (a) Excessive over distention, (b) Extreme spasmodic con- 
traction, (c) Sudden interruption of the intrinsic blood supply, and (d) effort 
that exceeds muscular reserve, i.e., obligatory overstrain with underlying weak- 
ness and insufficiency. 

That 'cardiac pain necessarily or inevitably arises from coronary sclerosis 
of itself cannot be maintained in the light of modern investigations showing 
extensive sclerosis without angina pectoris and typical "heart-pang" in the 
entire absence of sclerosis. 

That a temporary insufficiency of the intrinsic myocardial blood supply 
may result in weakness and pain, especially under emotional stress or effort, 
is certain, and is readily explained by the instantaneous reflection of blood 
shortage in a heightened myocardial irritability and narrowing of the field 
of painless muscular response. 

Pressure Pain. — Qne additional cause of pain, extracardial in its nature, 
may be encountered in aortitis with decided dilatation or actual sac forma- 
tion, namely, pressure, and it should be remembered that luetic aneurysm, 
by reason of its preferred locations, is especially adapted to the production 
of pressure symptoms related to the diverse and important structures which 
traverse the mediastinum. (See "Aortic Aneurysm.") 

The commonest source of error in relation to aortitis is the failure to remember 
that early in any case of cardiovascular insufficiency the clinical meaning and 
significance of a mere sense of constriction, oppression, or crowding, may be 
exactly the same as the vice-like gripping or the rending tearing pain of major 
angina pectoris. Of no less importance is the misleading fact that, frequently, 
anginal pain and discomfort are maximal in the epigastrium or over an even 
wider upper abdominal area. 

As the author has pointed out frequently of late years, significant miniature 
replicas of angina pectoris may occur, and the cardiovascular pain-complexes 
of vital importance are often mere fragments or, at best, imperfect mosaics of 
the classical picture. 

Many or, indeed, most of the cases of luetic, rheumatic, variolar, scarlatinal, 
influenzal or gonococcal aortitis, may wholly lack severe pain, and he 



Overstretch- 
ing, spasm, 
and overload. 



An exploded 
fallacy. 



Coronary 
insufficiency. 



Extracardial 
pain. 



Pain 
alternatives. 



Angina pectoris 
miniatures. 



Pain often 
absent. 



756 



MEDICAL DIAGNOSIS 



who waits for it to appear in its typical form will accomplish little for his 



s. 



One must recall also the fact that aortic pain of severity may or may not 
radiate from mid-sternum, or mid-sternum and epigastrium, to the left arm, 
shoulder, wrist or fingers, to the neck or the roots of the lower molars. It 
may be both left- and right-sided, or, rarely, affect the right side alone, in- 
volving in its cephalic radiation the same (brachial plexus) distribution 
wholly or partially in each instance. 

Dyspnea. — No ailment presents more striking and dramatic dyspneic 
pictures than may aortitis in its advanced stages, but in none should one 
seek more carefully for the earlier and far more important, lesser or masked 
manifestations. 

Its most extreme forms are, (a) cardiac or aneurysmal asthma, often 
absolutely indistinguishable from bronchial asthma, unless suggestive asso- 
ciated- or interval-pain and characteristic physical signs are present; (b) 
laryngeal spasm, a most distressing symptom usually due to pressure upon 
the recurrent laryngeal nerve, and; (c) an abruptly enforced orthopneic 
dyspnea which instantly and imperatively brings the recumbent patient to 
a sitting or even standing posture, and, in the author's experience, is asso- 
ciated usually with a conviction of impending dissolution, suggesting its 
relation to angina pectoris. 

As stated repeatedly in this volume, instant death may result from a 
natural but mistaken effort on the part of the attendant to enforce the recum- 
bent or semirecumbent posture in such instances. 

Another interesting variant of obligatory orthopnea is that which forces 
the patient to lean far forward day and night. 

None of the preceding or following forms of dyspnea or pain are peculiar 
to luetic aortitis. They may be encountered frequently in, other forms of cardio- 
vascular disease, in mediastinal tumors of almost any sort, and especially in 
progressive enlargement of the mediastinal glands in Hodgkin's disease. 

Of far more value in relation to early diagnosis are the minor dyspneic 
variants when persistent or frequently recurring. 

A mong these are: (a) Slight exertion dyspnea, (b) Inability to walk against 
a wind or in cold air without inducing breathlessness or precordial oppression, 
(c) Excessive sensitiveness to a close atmosphere, (d) Frequent sighing, (e) 
A mere subjective sense of deficient lung ventilation. (/) Inability to hold the 
breath on command or at will. 

Such symptoms may precede by months or years the more serious mani- 
festations of arterial or myocardial insufficiency. 

Narrowing the Cardiovascular Field of Response. — With respect to both 
physical and mental exertion, one may perceive as one of the earliest symptoms 
of this as of other cardiovascular lesions a narrowing of the field of effortless, 
fatigueless response. So marked may this be and so striking the nervous symp- 
toms as to lead physicians in many instances to diagnose and treat the condition 
as a "neurasthenia," that bastard euphemism for "don't know" 

Physical Signs. — With respect to the physical signs little need or can be 



CARDIOVASCULAR SYPHILIS 



57 



said without entering into a useless repetition of the descriptions of aortic 
regurgitation, aneurysm, aneurysmal dilatation, or, angina pectoris. 

Roentgenoscopy and roentgenography afford important information. 
Both the screen and plate should be used, with sagittal and oblique exposures, 
and, in the absence of either actual aneurysm or diffuse dilatation, the quality 
and outline of the aortic shadow itself and any increased range of pulsatory 
excursion should be carefully noted. 



Extreme value 
of the X-ray. 




Percussion. — This is of slight value relatively but one should always test 
the note over the manubrium, third right interspace and third rib and the 
second right interspace for the dulness "en casque" of Potain, and inspect 
and palpate carefully for expansile pulsation. 

Auscultation. — The character of the second sound as heard over the 
third left interspace may be of the utmost value before any considerable 



Dulness 
en casque. 



The split 
" second." 



758 



MEDICAL DIAGNOSIS 



degree of aortic leakage is established. It may be blurred and murmur- 
ish, or remarkably and suggestively clear and intense, and one of the most 
important variants in the author's experience has been the split second sound, 
often heard over the third left interspace near the edge of the sternum, or 




Fig. 412 — .One type of luetic diffuse dilatation of the aortic arch (2d and 3d 
portion). Strong resemblance to actual aneurysm as in Fig. 409. Correct diagnosis 
1 shown in Fig. 412 in which the oblique method was employed. First exposures several 
months before showed no arterial change though the same enlargement of the heart existed 
together with the "fatty tail" at the left cardiodiaphragmatic angle, indicating fatty 
overgrowth. Patient highly "neurasthenic" at this time and showing some subjective 
signs of limitation of myocardial reserve. See Fig. 411. 

over its corresponding left half at the same level, as described by him several 
years ago. This may be present persistently or intermittently long before 
the true murmur appears and may later alternate with the short imperfect 
diastolic bruit even during a single clinical seance. 



CARDIOVASCULAR SYPHILIS 



An important 
sign. 



Much importance is to be ascribed to a "clanging* 1 second tone, for al- 
though it can hardly be regarded as in any sense pathognomonic, or as of 
great importance differentially, certainly it suggests when present aortic dila- 
tation or abnormal dilatability, a very important link in the chain. 

The same may be said of palpation of the lengthened aorta in the supra- 
sternal notch when this is accessible. 

Obviously (he fundamental suggestive factors are: 

(a) Aortic aneurysm involving the first portion, or the transverse portion 
of the arch. 

(b) Din use dilatation in the same areas. 

(c) Aortic regurgitation first becoming manifest in individuals above the 
age of 30 or even 25, and in some degree all aortic regurgitations not directly 
attributable to other known causative illnesses. 

(d) Symptoms suggestively mediastinal in origin. 

(e) Angina and dyspnea, major or minor, frank or masked. 
(/) Subjective manifestations of impaired reserve. 
{g) A positive Wassermann or luetin test or frank evidences of syphilitic 

infection. 

(h) A favorable response to proper antiluetic medication. 

It should be borne in mind that demonstrable peripheral arteriosclerosis 
present or absent is of no importance in relation to diagnosis. 

A man may drop dead from luetic mesaortitis when every accessible artery 
is as soft as a baby's. 

Premature Assumptions. — A few words of caution may not be mis- 
placed with reference to the diagnosis of a condition of most extreme inter- 
est and importance. It must be remembered that exceptions exist to every 
rule and that before one jumps to the conclusion that he is dealing with 
cardiovascular syphilis he must first of all be sure that the patient reacts 
positively to the Wassermann or luetin tests, or to conservative therapeutic 
procedure, and that the former tests have been made by men thoroughly 
competent to perform and to interpret them. 

Many " Wassermann Tests" Valueless. — In the case of the Wassermann 
test it cannot be stated too frequently and emphatically that no one save an expert 
serologist can be trusted to do accurate work and that a vast number of reports, 
now made the basis of opinion and action of the utmost importance to the in- 
dividual affected, are not worth the paper they are written upon. 

A negative Wassermann test must not be permitted to override positive 
data of importance nor should any single negative test be accepted under 
such conditions. It must be remembered also that the mere fact that a 
Wassermann co-exists with angina pectoris, or aortic leakage does not ab- 
solutely prove that the lesion is luetic, though the chance of misinterpretation 
is trivial in such an instance. 

It should also be stated that experience has proven that Ehrlich erred a. fallacy 
in sounding a warning against the active treatment of luetic vascular lesions. 
They should not only be treated but any measures should be instituted as 
early as possible and repeated as may be necessary. According to the 



Value of timely 
treatment. 



760 



MEDICAL DIAGNOSIS 



Great increase 
of knowledge. 



Seatofelection. 



Aortic 
localization. 



Aneurysm and 
"heart pang." 



Silent cases. 



Reform 
imperative. 



Damaging 
errors. 



opinion of the author, mercury and to a less degree the iodides are likely to 
prove quite as valuable and possibly more so than salvarsan, the effects of 
which seem to be somewhat fleeting on the one hand, or, on the other hand, 
excessive, if the drug is used in full doses rather than by the fractional method. 

SUMMARY 

1. The discovery of Treponema pallidum, perfected methods of demonstrating 
it in body tissues, the development of the W assermann and luetin tests, and 
carefid and extended studies based upon these, have resulted in an exact knowledge 
of the wide dissemination of syphilis and its enormous importance as a factor 
in the causation of diseases of extraordinary diversity. 

2. We now know that the term "cerebrospinal syphilis'* embraces a large 
number of diseases in which its presence was formerly only assumed or wholly 
unsuspected. 

3. It now appears that to an extraordinary degree, the mortality of the disease 
depends upon its vascular ravages which are proven fundamental in many ail- 
ments of strikingly diverse complexion. 

4. It may assume any one of the various forms of sclerosis, endarteritis or 
myocardial degeneration, but presents, in most instances, in the earlier stages of 
the latter, certain characteristic lines of attack and modes of histologic expression. 

5. The most characteristic of these is the productive mesaortitis of Francis 
H. Welch, extraordinarily prevalent, almost constant microscopically in a 
more or less developed form at autopsy in every case of death from proven syphilis, 
and the actual cause of death in 50 per cent, or more of such cases. 

6. This disease shows a peculiar affinity for the first portion and arch of the 
aorta and tends to assume at the root of that artery a characteristic line of march 
which in 80 per cent, of the cases results in the establishment of secondary aortic 
regurgitation of a peculiarly progressive and intractable type, once it reaches 
the stage of frank myocardial insufficiency. 

7. In 20 per cent, of such cases of the advanced type, true aneurysm or 
frank angina pectoris major, occur in about equal proportion. 

8. The leading symptoms, aside from those of aneurysm and actual angina 
pectoris, consist of pain, dyspnea, diffuse dilatation of the aorta, and progressive 
crippling impairment of vascular reserve. 

9. Many of the cases are wholly silent and the symptom complex may be 
blended, incomplete, or so misleading, as to be most readily misinterpreted. 

10. Only through recourse to more rational methods of early diagnosis, 
dependent upon the proper recognition and weighing of minor symptoms, sub- 
jective and objective, may these cases be detected early enough to render specific 
treatment properly effective. 

11. The utmost importance attaches to the W assermann test, but only when 
it is in the hands of an expert serologist. 

12. The improper use of this test and the false reliance placed upon it must 
vitiate many reports, and result in errors of omission and commission, damaging 
to the physician and a source of humiliation and injustice to the patient. 



ARTERIOSCLEROSIS 



761 



13. Finally. — A consideration of this topic emphasizes not only the im- 
portance of the individual cardiovascular luetic lesions, but also the terrible 
potency of syphilis as a cause of death at a period remote from the primary in- 
fection and through channels which so conceal its identity as to obscure the fact 
that it may yet come to be called the "Captain of the Men of Death ." 

ARTERIOSCLEROSIS 

ATHEROSCLEROSIS.— Definition.— A chronic, inflammatory degener- 
ative disease of the arteries, either generalized or more or less localized, slowly 
but inexorably progressive, and tending to regional predominance. 

77 assumes one of three forms, viz.: nodose arteriosclerotic, a senile type, or 
a more or less distinct luetic variety. 

In all cases the dominant change in the arteries is a fibrosis and the clinical 
results are diminished elasticity, palpable thickening, a tendency to diminution 
of caliber and lessened vascular reserve. 

Etiology. — Sclerosis of the arteries suggests an overdone effort on the part 
of nature to forestall or repair the damaging effects of chronic toxemia, such 
as that induced by renal disease, lead, gout, infections of various sorts and 
especially syphilis, and cryptogenetic local sepsis, together with auto-intoxi- 
cation, chronic alcoholism, emotional strains and excessive overwork (bodily 
or mental) carried on under unfavorable conditions. 

The summation of minor, more or less transient, periods of toxemia with 
or without associated arterial hypertension, or persistent hypertension what- 
ever the cause, are doubtless the chief factors in causation.* 

In aortic regurgitation, whether syphilitic or rheumatic in origin, the 
enormous, persisting, rhythmic variations in arterial tension must be at 
least a factor in the promotion of complicating aortic changes. 

Heredity. — It cannot be doubted that heredity plays a large part in the 
occurrence and age incidence of many cases. The individual is as old as his 
arteries and the arteries of the ancestors determine to a large degree the 
longevity of their descendants. 

Physical Work. — The part played by hard physical labor alone has doubt- 
less been overestimated in the past, though when combined with other untoward 
conditions it is doubtless of importance.^ 

Interstitial Nephritis. — This kidney lesion is invariably associated with 
a more or less generalized sclerotic change, even to arterio- capillary fibrosis, 
and in these cases the sustained excessive vasoconstriction and, to a small 
degree, the sclerotic change in the vessel itself, combine to produce very high 
sphygmomanometric readings. In fact, nearly all cases showing a systolic 

* It is a well-known fact that variations in blood pressure normally attend hard physical 
labor, just as it is certain that this involves a multitude of radical and suddenly induced 
changes of rate and force, but if the machine is sound, fuel and lubrication alike perfect, 
the machine runs on without damage even though the blood pressure varies from time 
to time from a systolic level of 125 mm. Hg. to 170 or even more. 

t In occupations involving the daily exposure of the hands or arms, legs or feet, to vio- 
lent changes of temperature, one may see decided localization of atherosclerotic or produc- 
tive (obliterative) endarteritis in the portions of the body so exposed. 



Lethal 
potency. 



Weakness in 
strength. 



762 



MEDICAL DIAGNOSIS 



Arterio- 
sclerotic 
kidney. 



A deadly com- 
bination. 



Degree and 
distribution 
variable. 



Aging- 



Precocious 
types. 



Vermicular 
pulsation. 



blood pressure persistently above 160 and a low " pulse pressure" yield other 
clinical evidence of morbid change in the kidney. 

Conversely, a type of kidney (the arteriosclerotic kidney) is encountered 
as an apparent result or concomitant of primary arterio-capillary fibrosis.* 

It is evident that serious arterial degeneration may exist within, without 
visible or palpable outward signs, yet fortunately, in most instances, some of 
the accessible arteries of the body reveal significant changes. 

An exact separation of the senile arteriosclerotic kidney from that of chronic 
diffuse arteriolar {interstitial) nephritis is sometimes impossible though it is 
probably true that the high blood pressures characterizing the more advanced 
stages of the latter are not reached in the former. 

Vicious Complication. — The combination of arteriosclerosis and hyperten- 
sive renal disease constitutes a most damaging combination inasmuch as it 
presents chronic toxemia and excessively high blood pressure coincident with 
rigid arteries, a toxic state of the myocardium and increased demand upon the 
heart. 

Distribution of Lesions. — One seldom finds either a universal arterio- 
sclerosis of uniform grade, or a regional sclerosis, without general changes of 
some degree. Both the degree and distribution of the pathologic processes 
are often strikingly irregular and in many instances affect chiefly those por- 
tions of the body which are most directly concerned in overwork in connec- 
tion with chronic toxemia. In the brain worker the cerebral arteries may 
suffer most; in the day laborer predominant involvement of arteries of the upper 
extremities is common. Little that is positive can be known of the actual 
distribution ante-mortem. 

Physical Signs. — Inspection. — A more or less characteristic outward 
change in individuals with arteriosclerosis is that known as "aging" and this 
is peculiarly striking in certain cases of the "precocious" type in which one 
sees slight or marked senile changes in the skin and in the general appearance 
of the juvenile or relatively young patient. 

The most striking evidence, however, usually, is the appearance of readily 
palpable superficial arteries in the forearm, at the wrist, or in the region of 
the temporals. Outward evidence of this kind may be reenforced in cases 
of an advanced type with arterial rigidity, by a peculiar tortuosity of these 
vessels and in the brachial or especially at, or just above, the bend of the elbow 
a peculiarly vermicular lengthening and shortening of the arterial curve may 
be apparent. This may be so marked as to simulate the jerky throb of 



* The development of a chronic Bright's creates a condition of impaired renal permeabil- 
ity and more or less constant or persistently recurrent, minor toxemia such as would tend 
to promote or even cause an arteriosclerosis, and its co-existence leads certainly to progress- 
ively increasing tonic vaso-constriction of damaging degree. 

We are still in the dark as to the actual time relationship between the onset of intersti- 
tial nephritis, or even the arteriosclerotic kidney and that of a generalized arteriosclerosis. 

A growing appreciation of the importance of the cryptogenetic foci of chronic, chronic- 
ally remittent, or intermittent, streptococcic infection seems likely to place under this head 
many chronic degenerative conditions now lacking any specific etiology and the three 
conditions may sometimes be proven to have a common chief cause. 



ARTERIOSCLEROSIS 



763 



aortic regurgitation with which lesion it is associated in many instances 
so that either simulation or actual concurrence are common events. Mere 
prominence of the temporal arteries does not prove a sclerosis and is very 
common. 

In extreme cases the veins of the forearm or back of the hand may show a 
sclerosis on palpation (phlebosclerosis). 

Retinal Arteries. — To the skilled observer his ophthalmoscope often reveals 
arteriosclerotic changes in the vessels of the retina at a comparatively early 
stage (see "Ophthalmoscopy"), but otherwise our eyes cannot be trusted 
in the diagnosis of this condition, even when external, and we must resort 
to palpation.* 

Palpation. — An artery which, when the pulse is obliterated by proximal 
compression by one finger, can be rolled under the finger or distinctly out- 
lined as either a rigid or a soft tube, is the seat of sclerotic changes and if 
plaques are formed the sensation of trachea-like inequalities imparted is 
extremely characteristic (windpipe arteries). 

One should not be content to examine the radial s but should carry the 
investigation to other accessible arteries and if any complaint of rheumatic 
or "gouty" pain or lameness is made by the patient one should carefully 
palpate both the dorsal pedis and posterior tibial arteries for any deficiencies 
of pulsation such as may be associated with intermittent limping ("intermit- 
tierende Hinken") or may suggest the possibility of oncoming senile gangrene. 

These circulatory evidences of what may prove to be a dangerously ad- 
vanced, but otherwise concealed peripheral, obliterative endarteritis have been 
relatively frequent occurrences in the author's practice. f 

Auscultation. — The aortic second sound is usually accentuated and may 
be markedly so if, as so often happens, the aorta itself is diseased. In such 
cases one often encounters in addition a systolic murmur transmitted into 
the vessels of the neck, precisely as is the case in aortic stenosis, and often- 
times to be differentiated positively from that lesion only by the presence of 
a well-defined and accentuated second sound in the aortic area. 

The author has found the maximum of the murmur and of the accen- 
tuated second sounds alike, in such cases, is usually not at the second right 
intercostal space but one space higher on the same side. It must be remembered 
that after the fourth decade sclerotic changes in the aorta or aortic valves 
are progressively common and that the aorta is one of the selective sites of 
early luetic invasion and belated clinical expression. (See "Cardiovascular 
Syphilis.") 

Mesenteric Arteriosclerosis. — This interesting condition, said to be most 

* The traditional, specific association of general arteriosclerosis with the " arcus senilis," 
so often seen as a whitish ring more or less completely encircling the cornea at the corneo 
scleral junction, is a medical myth. 

t In a number of instances a cardiovascular breakdown and death have followed the 
usual resort to "Spas" for the relief of what was supposed to be rheumatism, or, in a few 
instances, chronic sciatica. 

In all of these the deficiencies of the pulse in the foot or ankle were readily recognizable, 
and a history of long sustained subjective symptoms of impaired reserve was seldom lacking. 



Phlebo- 
sclerosis. 



"Goose-craw 
arteriea." 



Intermittent 
claudication. 



Accentuated 
aortic 2d. 



Area of 

maximal 

accentuation. 



Lues. 



764 



MEDICAL DIAGNOSIS 



frequently associated with interstitial nephritis and high blood pressure, is 
rare and can seldom be positively diagnosed, unless we assume its presence 
in all such cases showing very high systolic sphygmomanometric readings and 
a low "pulse pressure," or so translate attacks of severe abdominal pain or dis- 
comfort of a paroxysmal nature, often peculiarly relieved by the sitting or 
erect posture and increased in recumbency. It is asserted, wrongly, that 
excessive systolic and diastolic readings and low pulse pressure do not occur 
in arteriosclerotic cases until the splanchnics are involved. 

In some cases associated with terminal interstitial nephritis or disease 
of the aortic valves this distress is so marked either precordially or abdom- 
inally as to lead the patient to disobey the most stringent orders as to abso- 
lute physical rest and to even leap from the bed to the floor or, at the least, 
abruptly assume a sitting posture in bed. 

In such crises as in the ordinary major angina pectoris, the sphygmoman- 
ometer may reveal a sharp rise in blood pressure. 

The author is convinced that in most of these, the crisis should be regarded 
as an epigastric or abdominal maximal expression of an angina pectoris. 
Cases of coincident or alternating paroxysmal thoracic and abdominal pain 
are common in major attacks and the tendency of decompensated hearts to 
refer their pain to the upper abdomen is well proven. 

A s stated previously, in such instances it is extremely unwise to attempt to 
force a patient back into the recumbent position as sudden cardiac death has re- 
sulted in many instances from such mistaken discipline. 

Caution. — Crises of spastic vasoconstriction, whether of abdominal or 
precordial localization are characterized chiefly by increased distress in 
recumbency, intense pain, tympanites and an abrupt and excessive increase 
of any preexisting arterial hypertension.* 

Both may be initiated by indiscretions in diet and consequent flatulent 
overdistention by physical fatigue, anger, fear, joy, or other emotional dis- 
turbances. 

In true abdominal crises, it is probable that a spastic contraction of the 
vessels results in ischemia and spastic intestinal colic. This ischemia is 
initiated, no doubt, in many instances, by mere excessive flatulent distention 
which greatly diminishes mesenteric blood-flow in normal vessels. 

Mesenteric arteriosclerosis is rarer, however, than was formerly supposed 
and the frequency of true spastic crises of the abdominal type probably has 
been overestimated greatly. 

Too ready an acceptance of paroxysmal spastic vasoconstriction of the mesen- 
teric arteries involves the danger of serious or fatal neglect of far commoner, more 
important, and oftentimes lethal lesions of the abdominal viscera and of the 
heart and its intrinsic arteries. 

Limited Auscultatory Field. — It will be understood that auscultatory signs 
in arteriosclerosis are practically limited to those cases in which there is aeon- 
junction of high pressure and sclerotic changes in the aorta or its valves. 

* The author has measured an increase to 300 mm. Hg. in a case showing just be- 
fore the attack 190. The usual rise is 50 mm. plus. 



fnsufficiency. 
Senile decav. 



ARTERIOSCLER' SIS 765 

In the latter case there is often an obtrusively visible and palpable pulsa- 
tion in the jugular fossa most evident during the act of swallowing which may jugular fossa 
falsely suggest aneurysm and this erroneous influence may be further strength- 
ened by the existence of a fairly well-defined pulsation in the second right 
intercostal space. The X-ray picture in such instances is likely to show a x-ray. 
marked lengthening of aortic curves and a low position of the heart closely 
simulating the condition present in an aneurysm of the arch. 

It constitutes nevertheless one of the indications of diffuse dilatation of 
the aortic arch. See ' "Cardiovascular Syphilis.' 3 

Another misleading feature with respect to the same lesion is the occasional 
occurrence of decided inequality and lack of synchronism in the carotid and sub- 
clavian pulse, this indicating, usually, a decided aneurysmal involvement of 
the transverse portion of the aortic arch but occurring also in its absence in many 
instances. In such cases both the carotid and subclavian^ are likely to be 
palpably sclerotic and to show exaggerated length and abnormal curves.* 

General Symptoms of Arteriosclerosis. — These, or*: extremdy ::riable. 
oftentimes indefinite, but in general they are those of a snail-like progression 0; 
circulatory insufficiency together with a progressive narrowing of vascular fields vascular 
and of arterial and cardiac response. 

We are all familiar with the senile type which results from an obliterative 
cerebral endarteritis with the impaired, chronologically reversed, memory 
and clouded intellection, diminished reasoning power with increased tenacity 
of opinion and intolerance of opposition, pronounced mental confusion, and 
even incoherence, slovenliness and degenerate ac:s. 

Early Cerebral Symptoms. — Still earlier symptoms,, also of the cerebral 
type, are irritability, headache, vertigo, and readily induced fatigue. Day 
drowsiness and disturbed sleep are also prominent features in some instances 
and the early waking in old people is more or less characteristic of all cases in 
which the cerebral vessels are involved, but by no means limited to this form of 
circulatory deficiency. 

Tliese "early" symptoms as a whole are common to all types of cardiovascular 
decompensation though less constant in appearance and type in forms other t'r. 
the arteriosclerotic. 

Gastrointestinal Symptoms. — Disturbances of the gastrointestinal tract 
are common such as loss of appetite, capricious appetite, inordinate appetite. Djsre—c 
or indiscriminate gorging, flatulence and general dyspeptic manifestations, 
often of a misleading sort and very frequently to be referred to the heart 
rather than to the sclerosis itself or to the stomach. 

In cases of marked splanchnic involvement usually associated with renal 
changes one may encounter the painful seizures already described and these splanchnic 
may be associated with a decided and dangerous tendency to meteorism and 
even, possibly, to acute dilatation of the stomach, t 

* Slight inequalities are encountered very commonly in instrumental pulse records. 

f As common diagnoses of the cause of sudden death "acute indigestion" and 
"acute dilatation" are merely the euphemisms of "don't know." In nearly every instance, 
undoubtedly, previously unsuspected cardiovascular disease is the actual cause of death. 



766 



MEDICAL DIAGNOSIS 



Demands upon 
right heart. 



Arterial 
changes. 



Curious Cerebral Seizures. — Curious transient attacks of unconscious- 
ness, monoplegia, pseudo-cerebral epileptic seizures and temporary disturb- 
ances of speech may occur suggesting localized vasoconstrictor spasm and 
ischemia, these oftentimes being associated, according to the experience of 
the author, with temporary but decided cardiac weakness and, not infre- 
quently, a transient pulmonary congestion or edema. 

Vertigo may be an exceedingly troublesome and intractable symptom and 
deafness is often marked and slowly progressive. 

Pulmonary Block. — Whatever tends to impair free respiration retards the 
pulmonary circulation and many pulmonary ailments actually reduce the capil- 
lary area or block both venous and arterial flow. 

Thoracic Ailments Commonly Associated with Arteriosclerosis. — There- 
fore, we expect to find a tendency to ultimate hypertrophy and dilatation of 
the right heart in such extreme chronic pulmonary or thoracic affections as 
emphysema, acute and chronic asthma, extensive chest deformity, as in 
kyphosis, chronic pleurisy, extensive adhesions, fibroid phthisis, or severe 
chronic bronchitis and a considerable number of old chronic phthisical cases 
of the ordinary type will show decided arteriosclerosis and cardiac changes. 
I So also sclerosis of the pulmonary artery itself or of the coronary arteries (the 
right, chiefly) may be present in many such conditions as are noted above 
and all grades of right-heart cardiac insufficiency ultimately may appear. 

Disturbing Factors.— Several factors interfere with accurate diagnostic 
results in this connection. 
■ i. The voluminous lungs of asthma and emphysema. 

2. The fact that right heart hypertrophy and dilatation may be so great as to 
simulate combined left and right heart change, the apex-beat formed by the right 
heart being sometimes carried beyond the nipple line. (See Heart Section.) 

3. The various changes in the position of the heart itself due to adhesions, con- 
traded lung, mediastinal pleural or pulmonary growths, unilateral effusion and 
the like. (See Lung Section.) 

4. The deformity and displacements due to kyphoscoliosis. 

Dyspnea, cyanosis, enlarged liver, renal stasis and edema of_ the lower 
extremities, are the striking symptoms in serious incompensation. 

Attacks of cardiac asthma are not uncommon, pulmonary edema is 
frequently a terminal event and pulmonary infarct a common complication. 

Kypho scoliotic victims, who escape death from the local disease of the spine, 
die of right heart weakness in middle age or of acute pulmonary affections of 
which it constitutes a serious complication in at least 80 per cent, of the cases. 

Rationale. — It shotdd be remembered that by no means all of the individuals 
carrying arteriosclerotic changes give evidence of them or suffer serious impair- 
ment of health by reason of their presence. 

In many instances the changes are so slight or their localization so fortunate 
as to produce no effect upon the- health such as is clinically appreciable. 

It is also true that arterial hypertension is often absent, seldom or perhaps 
never, extreme, by reason of the arteriosclerosis itself and that such rise as does 
persist is due chiefly to peripheral and not splanchnic sclerosis (as formerly 



ARTERIOSCLEROSIS 767 

believed), although these vessels may be the seat of extreme and damaging tonic 
or labile vasoconstriction. A decided, persistent, but seldom excessive pressure 
ultimately appears in about two-thirds of the cases of demonstrable arteriosclero- 
sis, and to increase of blood pressure, rigidity of the vessels and diminution of 
their caliber, there may be added an increased irritability, leading to excessive 
tonic vasoconstriction in the persistent presence of toxins. This is best illus- 
trated in complicating chronic nephritis, or, visibly in cases of recurrent spasm 
in the legs (or occasionally the arms) in cases of intermittent claudication (inter- 
mitt ierende Hinkcn)* 

Lesser Hearts. — The arteries are lesser and subsidiary hearts which in 
their normal condition are capable of regulating and to a certain extent, of 
diverting, blood flow, according to the passing needs of the human organism.! 

Storage Power Plant. — The aorta by its elasticity converts what other- 
wise would be an intermittent stream into a continuous current through the 
elasticity of its walls which take up the primary excess of pressure represented 
by the systolic ventricular drive and so store and gradually release the energy 
represented by the individual systoles of the ventricle as to maintain a suffi- 
ciently uniform pulse pressure and that steady slow flow through the capil- 
lary deltas, necessary to the vital chemical exchanges of body metabolism. 

Exactly as in the case of the heart, we find in an artery a certain amount of 
reserve force, indispensable to the proper maintenance of circulation. 

Sclerosis of the arterial wall diminishes the storage capacity or, reserve, of 
the aorta, and the excessive initial amount of the power transmitted through 
the ventricular systolic drive unduly accelerates the flow. The lack of stored 
power permits the pressure and the stream to slow with undue rapidity and 
thus the diminished elasticity tends to establish an abnormal variation be- 
tween pressure and rate of flow in systole and diastole, i.e., to increase the 
so-called "pulse pressure,'' and convert a relatively stabile and sustained 
continuous current into an intermittent or remittent flow. 

In advanced arteriosclerosis, a marked or extreme disturbance of the 
marvelous automatic adaptive and compensatory action of the vasomotor 
mechanism and an inability to correct and balance localized or general 
inadequacy of blood supply, lead to a narrowed and depressed functional 
activity, to actual atrophy, or to necrosis (obliterative endarteritis) in 
local areas. 

How greatly this need may be felt in the arteries of the great splanchic 
area (the "regulatory reservoir" of the circulatory system) and how vast an 
increase of peripheral resistance results from sustained excessive vaso- 
constriction of their own is evident. 

Increased resistance means increased ventricular drive. This must be 
steadily maintained and emergency demands upon reserve must be gradually 
increased by reason of the breakdown in the regulatory vasomotor mechanism 

* In "Raynaud's disease" the vessels are normal through the seat of spasm, 
f "The heart gives to the blood stream its motion; the blood vessels, its apportionment." 
(Jacob Henle). 

"The arteries are true hearts under a different form," (Senac). 



Arterial 
reserve. 



768 



MEDICAL DIAGNOSIS 



Angina 
pectoris. 



Important 
selective fooi. 



Obstructed 
flow. 



Varying 
grades. 



Myomalacia 
cordis. 



Cardiac 
aneurysms. 



Parenchyn* 
tons degen- 
eration. 



Long latent 
and silent. 



and usually the added peripheral resistance due to the excessive variations in 
an already excessive blood pressure which accompany increased physical effort. 
In the meantime the nutrition of the heart itself must suffer, perhaps 
only through the general depression of metabolism, but oftentimes because 
of the participation of its intrinsic arteries in the arteriosclerotic circulatory 
debacle. Responsive obligatory hypertrophy, increased work under unfa- 
vorable conditions, increased degeneration of the heart muscle and of the 
larger vessels, progressive increase of the element of dilatation and dimin- 
ished myocardial reserve would roughly express the factors leading to the 
circulatory breakdown. This is often anticipated by death from intercurrent 
infection, apoplexy, or uremia, if the kidneys are involved, as is usually the 
case when excessive arterial hypertension is evident. 

PAROXYSMAL SPASTICITY OF THE CORONARY ARTERIES AND 

ANGINA PECTORIS 

With or Without Coronary Arteriosclerosis 

CLAUDICATION OF THE HEART.— Etiology.— The etiology of coro- 
nary sclerosis is of course identical wdth that of the arteriosclerosis of which 
it is a part, but merits a special description because of its frequent association 
with major and minor angina pectoris and the far rarer cardiac aneurysms. 

The left heart vessels are chiefly affected save in emphysema and extreme 
kyphoscoliosis in which involvement of the right usually predominates. 

Morbid Anatomy. — A peculiarly frequent feature of this condition is the 
arteriosclerotic involvement of the aorta itself at the point where the coronary 
arteries are given off and the tendency of those vessels to show sclerotic 
changes at this point and at their branchings. This results in a diminished 
intrinsic blood supply and a poorly maintained and illy-regulated arterial 
pressure for the myocardium. 

The changes themselves are of the most varied description both as to their 
form and the degree to which their caliber is diminished in different areas. 

The associated myocardial degeneration usually takes the form of a domi- 
nant cardiosclerosis more or less diffused and there is a decided tendency to 
obliteration of the lesser branches and replacement of muscle fibers by scar 
tissue. This may result, to a greater or less degree, in the condition known 
as myomalacia cordis and lead even to cardiac aneurysm. 

In the presence of chronic recurrent infection there may also be changes 
due to a chronic myocarditis of the parenchymatous type. A true endarteri- 
tis is uncommon and if present is usually syphilitic. 

Symptoms. — For long periods no symptoms may arise and suclras first 
appear are manifested usually only under excitement or such exertion as 
makes abrupt demands for increased coronary flow. Inasmuch as the 
myocardial blood supply progressively diminishes and the irregularity of 
its distribution slowly becomes more marked, the arteries become concur- 
rently more irritable, and less responsive to the heart's demand, and the field 
of unconscious, effortless and painless cardiac response is greatly diminished. 



ANGINA PECTORIS 



769 



Even in this Stage the general symptoms usually are merely those of minor 
myocardial insufficiency, as a rule unattended by marked dilatation or by any 
murmurs save those of associated disease of the aortic or mitral valve or the 
relatively common "pseudo-aortic-stenosis" murmur due to sclerosis of the arch 
and associated with a markedly accentuated second aortic tone most intense in 
the first or second rigid interspace. 

The cardiac area may be much enlarged later and, in the terminal periods, 
show a marked dilatation both right and left and a peculiar outline somewhat 
resembling radiographically that of the percussion area of a pericardial 
effusion, evidently because of an extreme lack of general myocardial 
tonus ( u the heart of txtreme general insufficiency"). 

The Pulse. — The pulse will vary greatly according to the stage of the 
disease and the nature of any associated lesions, but in pure coronary sclerosis 
of marked degree it tends rather to be weak than strong and is usually, but 
by no means invariably, arrhythmic. 

As the disease advances any preexisting arrhythmia tends to become con- 
firmed and, with the progressive destruction of muscle fiber, a well-defined 
bradycardia sometimes supervenes which not infrequently corresponds to a 
period of immunity from any preexisting angina or paroxysmal cardiac 
asthma and to the onset of typical and decided heart block. 

If the block be complete and the pulse drop into the thirties such patients 
may show the complete clinical picture of the Adams-Stokes syndrome (see 
" Heart Block"). The lesser degrees of block (increased "a-c" interval, etc.) 
are naturally somewhat common in this ailment. 

Inconstancy of Pain. — Many cases of well-marked sclerosis of the cor- 
onary arteries exist for years and terminate in death without any such severe 
manifestations of pain as cause serious complaint on the part of the patient. 
On the other hand, in many instances, typical angina pectoris major occurs 
in connection with valvular disease, fatty degeneration and cardiosclerosis 
in which no material sclerosis of the coronary arteries is demonstrable at 
autopsy. 

Nevertheless decided coronary sclerosis is commonly associated with at- 
tacks of precordial pain of a peculiarly atrocious and alarming character. 

Angina Pectoris.— Major Seizures. — An attack of major angina pectoris 
is most dramatic and terrifying both to the patient and the onlooker. 

Often without warning and, frequently, in the early morning hours 
between midnight and four o'clock, the patient is awakened suddenly, feels 
as if his heart were held in a vise and is overwhelmed by an inward conviction 
of impending death. He finds himself in an obligatory sitting posture which 
rigidly he must maintain. His terror-striken face is pallid, gray, and covered 
with cold perspiration; his breathing is shallow, but his pulse, though often- 
times feeble and sometimes momentarily lost at the radial, may be normal, 
markedly accelerated or distinctly slow, and arterial tension is in most in- 
stances decidedly or extremely high, shortly following the onset and through- 
out the attack. He may have originally clutched at the precordium and if so 
usually maintains that position supporting himself by the opposite hand, but 
49 



Arrhythmia 
common. 



Bradycardia 
and heart 
block. 
Luetic type. 



Sclerosis sine 
angina. 



Angina without 

marked 

sclerosis. 



Time and 
abruptness 
onset. 

Fear of death. 



Facies. 



Pulse and 

tension 

variable. 

Obligatory 
posture. 



77° 



MEDICAL DIAGNOSIS 



Immobility. 



Duration. 



his whole attitude is one of intense suffering, extreme apprehension and rigid 
immobility. 

These attacks may at first last but a few moments and be very mild but tend 




Fig- 4t$. Fig. 414. 

Figs. 413 and 414. — Relatively common area of pain and residual tenderness in extreme 
angina pectoris, especially in those with extremely high blood pressure. In one such case 
observed by the author the slightest touch applied to the skin overlying the sternum brought 
on a spasm of cough. (After Henry Head.) 




Fig. 415. 



Fig. 416. 



Figs. 415 and 416. — Another relatively common area of pain and residual hyperesthesia in 
angina pectoris major. (After Henry Head.) 

to increase in frequency and in some instances would last for hours without 
medical aid.* 

Exciting Causes of Anginal Seizures. — These attacks may and often do occur 
at irregular periods during the day, being precipitated by such causes as emotional 

* All such patients learn to have near at hand some means of ready relief or 
amelioration. 



ANGINA PECTORIS 



771 



excitement, cold air, facing a heavy wind, physical overstrain, a distended 
stomach or intestine, straining at stool or sexual intercourse. 

Distribution and Degree of Pain. — Three features in connection with 
angina pectoris should be especially emphasized, viz.: 

1 . The pain of angina pectoris major and minor may be, and often is, maxi- 
mal at points remote from the heart. 

2. Not infrequently more or less complete replicas of the major 
seizure have been observed by the author in cases of myocardial degenera- 
tion with or without coronary sclerosis or valvulitis and seem to be associated 
with the lesser degrees of ailatation and lack of muscle tonus and effective 
contractility. 

3. Any or all anginal pains may be accompanied by most misleading areas 
of coincident and residual hyperesthesia. 

Common Distribution. — In a large majority of cases of major angina the 
pain and hyperesthesia are referred to the left shoulder, inner aspect of the 
arm and over the forearm along the ulnar or radial distribution or over the 
entire hand. They may also be carried up the neck along the left carotid, 
may effect the right side exclusively* in rare instances or involve both 
simultaneously. 

Important Variations. — More interesting and important is maximal 
intensity of both pain and tenderness over the epigastrium and region of the gall- 
bladder, common as to the former, occasional as to the latter, sometimes mislead- 
in gly associated with antecedent or subsequent nausea or vomiting. In such cases 
there may be relative freedom from referred pain in the upper extremities or over 
the heart itself, but the latter is usually sufficiently involved to yield significant 
evidence upon close examination and inquiry. (See "Pain in Disease of the 
Heart and Blood Vessels.") 

Dangerously Misleading. — Both its minor and major forms if attended by 
this distribution are dangerously misleading to the surgeon, as is attested by 
many futile operations upon the gall-bladder, stomach and appendix under- 
taken because of the dominance of pain, alone or with misleading associated 
tenderness, over these structures and neglect or undervaluation of the precordial 
manifestations. 

In several of the author's cases, vomiting has intensified the patient's 
suffering and added to the opportunities for misinterpretation. In another 
a violent agonizing cough attended each paroxysm. This was found to be 
a reflex from the exquisitely hyperesthetic chest wall, ceasing when the 
desperate clutch of the patient was released. 

In all such cases the possibility of a lesion of the structure underlying the 
area of maximal pain must be considered even though the attack itself is cardio- 
vascular in origin. 

Caution in both directions is indicated. 

PaVs splanchnic abdominal crises have been described under arterio- 
sclerosis and these, so far as they have been observed by the author, for the 

* This is suggestive of predominance of a predominant right coronary sclerosis or the 
rare cases of pulmonary insufficiency but is not proof of such change. 



Pain. 



Potent factors. 



Referred pain. 



Simulates 
abdominal 
ailments. 



Misleading 
tenderness. 



772 



MEDICAL DIAGNOSIS 



Exact nature 
unknown. 



Diminished 
"field of 
response." 



An everyday 
parallel. 



Hollow muscle 
pain. 



Acute dilata- 
tion frequent. 



Replicas in 
miniature. 



Misleading 
tenderness. 



greater part have appeared to be merely cardiac anginas attended by domi- 
nant epigastric or upper abdominal pain-reference and localization.* 

RATIONALE. — No thoroughly satisfactory explanation of the genesis 
of major angina pectoris has yet been firmly established. 

Both in this form and its rarer substitute, paroxysmal cardiac asthma, 
which obeys the same laws of incidence but may be indistinguishable from 
spasmodic asthma, it is evident that in most instances there is a diminished 
and unstable myocardial blood supply, spastic vasoconstriction and an 
excessive diminution of the field of painless cardiac response. 

Reasonable Assumptions. — The night attacks come on usually during deep 
sleep and at a period when the enfeebled and rigidly limited coronary and general 
circulations are alike at lowest ebb, and any reflex asphyxial vasoconstriction 
might readily precipitate an abrupt localized ischemia. The day attacks seem 
rather to represent an abrupt unusual demand unsatisfied.^ 

The result would apparently be the same in both cases, viz., a relative 
myocardial ischemia and a consequent loss of adequate painless contractility, 
intensified by reflex paroxysmal vasoconstriction. 

The author feels that in many such instances, as in any case of cardiac 
fatigue, the case is parallel to that of the spasmodic cramping of the calf 
muscles in sustained maximal overexertion, or, the spasmodic pain of deficient 
blood supply due to coincident arteriosclerosis and arterial spasm, such as is 
observed in intermittierende Hinken. The pain induced in a hollow muscle 
under conditions of abruptly produced ischemia may well be spasmodic and 
intense, as is shown by the dramatic and misleading onset of mesenteric 
infarction. 

In most of the author's cases, recently observed, the heart has been distinctly 
and in some cases surprisingly dilated during the attack and in those cases where 
an associated interstitial nephritis was present the blood-pressure reading at 
the height of the seizure was from 60 to no or more mm. of mercury above the 
records preceding and succeeding immediately. 

Minor Anginas. — These have been discussed under the title of " subjec- 
tive symptoms" of cardiovascular insufficiency. 

// is illogical to assume that everything resembling angina pectoris, but 
not atrocious or typical, must be a pseudo-angina. 

Some of the minor attacks are replicas in miniature of the major attacks 
here described. Others are incomplete, which is exactly what one would 
assume as probable from our present knowledge of the pain manifestations of 
hollow muscular viscera. A separate classification of purely nervous attacks 
of precordial distress under the title, "pseudo-angina pectoris," is most 

* In three cases observed by the author throughout the attack the distress was at first 
distinctively abdominal, but after a few minutes became that of classical angina pectoris. 

f The author has been fortunate enough to find several opportunities for unusually 
close observation of both the major and minor anginas and believes that too little attention 
has been given to the attacks that strike during sound quiet sleep or absolute physical rest 
and relaxation during the day. 

In one patient he observed the onset of three such attacks under what should have been 
ideal conditions for their prevention if mental calm and physical rest might be so regarded. 



ANGINA PECTORIS 



773 



unfortunate as tending to obscure the importance, and render less likely the 
recognition of minor or true anginas such as are not at all uncommon in 
nervous individuals who carry weak overstrained hearts. No one who has 
ever seen a major attack will be deceived by a mere hysterical seizure. It 
is one of the most pitiful, dramatic, and convincing of clinical pictures. 

Prognosis. — If the attacks are severe, occur persistently and with increas- 
ing severity and duration, the outlook is bad, but intelligent well-to-do 
patients can oftentimes be taught to observe their own limits of safety, and 
under such conditions often may remain fairly comfortable under measures 
directed to the reduction of any existing dilatation and the strengthening of 
the general circulation. 

Among the most difficult cases are those carrying the persistent high 
arterial tension and marked and widespread arteriosclerosis of an interstitial 
nephritis, yet even these under proper management often secure long periods 
of immunity. 

ANEURYSM OF THE THORACIC AORTA 

Definition. — A true aneurysm represents a local dilatation of an artery? 
due to the weakening effect of a chronic arteritis. 

Etiology. — Aneurysm in this region is almost invariably due to the 
syphilitic productive mesaortitis of Francis Welch and any factor that promotes 
arterial degeneration on the one hand, and abnormally great vascular ten- 
sion upon the other, may contribute to its progress. As is often said, the 
victim is usually one w T ho has worshipped at the shrine of Venus, Bacchus or 
Vulcan, but the influence of the first of this triad is dominant in etiology.* 

Intemperance in eating or drinking and physical and mental overwork 
or overstrain act as contributing causes, the first symptom in many cases 
dating from sudden, severe or prolonged muscular effort. Several cases 
coming under the author's observation have dated their symptoms from 
severe falls or a railway accident. 

It is quite possible that a congenital weakness of the vessels is a factor in 
the aneurysms of the young, but in all these cases it is difficult to believe 
that we can exclude a primary inherited degenerative process due to one of 
the chief factors originally mentioned. 

The disease is much more common than is generally supposed and is a 
frequent cause of sudden deaths, which, in the absence of autopsy, are referred 
to other conditions, chiefly " acute indigestion," " acute gastric dilatation," 
and "hematemesis." 

Difficulties Encountered in Diagnosis.- — The use of the fluoroscope and 
the X-ray photograph has added greatly to our diagnostic resources and made 
it possible to detect aneurysm in its earlier stages. Otherwise no disease is 
more easily recognized in the presence of its classical symptoms, nor more 
frequently overlooked when these are absent. (See "Roentgenography.") 

* The results of the Wassermann and luetin tests have greatly strengthened the belief 
that practically all such cases represent the effect of past syphilitic infection. This etio- 
logic relationship of aneurysm on the vascular side to syphilis is practically parallel to that 
of locomotor ataxia on the side of the nervous system. (See "Cardiovascular Syphilis.") 



Devotees of 

Venus. 



Traumatism. 



Valuable aid. 



774 



MEDICAL DIAGNOSIS 



Old divisions. 



Important 
points. 



Sadden death. 



Clinical Divisions. — The old clinical divisions were: (i) Aneurysm with 
signs and symptoms; (2) aneurysm with symptoms but no signs; (3) aneurysm 
with neither symptoms nor signs. 

It should be remembered that (a) classical symptoms develop only in certain 
cases and then usually when the terminal stageis reached; (b) that large aneurysms 
may exist without them; (c) that in cases of sudden death from this cause aneurysm 




Fig. 417. — Luetic mesaortitis. An enormous aneurysm of the ascending portion of 
the arch. One of three such abnormal areas seen by the author. + = only point of 
marked pulsation. Patient died of external rupture succeeding necrosis of thoracic tissues. 

is frequently unsuspected, both ante- and post-mortem, in the absence of an 
autopsy; (d) that ordinary diagnostic resources are oftentimes unsatisfactory, 
inefficient and inadequate; and (e) that the fluoroscopic picture or X-ray photo- 
graph offers usually the only certain means of early diagnosis at our command. 

Statistics of Aneurysm. — Roughly speaking, 60 per cent, of all recognized 
aneurysms are aortic, and 85 per cent, of these involve the thoracic aorta. Of 
these, 90 per cent, are saccular; from 80 to 90 per cent, affect tJte male, and 60 
per cent, occur after the age of thirty and kill before fifty * 

The people whose habits most largely represent intemperance in food and 
drink and occupations which involve the maximum of such intemperance and 

* No statistics of relative frequency, age incidence, or mortality can be more than 
approximate, by reason of the frequency of unrecognized cases of this internal and concealed 
group. The diagnosis of other aneurysms, even those of the abdominal aorta is simple. 



AORTIC ANEURYSM 



775 



of liability to syphilitic infection furnish the chief examples to the incidence 
and mortality of the disease. 

Favorite Sites. — The root of the aorta, the junction of its ascending and 
transverse portions, and the descending arch represent the chief points of 
attack in the frequency indicated by their order. 

Termination. — The peculiar situation of these tumors with a reference 
to adjacent and related structures readily explains their symptomatology 
and termination. Death occurs suddenly in almost every instance because of 
rupture of the sac. The blood may pass into the pericardium or adjacent 




Fig. 418. — ^Same patient as shown in plate 349, showing retraction of area of percussion 
dulness, following prolonged rest. 

pulmonary artery, into the superior vena cava, the esophagus, any one of the 
four heart chambers, the lung itself, the mediastinum, or, gush forth exter- 
nally in certain massive aneurysms causing pressure necrosis of the overlying 
tissues. As regards relative frequency, the pericardium, pulmonary artery, 
and right auricle head the list of recipient structures in the order given. 

Symptoms. — A pulsating and gradually but inexorably enlarging tumor, 
within a limited space filled with important anatomical structures means a 
possible predominance of pressure symptoms the relation of which to the structure 
primarily compressed, determines their nature. These may be epitomized as 
follows: 

Esophagus: dysphagia. Trachea: brazen cough (gander cough), dys- 
pnea, stridor, bronchorrhea and hemoptysis (if the blood does not ooze from 
the sac itself). Root of the lung, and the pleura: symptoms suggesting 
phthisis, pulmonary collapse, pleurisy, etc. Pericardium: pericarditis. 



Predominant 

pressure 

symptoms. 



776 MEDICAL DIAGNOSIS 



Chest wall : localized, dull pain. Nerve trunks : neuralgic pains, paroxysmal 
and intermittent, often severe and intractable. Pulmonary artery : systolic 
pulmonary murmur, dilated right heart. Sympathetic fibers: dilated or 
contracted pupil, unilateral sweating or pallor. Cardiac plexus: anginal 
attacks. Superior vena cava : edema of upper extremity, cyanosis. Thoracic 
duct : marasmus. Vagus : dyspepsia, nausea, vomiting, dyspnea. Phrenic : 
hiccough, unilateral diaphragm spasm or paralysis. Recurrent laryngeal: 
hoarseness, aphonia, spasm or paralysis left cord, paroxysmal dyspnea. It 
must not' be forgotten that any or all of these symptoms may be caused by 
mediastinal growths other than aneurysms and that the incidence of such 
symptoms is variable and irregular. 

PHYSICAL SIGNS.— Inspection.— This must be both direct and tan- 
gential and one seeks primarily to discover any local bulging or pulsation. 




Fig. 419. — Aneurysm of the ascending portion of the arch. The aneurysm represented 
by the percussion outline shown ruptured into esophagus in the author's presence, as the 
patient suddenly sat up, because of abrupt anginal obligatory orthopnea. 

The region of the manubrium, and the back between the left scapula and the 
spine should be examined with special care. 

The Primary Signs are: (a) Abnormal pulsation usually in the locality 
mentioned, yet variable in position, degree and extent, and if typical, heaving 
and expansile, (b) Rarely, a visible tumor yielding expansile pulsation and 
covered by tissues which may be normal, tense, shiny, and congested or even 
necrotic (c) A positive radiogram. 

Secondary Signs. — (a) The peripheral signs of an associated aortic regur- 
gitation may be present, (b) The apex-beat is low and may indicate left 
ventricular enlargement, a condition commonly but not invariably associated 
with thoracic aneurysm, {c) Signs of sclerosis in the peripheral arteries, (d) 
Cyanosis, localized edema and unequal pupils, vasomotor symptoms such 
as unilateral pallor, congestion or sweating, (e) Stridor, visible dyspnea. 



AORTIC ANEURYSM 



777 



(/) Paralysis of the vocal cords, associated hoarseness or aphonia, (g) 
Brazen cough. 

Palpation. — Expansile pulsation and thrill and the so-called diastolic shock 
are chiefly to be sought. In certain aneurysms involving the transverse por- 
tion of the arch, one may find the "tracheal tug" first described by Oliver. 

To obtain this, the cricoid cartilage is grasped by the thumb and finger 
of the observer as the head of the patient is tipped slightly backward; upward 
traction is then made and a tugging sensation may be felt with each cardiac 
impulse. The observer is often misled by the pulsation of vessels under the 
finger, particularly if aortic incompetence exists, and also by checked respira- 
tory movements. 

Furthermore, the sign is undoubtedly present in rare instances in persons 
free from aneurysms but carrying a strongly overacting "drop" heart, and in 
those who have residual pleural adhesions, and is as certainly absent in a very 
large proportion of the cases of true aneurysm. 

Lateral rhythmic movement of the larynx sometimes may be detected 
(Cardarelli's sign). 

The Pulse. — Aside from the signs of a coincident regurgitation the pulse 
yields information of real value in many cases. The observer should care- 
fully compare the beat in the two radials and carotids and note any decided 
delay or inequality. Resulting, as these do chiefly, either from the direct or 
indirect pressure of the sac or from deformed arterial outlets in the portions 
involved, such differences, if gross, furnish excellent corroborative evidence 
and sometimes assist in localizing aneurysmal tumors. 

Percussion. — In advanced and well-defined cases percussion may furnish 
direct evidence in the form of marked dulness over aneurysmal areas, but in 
the earlier cases it is deceptive and misleading. Auscultatory percussion is 
usually more valuable than simple percussion. Student and practitioner 
alike should be thoroughly familiar with the normal variations in the per- 
cussion note yielded by the manubrium sterni. 

Auscultation. — A systolic or more rarely a diastolic murmur, or both, may 
be heard, but the latter is due in most instances to associated valvular disease 
in aneurysms involving the first portion of the arch. A systolic bruit, 
often harsh, vibrant and associated with palpable thrill not uncommonly is 
produced by the sac itself. Pressure upon the pulmonary artery may also 
cause a systolic murmur. Such systolic bruits as are, produced at the aortic 
orifice or by the sac often are widely transmitted along the vessels, and a 
localized systolic bruit heard at the left of the spinal column is an important 
sign of aneurysm of the descending aorta. 

The most important single sign of aneurysm of the first or second seg- 
ments the author believes to be a distinct ringing, metallic, second sound, 
when heard maximally, not over the aortic valve itself, but over the sac. 
The maximum intensity of the true sac murmurs may occupy the same sug- 
gestive site. 

In mere dilatation of the aorta this sound is maximal usually over the 
valve area, but this distinction is not constant. 



Tracheal tug 
valuable but 
overrated. 



Important. 



Often useless. 



Valuable 

suggestive 

sign. 



May be long 
absent. 



Thrills and 
murmurs. 



77 8 



MEDICAL DIAGNOSIS 



Symptoms 
often marked. 



Subjective Symptoms. — Dyspnea, precordial oppression and pain are the 
chief subjective signs, and, of these, pain is by far the most important. 
Theoretically, every large aneurysm should be accompanied by severe pain ; 
actually, a large number go to a fatal termination without it. When present 
it may be localized, diffuse or referred, shooting, cutting, or more commonly 
dull or gnawing. Usually it is long misinterpreted, regarded as neuralgic, 
and so treated. 

SPECIAL SYMPTOMS.— Aneurysm of the First Portion of the Arch.— 
Any statements made under this heading are liable to exception, but in 
general it may be said that if the first portion of the arch is involved, a 




Fig. 420. — Luetic mesaortitis. Aneurysm of the ascending portion of the aortic 
arch. Note that application of old flat-finger percussion method yields an impossible Ml. 
dimension. 

pulsation or rarely an expansile tumor is likely to appear at or about the 
second right interspace, which tends to extend its area of dulness outward 
and upward. 

Attacks of angina pectoris and severe palpitation are common in this 
type of lesion. The aortic valves are likely to be involved and symptoms of 
aortic regurgitation and a double murmur are often present at the base, 
associated with systolic thrill and marked diastolic shock. Extension of the 
sac tends to cause localized edema, cyanosis, vasomotor symptoms and, 
possibly, pleural or even pericardial inflammation. 



AORTH ANEURYSM 



779 



Aneurysm of the Transverse Portion of the Arch. — The common symp- obtrusive 
toms are dulness and pulsation over and about the manubrium and in the 
episternal notch, together with tracheal tug in some cases, paralysis of the 
vocal cord with a whispering voice and brazen cough and marked pressure 
symptoms; pain (variable and usually less severe than in aneurysm of the 
first portion), systolic bruit, diastolic shock (often lacking), pulse variations 
(often marked), dyspnea, and precordial pressure. Pseudo-asthmatic seizures 
are not uncommon and lead oftentimes to mistaken diagnosis and treatment. 



Pseudo- 
asthma. 




Fig. 421. — Malignant growth and aneurysmal dilatation. "Drop" heart greatly enlarged. 

Aneurysm of the Descending Portion of the Arch. — The symptoms may j obscure, 
be slight or absent, are usually posterior in localization, may include bruit, 
percussion dulness, superficial posterior pulsat on or actual tumor with ulti- 
mate external rupture, and are commonly accompanied by a considerable 
degree of posterior percussion dulness and gnawing pain.* 

General Considerations and Differential Diagnosis. — Of a series of fifty 
* In the author's experience, however, this pain has been of a remittent type, and 
relieved by absolute rest, prior at least to the terminal stages of the disease. 



780 



MEDICAL DIAGNOSIS 



Early'diag- 
nosis rare. 



Value of 
X-ray. 



private cases of thoracic aneurysm observed during the past few years, many 
would have gone unrecognized had the X-ray not been used. Even certain ad- 
vanced, rapidly progressive cases presented vague signs. Nearly all had been 
treated under erroneous diagnosis for neuralgia, asthma, dyspepsia, "neuras- 
thenia," disease of the spine or pulmonary tuberculosis. 



Wassermann 
test valuable 
throughout. 




Fig. 422. — Syphilitic mesaortitis and malignant growth. Malignant growth producing 
stenosis at the cardia and extending upward in the mediastinum. Heart and dilated aorta 
are represented by the deeper shadow. Confirmed by repeated photography and finally 
by autopsy. 

The accepted symptomatology of thoracic aneurysm needs revision and our 
diagnostic methods should be reinforced oftener by the roent geno graphic findings .* 
(See discussion of "Syphilitic Mesaortitis.") 

Differential Diagnosis. — Mediastinal Abscess. — Its relatively rapid 
development with symptoms of suppuration and the absence of aneu- 
rysmal symptoms other than pressure symptoms should be sufficient to 
exclude this lesion. 

Pulmonary Fibrosis. — Cases of fibroid phthisis or any case involving the 
retraction of lung may give rise to suggestive pulsation in aneurysmal areas, 

* Of these cases nearly all have already died suddenly, in several instances without 
developing the more marked symptoms. 



AORTIC AM CRYSJJ 






but ordinary methods should be sufficient to establish the actual conditions 
present and should be reenforced by a fluoroscopic inspection of the arch. 

Pulmonary tuberculosis with a large cavity adjacent to the aneurysmal 
areas may produce pulsation and certain other aneurysmal signs, but the 
history, sputa, breath sounds, etc., should make error impossible. 

Anemic pulsation should be readily differentiated by rational methods. 
rtic regurgitation is frequently associated with aneurysmal dilatation 
both dynamic and true: if unassociated, it should offer little difficulty.* 

Malignant Growths in the Mediastinum. — When these are associated with 
evidences of malignant disease elsewhere in the body they offer little difficulty, 
but when not so associated they occasionally become most difficult to differ- 
entiate in the absence of the rluoroscope. They may yield all of the pressure 
svmptoms and even pulsation in aneurysmal areas. The following points important 
assist in differentiating them: [a) Knowledge of a primary focus of malig- 
nant growth, (b) Absence of the auscultatory signs of aneurysm, (c) 
Rapid emaciation, (rf) Absence of expansile pulsation, whether upon ordi- 
nary inspection, or more definitely, as determined by fluoroscopic methods. 
(e) The absence of marked improvement and relief of pain when pla-ced absolutely 
at rest. In two cases seen recently by the author a decided aneurysmal dila- 
tation coexisted with a large mediastinal growth, in the one case a sarcoma, in 
the other, carcinoma. Certain vascular grouths with definite expansile pulsa- 
tion lead occasionally to unavoidable error. 

FINAL CONSIDERATIONS AND CONCLUSIONS.— Certain cases of 
aneurysm yield no symptoms save those determined by X-ray examination. 
Here, as elsewhere, a knowledge of the normal heart sounds is of the first 
importance. All ringing and distinctly metallic second sounds at the base of 
the heart should be regarded as suspicious when their points of maximum 
intensity are found at some distance from the proper valvular area and pain or 
pressure symptoms are present. Tangential inspection should never be omitted 
and in doubtful cases yielding percussion dulness the effect of absolute rest 
should be determined. In all walking cases of aneurysm any existing area of 
dulness is perceptibly reduced by a few days of rest, and the daily variabilitv 
of pressure symptoms as related to the occupation or the pursuits of the 
individual should be considered. The temperature record, strength, and 
nutrition should be watched: unilateral loss of knee-jerks is suggestive and 
the proof of past syphilis or external signs of a denied lesion are most impor- 
tant. It should be remembered that active pressure ulceration of the pul- 
monary structures may produce the physical signs of a tuberculosis, that senile 
pericarditis is often aneurysmal, and, finally, that with the rluoroscope one 
usually may see and accurately measure the sac, determine true expansile 
pulsation and accurately record the changes induced by rest or treatment. 

PERICARDITIS 

Definition. — An inflammation of the pericardial sac almost invariably 
secondary to. coincident with, or superimposed upon, other diseases; occurring Usually 
e Roentgenography. 



Offer 
difficulties. 



points. 



Aneurysm 
may coexist. 



Confusing 
conditions. 



All important 
data. 



secondary. 



782 



MEDICAL DIAGNOSIS 



as an acute, subacute or chronic ailment; dry and fibrinous in type, or associated 
with a serous, hemorrhagic, purulent or sanious, effusion. 

Etiology. — Between 40 and 50 per cent, of the cases of acute and subacute 
pericarditis are caused by acute rheumatism and the etiologic factors are in the 
main identical with those of endocarditis, already described. 




Fig. 423. — Large Pericardial Effusion (fluoroscopic outline). In the early stages the 
angle formed by the right border of the heart and the diaphragm (junction of right heart 
dulness and hepatic dulness) at the right sternal border is acute in the case of the normal 
heart, a right angle in the case of the extreme type of "drop" heart, with the accumulation 
of fluid the angle is rendered obtuse by decided dulness or flatness, on light percussion, and 
so demonstrable in many instances. The position of the angle is shifted to the right, but 
as the effusion distends the sac an acute angle is formed decided dulness or flatness ex- 
tends far beyond the sternum to the right. The secondary resumption of the acute angle 
may not be demonstrable by percussion, though readily revealed by the fluoroscope. 



Cryptogenetic focal infections of the most varied actual origin are adequate 
to produce the disease and a considerable number of cases result through 
direct extension and circulatory and structural continuity in cases of pneu- 
monia, pleurisy and peritonitis. 

Whether the disease may be said to be caused by Bright's disease, scorbu- 
tus, purpura and other ailments of like nature may be doubted. The depress- 




Fig. 424. — General dilatation and insufficiency. This may resemble pericardial effu- 
sion yet more closely in certain universal dilatations of the "drop" heart occasionally en- 
countered in acute prostrating infections. (Schwartz, modified.) (See Fig. 358.) 

ing constitutional effect of such toxemias doubtless invites infection from the 
many obscure but potent sources now known to exist in a considerable pro- 
portion of individuals. The same statement applies to pericarditis associated 
with pulmonary tuberculosis in some instances, many of these being non- 



PERICARDITIS 



783 



tubercular and probably due to the same conjunction of predisposition and 
potent pathogenic organism. 




Fig. 425. — Pericardial effusion, typical and decided but not extreme. (Dorso- ventral 
aspect.) The limitation of the ascent of the liquid by the attachment of the pericardial 
layers to the great vessels and the resulting stubby neck of the "flask" or "decanter" 
profile is indicated quite clearly. Dulness decided to right as well as left of sternum, true 
apex-beat absent, heart sounds lost or extremely faint at apex. (Repetition of figure 
shown under "Roentgenography.") {Dr. Frank S. Bissell.) 

In all cases of endocardial and myocardial disease the possibility of a peri- Pancarditis. 
cardial complication must be held in mind and, in children especially , involve- 
ment of the entire structure of the heart (pancarditis) is extremely common. 

Age, Sex. — By far the greater number of cases occur in children and young 
adults and according to most statistics there is decided male predominance. 



7 8 4 



MEDICAL DIAGNOSIS 



Dry vs. Wet Cases. — Cases of fibrinous pericarditis and those of the 
exudative form occur in about equal proportion according to available statis- 
tics. It is wholly probable that the true relative incidence, if known, would 
show a great predominance of the former type. 




Fig. 426. — Greatly and universally dilated "drop" heart. Residual acute dilatation. 
Heart sounds sharp and distinct. Soft systolic bruit at apex. Apex beat diffuse, systolic 
retraction marked over right ventricular area. True apex beat diffuse, sharp and un- 
sustained. Superficial and deep dulness well defined to left of sternum, former showing 
extension to right sternal border. Area of relative dulness to right of this point not accu- 
rately definable. In a second picture taken a few weeks later a better plate and exposure 
brought out the areas of residual infiltration and extremely dense hilus shadows remi- 
niscent of the causative influenzal broncho-pneumonia. The former are suggested 
faintly in the shadow of the right ventricle (to the left of the sternum) and also over the 
same chamber to the right of the sternum. Both this and the final radiogram, showing 
the resumption of the narrow "drop heart" outline normal for its congenitally asthenic 
possessor are shown under "Drop heart." Acute dilatation may involve the right, left 
or both chambers of the heart. (See also Figs. 424, 425 and 427.) 



I'KKIl'AKDll'lS 



78S 




Fig. 427. — A case of chronic universal enlargement of a heart primarily of the normal 
type. (Dorso-ventral aspect.) Hypertrophy and dilatation are present, the patient, an 
unusually powerful broad-chested man, attends to his business as a building contractor, but 
carries hepatic engorgement, diurnal edema of the ankles and persistent rales at the lung 
bases. Is exhausted easily and has decided exertion dyspnea. A "fatty tail" indicating 
some degree of "fatty overgrowth" ("fatty infiltration," "fatty heart"). It will be noted 
that this condition obliterates both right and left inferior angles. Total transverse meas- 
urement 19 cm. If this myocardium were to become profoundly toxic, during a pneu- 
monia, influenza, septic cholecystitis, acute rheumatism or other such prostrating ailment 
such a heart might assume the form shown in Fig. 424, a silhouette usually exaggerated, as 
to the loss of the lower left ventricular curve, by the high position of the diaphragm so often 
present, according to the author's experience. Usually, at the stage where such an outline 
is obtainable, the patient has difficulty in breathing and quite often ascites of some degree 
or excessive flatus is present. 

Furthermore, the author has found in two instances, at autopsy, that a complete loss of 
both right and left cardio diaphragmatic angles in such a heart was due apparently to a 
considerable amount of pericardial exudate filling them when the patient was in a sitting 
or erect posture, with a large amount of fluid the angles would have been indicated sharply, 
as in Figs. 423 and 425. This heart presented no murmurs of any kind and, as is so fre- 
quently the case, the patient was complaining only of "dyspepsia" and "nervousness" 
and had been treated for these conditions alone. A "fatty tail" is clearly shown at the' 
apex. 

So 






MEDICAL DIAGNOSIS 



Often 
obscured. 



Their number 
decreasing. 



Obscure focal 
infections. 



Obscured 
rheumatic 
cases. 



Afebrile cases. 



Sources of 
pain. 



Silent and Unrecognized Cases. — To a remarkable extent this important 
disease is overlooked, as must be the case with any ailment so largely secondary and 
so likely to be overshadowed and dominated by the primary disease. 

Autopsy reports prove its presence in 12 per cent, of the fatal cases of 
pneumonia and it is recognized clinically in only 1 per cent. It is found in 5 
per cent, of the cases of chronic tuberculosis coming to post-mortem section 
and in these is almost never recognized. 

To a remarkable degree its presence is coincident with that of endocardial 
lesions, preexistent or otherwise, and the striking symptoms of endocarditis may 
dominate the clinical picture, even of a pancarditis. 

The " Idiopathic " Cases. — In the past many such have been reported but 
at present and in the future the number will be greatly lessened because of 
our recently acquired knowledge of the etiologic potency of chronic crypto- 
genetic septic foci notably those represented by infected tonsils, accessory 
sinuses and peridental tissues, together with our better appreciation of the 
peculiarly silent character of many cases of obscure acute rJmimatism occurring 
in young children, among whom many of these so-called "idiopathic'' cases 
have been noted in the absence of active joint symptoms, such as we now 
know are oftentimes wholly lacking in many entering into that age group. 

The painlessness of a considerable proportion of the acute and subacute 
pleurisies has served~also to mislead the physician. 

SYMPTOMS COMMON TO BOTH DRY AND WET CASES.— One 
must sharply distinguish between these two groups of cases, viz: those with and 
those without a liquid effusion; and also two groups of symptoms, viz: those com- 
mon to both conditions and those chiefly characteristic of tfie one or the other. 

Fever. — The number of afebrile cases of pericarditis is probably considerable 
and this statement is especially true of those instances in which this disease com- 
plicates a preexisting ailment maikedly affecting the nutrition and resisting power 
of the patient. 

In many other instances the fever of a primary lesion dominates and 
obscures that due to secondary, complicating pericarditis. Fortunately, in 
acute rheumatism and certain other ailments the temperature chart often 
shows a suggestive sudden ascent coincident with the pericardial onset. 

Fever, when present, may endure but for a few days or continue for two 
or three weeks, in some instances. In septic cases the characteristic curve is 
present, but this form of fever is seldom long continued because of the short 
duration of life in such cases of this type as fail to secure immediate or very 
early radical surgical intervention. 

Pain. — Pain or decided discomfort is present in about three-fourths of the 
cases of pericarditis as a primary symptom, but one must distinguish clearly 
between that which is apparently due to actual pericardial friction and its result- 
ing irritation, that which is the result of such greatly increased intrapericardial 
pressure* as accompanies a massive effusion, and that which is largely due to 
the cardiac inadequacy of associated myocardial toxemia or actual myocarditis. 

Any primary pericardial pain may subside either from (a) a marked increase 

* Sufficient actually to rupture a myocardium so distended. 



PERICARDITIS 



787 



of the fibrinous exudate of the dry pericarditis, (b) the attainment by adhesion of 
local immobilization of inflamed serous surfaces, or (c) the outpouring of a 
liquid exudate which separates the pericardial layers. 

The last event, as previously suggested, may relieve a primary pain, only 
to cause the reappearance of one of a different character, usually best de- 
scribed as discomfort or distress, yet agonizing in rare instances. 

Localization of Pain. — Pericardial pain is seldom sharply localized save in 
those cases in which it is referred to the left shoulder and arm or to the neck 
as happens especially in cases of greatly increased intrapericardial pressure 
or associated or antecedent myocardial or coronary disease. In either wet 
or dry pericarditis it may be referred to the epigastrium, which is sometimes 
the initial seat of any pain present in the case and is frequently a point of 
maximal discomfort and distress in cases of effusion. In some instances at- 
tacks indistinguishable from classic " angina pectoris" occur and these are 
due doubtless to myocardial involvement and to interference with the intrin- 
sic blood supply of the heart through actual extreme pressure or, later, the 
involvement of the coronary arteries or the heart chambers in compressing 
or constricting bands of adhesion. 

Even slight precordial pain is suggestive when occurring in diseases of which 
pericarditis is known to be a frequent complication. 

The Pulse. — Acceleration of the pulse is the common rinding, but various 
forms of arrhythmia are extremely common and heart block occurs frequently 
in its minor grades, recognizable by instrumental means, and, occasionally, in 
its classic form, the pulse dropping to 40 or lower. Slow pulse not rarely 
occurs apart from actual heart block, apparently because of involvement of 
the vagus nerve and resulting excessive inhibition. 

Dyspnea and Cyanosis. — Dyspnea is common to both types of peri- 
carditis, though inconstant and seldom of marked degree in the dry form 
unless there be coincident involvement of the pleura and pericardium. In 
cases with effusion it may and often does attain a high grade, forcing an 
obligatory sitting posture on the part of the patient (orthopnea) and 
producing sometimes a truly pitiable condition. 

If in any case paroxysmal dyspnea or Cheyne-Stokes breathing occurs, 
renal disease is suggested strongly (Cowan). The author has also encoun- 
tered it in cases showing at autopsy a mere passive congestion of the kidneys, 
but marked myocardial involvement, and, in one instance, coronary sclerosis 
chiefly affecting the right heart. 

If the myocardium is greatly affected, the effect of exertion, even of the slightest 
grade, may be reflected promptly and significantly in marked increase of dyspnea 
and cyanosis or take the ominous form of sudden "ashen" pallor. 

Oddly enough cyanosis is common to both forms of pericarditis though it 
must be assumed that the slighter grade seen in the dry type of the disease 
is chiefly related to the coincident myocardial toxemia or to increase in the 
preexisting weakness of a diseased heart, such as is so often present in this 
predominatingly secondary ailment. 

In pericarditis with effusion, cyanosis may be of an extreme grade and its 



Shoulder pain. 



Epigastric 
pain. 



Angina 
pectoris. 



Rapid usually 



Slow pulse. 



Present in both 
forms. 



Decided in 
"wet" cases. 



788 



MEDICAL DIAGNOSIS 



variations together with the possible concurrence of decided pallor or its abrupt 
onset or increase constitute valuable evidence as to the grade of the lesion and 
prognosis in the individual case. 

The Friction Rub. — This is the dominant symptom of true dry peri- 
carditis, though, in a modified form and a lesser degree, it may persist in 
cases of effusion even of high grade in some instances, or in exceptional cases, 
return after the effusion has become absorbed. 

The friction rub, usually double, may be single or triple; is usually audible 
primarily and chiefly at the base of the heart in the neighborhood of the great 
vessels or, not infrequently, is heard primarily or coincidently at the apex or 
over the right ventricle. 

In rare instances, in the presence of decided dilatation of the left auricle 
such as might occur as a result of preexisting mitral stenosis, pericardial 
friction may first be audible in the region of the inferior angle of the left 
scapula. 

Quality of Pericardial Murmurs. — In an overwhelming majority of cases 
of dry pericarditis the quality of the friction murmur is so characteristic as to be 
pathognomonic and makes the diagnosis simple and direct. 

In rare instances, however, the rub may be softened by exudate until 
quality alone does not suffice for its differentiation from an endocarditic or 
accidental heart murmur. In the latter instances other peculiarities of peri- 
cardial friction are evoked and usually suffice for diagnostic purposes. 

In its typical form and common variants the murmur is accurately described 
by some one of the terms, "shuffling," "rubbing," "squeaking," "creaking," 
"grating" and these are often so loud and harsh as to readily explain the fre- 
quency with which one obtains by palpation the so-called "friction fremitus." 

Time of Pericardial Murmurs. — One of the most important characteristics 
of the pericardial friction rub as affecting differential diagnosis is its failure to 
occur in exact synchronism with the first or second sound of the heart. 

If only the single murmur is present it is commonly distinctly post- 
systolic, a point of the greatest value in differentiation inasmuch as it is this 
isolated rub which is most likely to create difficulties.* Commonly the rubs 
occur in pairs ("to and fro"), less often in triplets, the last being peculiarly 
characteristic when present and yielding a sort of frictional gallop rhythm. 

Superficial Quality of Pericardial Friction. — Pericardial friction conveys 
to the ear a sense of its nearness or superficiality, i.e., proximity of source, 
most important in differentiation and, fortunately, rarely lacking in distinct 
and recognizable degree. 

Stethoscopic Pressure Effect. — Save in very rigid chests or in the case of 
elderly persons carrying a pronounced emphysema, increased pressure with 
! the stethoscope bell usually results in an intensification of any existing peri- 
cardial friction sounds and this phenomenon is accompanied oftentimes by 
the elicitation of a most suggestive localized tenderness. 

On the other hand, excessive pressure, in rare instances, may obliterate it. 

* If the murmurs occur as triplets the third element is presystolic but utterly unlike a 
presystolic mitral murmur. 



PERICARDITIS 789 

Inconstancy of Pericardial Friction. — The tendency of friction murmurs 
to show marked changes in quality and even of the numbers of elements in 
each cardiac cycle from day to day, hour to hour, and even from minute to 
minute, in some instances, is sometimes a most helpful characteristic. They 
also may show at times decided variation with the phases of respiration and 
with changes of posture. Both of these latter phenomena lacking constancy 
in occurrence in pericarditis but being valuable when present. With coinci- 
dent pleurisy and pericarditis the " pleuro-pericardial friction sounds'' fully 
described elsewhere may be readily elicitable. 

Crescendo and Decrescendo Quality Lacking in Friction Murmurs. — 
Practically all murmurs due to valvular deficiency whether they be systolic, 
diastolic or presystolic in type show a definite and recognizable tendency to 
either '"wax or wane" during the period of their continuance. 

The " thrilling" classical presystolic murmur of mitral stenosis is typically 
and exquisitely crescendo; that of a mitral regurgitation is a systolic bruit 
and. like the diastolic murmur of aortic regurgitation, distinctly decrescendo 
beginning strongly and ending by gradual attenuation. With rare exceptions 
these qualities are wholly lacking in pericardial friction. 

The post-systolic " cardio-pulmonary murmur" or those % which may 
represent a very slight leakage late in systole due, perhaps, to slight muscular 
insufficiency can only be confounded with the rarest types of pericardial 
friction. 

Failure of Definite Transmission. — Those definite lines of transmis- 
sion so generally observed in true endocarditic lesions are wholly lacking in 
those of pericarditis, the area of audibility of any pericardial friction rub 
being dependent wholly upon its loudness and the presence or absence of 
conditions limiting its transmission to the surface of the chest. This point 
is often of cardinal importance in the rare cases of unusual obscurity. 

It must be remembered, however, that the common soft flowing murmurs 
of relative secondary or degenerative insufficiency of the mitral valve may be 
quite sharply limited to the apex. 

The point of chief importance is the fact that even a loud pericardial 
rub conforms to no law of transmission save the general one. 

SYMPTOMS CHARACTERISTIC OF EFFUSION.— The cardinal sign 
of pericardial effusion is an increased area of unusually decided dulness or 
actual flatness representing the profile of the distended pericardial sac and 
therefore assuming the form of a somewhat unsymmetrical big-bellied stubby- True outline, 
necked decanter or ancient vase, extending not only far to the left and right 
of the antecedent percussion profile of the heart, but often carrying median 
dulness upward to the level of the second rib. 

In massive effusions the left border may project so far as apparently to 
reach nearly to the left thoracic wall and the right border may extend to the 
mid-clavicular line or even beyond it. 

The area of superficial dulness to light percussion is greatly extended and 
actually flat, and the entire profile percussion is roughly triangular and more 
definitely dull and higher pitched than that of cardiac dilatation. 



79° 



MEDICAL DIAGNOSIS 



Rotch's sign. 



Often 

overlooked. 



The patient being recumbent, a small effusion may, rarely,* first become 
manifest over a small triangular area with its base upward, at the level of 
the second interspace. In any event evidences of effusion are likely to be 
indicated very early by flatness just to the right of the sternum in the fifth 
interspace, the region of the " cardiohepatic angle," which it obliterates 
(" Rotch's Sign"). This should be percussed primarily while the patient 
leans well forward and to the right. 

The liquid carries the dulness outward and to the right as well as upward, 
as the effusion increases. In some cases it is manifested early at the left 
border of the heart, extending beyond the normal profile and any visible 
apex-beat, the latter being often visible above and internal to the apparent 
boundary of the left heart. 

In liquid efusions of all decided grades any extension of the area of decided 
percussion dulness beyond the apparent apex-beat and flatness over the normally 
resonant area represented by the normal cardiohepatic angle at the right sternal 
border are symptoms of prime importance. 

Under certain conditions especially, it is said, in scorbutic cases, and 
certainly, according to the author's experience, in the chronic effusions of wet 
polyserositis, the pericardial sac may be so distended by reason of chronic 
inflammation and persistent accumulation of fluid as to contain 3 or even 4 
quarts of serum (Alonzo Clark). 

In many such cases a coincident pleural exudate may occur, not infrequently 
encapsulated by adhesions and mislead the physician into the belief that the 
entire flat area is due to pericardial exudate. 

On the other hand, such pleuritic effusions may cause the examiner to 
overlook a coincident pericardial accumulation. The possible concurrence 
of the two conditions should be borne in mind and in all cases of apparent 
gigantic pericardial effusions, the outer area should be first tapped, this pro- 
cedure sometimes revealing only a moderate residual exudate w T ithin the 
pericardium, the free border of which has been pushed aside in such a way as 
to exaggerate the actual condition. 

Changes in the Level of Dulness. — In moderate effusions, changes in the 
level of dulness may occur in response to alterations of posture but the sign is 
anything but constant. Very frequently postural changes increase any exist- 
ing precordial oppression. 

Pressure Symptoms. — One has only to recall to mind the narrow limits 
of the mediastinal space and the vital nature of its many contained structures 
to realize that any tumor within it, whether it be aneurysmal, malignant or 
only that of a distended pericardial sac, may produce striking pressure symp- 
toms, such as are dealt with under the head of " aortic aneurysm, " but it may 
be said that, in general, pericardial exudates produce fewer of these in any 
extreme form than would be assumed. 

Precordial and Epigastric Bulging. — The flexible chests of children may 
bulge from a pericardial exudate, and, in young adults of delicate structure, 
flush or even bulging interspaces may be observed. The epigastrium may be 

* In the author's experience. 



PERICARDITIS 



791 



prominent by reason of a dominant displacement of the left lobe of the liver 
due to the thrust of the distended pericardial sac and a striking and decided 
epigastric respiratory immobility, or relative passivity, is manifest in some 
instances. 

Hydropericardium. — The pericardium not infrequently contains a liquid 
transudate in cases of general dropsy such as accompany chronic Bright's 
disease or profound cardiac decompensation affecting the right heart. Occa- 
sionally such a transudate occurs as an isolated phenomenon under these and 
similar conditions and may prove puzzling or be wholly overlooked. 

Such an effusion may be wholly symptomless, for no fever is present unless 
it be that of some complicating febrile ailment. In other cases it may cause 
decided pain or precordial and epigastric oppression, seriously embarrass a 
crippled heart and prove a terminal event tmless promptly relieved. 

Pyopericardium. — Purulent pericardial exudates may be primary but are 
usually secondary to a similar process in the pleural cavity or, more rarely, the 
peritoneal space and, as previously stated, will in most instances prove 
rapidly fatal unless drained promptly. 

Such cases may present a typical septic syndrome, be obscured by similar 
symptoms due to the primary ailment, or run a wholly afebrile course. 

Pneumopericardium. — Almost invariably this condition is associated with usually 

pyo-pneumo- 

a purulent rather than a serous or hemorrhagic effusion and represents pericardium, 
in the rarest instances the activity of gas-forming bacilli though it usually 
arises from fistulous communication, accidental wounds or the maneuvers of 
aspiration. In the former case it demands immediate surgical interference, 
In the latter it may prove temporary and of trivial importance. 

The condition is excessively rare, but readily recognized, usually, by the 
peculiar melange of pericardial friction sounds and churning, splashing, tink- 
ling and purling liquid sounds obviously related to cardiac activity which 
makes a bizarre picture peculiar to this condition.* 

RATIONALE. — Pericardial Relationships. — A thorough understanding 
of the basic factors of pericardial inflammation, and of the nature and 
relationship of the pericardium itself, at once makes evident the genesis and 
logical sequence of the clinical signs and symptoms of pericarditis. 

The pericardium in health forms a potential, closed, lymph space, the 
outer wall of which is formed by its parietal layer, the inner by the visceral a lymph space. 
pericardium which is reflected upon the heart, of which it forms its outermost 
protective coat and with which it thus becomes structurally continuous. 

The Normal Surface. — The apposed surfaces normally are perfectly 
smooth, sufficiently elastic to be marvelously distensible in the presence of Perfect 
effusion, and so perfectly lubricated as to permit that soundless and symp- 
tomless play of the visceral and parietal layers necessary to their adapta- 
tion to heart movement and, to a lesser degree, the respiratory movement . 
of the lungs and thorax.. 

* The extremely interesting case reported by Cowan lacked fluid accumulation at the 
time of the X-ray examination and hence the signs just described were absent. Prior to 
this the case had been regarded as an obscure sepsis. 



7Q2 



MEDICAL DIAGNOSIS 



Further 

structural 

continuity. 



Secondary 
pleuritis, pan- 
carditis or 
peritonitis. 



Secondary 
pericarditis 
by extension. 



Complete 
adhesion. 



Mediastino- 
pericarditis. 



Secondary 
myocarditis. 



Dry pleurisy. 



Distribution of 
exudate. 



Exudate. 



Varying 
distribution. 



Diaphragm and Cervical Fascia. — The subserous connective tissue of the 
parietal layer is adherent -to and structurally continuous with that of the 
diaphragm below, the pleural sinuses anteriorly and below, the sternum and 
mediastinal tissue through two fibrous bands, and the cervical fascia above. 

An Important Area. — Moreover, the great vessels at the base are en- 
sheathed by it for i J^ inches or more before it blends with their own coverings 
and a small, relatively free space and a series of pouches are thus formed, in 
which, as in the cardiohepatic angle next the sternum or at the apex, any 
pericardial effusion first may be demonstrable. 

A consideration of the anatomic structure and relationship makes it 
obvious : 

i. That only when the serous surfaces are normal can the two layers of the 
pericardium glide upon each other with every heart cycle without exciting either 
sound or sensation. 

2. That inflammation may extend readily from the parietal pericardial layer 
to the pleura, the diaphragm or even the peritoneum, from the parietal wall to 
the mediastinal tissues or, from the visceral layer to the entire heart, its valves 
included. A pleuritis, peritonitis or a pancarditis is, therefore, wholly possible. 

3. That this process may be directly reversed and pericarditis result from 
direct extension, in pleurisy, pleuropneumonia, or peritonitis. 

4. That all these structures may be simultaneously involved {polyserositis) in 
either an acute or chronic process. 

5. That a chronic pericardial inflammation and the wholesale involvement of 
adjacent structures in this process, may produce all grades of residual adhesion, 
a complete obliteration of the potential pericardial cavity through the forma- 
tion of adhesions which would bind firmly to the surface of the heart {visceral 
pericardial layer) the parietal layer of the pericardium and even render rigid and 
immovable the entire mediastinum (" mediastino- pericarditis," " indurative 
mediastinitis") . 

6. That even though a pancarditis is absent, the myocardium is always to some 
degree affected and often undergoes actual infiltration and degeneration. 

7. That many of its symptoms are chargeable in part, at least, to this factor. 

Pathology. — At the beginning of an attack the pericardial serous mem- 
brane normally smooth, soft, glistening, well-lubricated and velvety shows 
patchy areas of opacity and becomes dry and harsh from the hyperemia and 
arrest of secretion. 

Beginning usually at the base of the heart in the neighborhood of the peri- 
cardial reflexions which form sheaths for the great vessels it tends to become 
practically universal and affect both the parietal and the visceral layers of 
the sac. 

In dry, fibrinous pleurisy the adhesive exudate appears first as flakes in 
the region near the arterial trunks or over the ventricles, if this region be 
primarily involved, and chiefly accumulates later at the point originally men- 
tioned and about the coronary vessels. 

It varies greatly in amount, may be abundant and universal or circum- 
scribed in distribution and very scant, and may be equally profuse on the 



PERICARDITIS 



793 



visceral and parietal layers or predominatingly affect one only. A primarily 
dominant inflammation of the parietal surface results from a primary pleuritis 
and represents direct extension by continuity of tissue and a common vascular 
supply. The surface of the pleura may be merely rippled or actually shaggy 
or villous (cor-villosum) . 

Adhesions. — Complete recovery from a fibrinous pleurisy may result 
with entire restoration of the normal appearance of the pericardium, but this 
outcome is undoubtedly rare. More or less adhesion commonly results, 
though fortunately it is seldom universal or very extensive, because of the 
continued movement of the heart. Adhesions may be filmy or tenuous, Adhesions, 
dense and massive, or divide the pericardial sac into several compartments. 
In certain instances the pericardium, the tissues of the mediastinal space, the 
pleura and even the peritoneum become jointly involved in chronic inflamma- 
tion and permanent massive adhesions. This is the so-called " mediastino- 
pericarditis" described elsewhere. In a similar manner the great arteries, 
veins, auricles or even the ventricles may be enclosed', embarrassed, and even 
cripplingly compressed. 

Genesis of the Friction Sounds. — We see that, as in the case of the pleura 
and of serous membranes in general, the response of the pericardium to in- 
fection takes the form of inflammation of the serous lining, at first patchy in 
distribution, but usually becoming general. This at once checks secre- 
tion over the portion involved and converts its velvety lubricated surface 
into a harsh dry membrane. Obviously this must transform the silent gliding 
play of these membranes in response to heart action into a forced rhythmic 
affriction, usually painful, audible and, not infrequently, palpable. 

The parietal layer is usually first involved and that portion of the heart 
subjected to the maximum of movement usually determines the primary 
location. 

It is evident, therefore, that the most frequent primary area of audibility 
of the friction sounds of pericarditis will be over the left base or, less com- 
monly, at the apex. They may spread over the whole heart or be more or 
less strictly limited to the original area and its immediate vicinity. 

In somewhat rare instances, they may first be heard at the epigastrium, 
a not infrequent site for maximal distress if pericarditis attacks a heart al- 
ready dilated as to its right ventricle, and, less frequently, near or over the 
spinal column at the inferior scapular level, being transmitted from the lefl ! 
auricle and base of the left ventricle.* 

Modifying Influences. — The variations in the qualities of pericardial 
"rubs" must obviously depend upon the varying dryness and harshness of Basic factors, 
the apposed surfaces as the fibrinous exudate is freely exuded or withheld, the 
variations in the rate and strength of the succeeding series of heart cycles, 
the formation of adhesions, the rigidity and thickness of the affected peri- 
cardial layers, and the external and internal pressure to which they are 
subjected. 

* One would assume that this would be most likely to occur, or occur only, in cases of 
preexisting mitral stenosis or regurgitation, attended by decided left auricular enlargement. 



Secretion 
checked. 



"Scuffing." 



Determining 
factor in 
location. 



Auscultatory 
points of elec- 
tion. 



Epigastric 
and inter- 
scapular 
"rubs." 



794 



MEDICAL DIAGNOSIS 



The "rub," the 
"blow" and the 
"crackle." 



Soft murmurs. 



The quantity of reactive inflammatory exudate and its quality alike, 
therefore, greatly affect the sounds. 

If both the apposed surfaces are dry and harsh, the sounds will be corre- 
spondingly rough and intense. If not equally affected, the murmur will be 
somewhat modified, and if a profuse fibrinous exudate or serous effusion is present 
they may be so modified as to resemble an endocardial murmur or, as the 
exudate stiffens, a superficial crackle, or, be wholly lost. 

Obviously they are well described as "shuffling,"" rubbing," "creaking," 
"squeaking" or "grating" murmurs; yet it is evident that they may be of all 
grades of harshness on the one hand or as soft as the pulmonary vesicular 
murmur on the other, because of the modifying influence of the fibrinous 
exudate. It is fortunate that the latter are rare, for their differentiation is 
sometimes less easy than their description. 

Postural Variation in Murmurs. — It is obvious that murmurs persisting 
after the appearance of an exudate may vary greatly as regards areas of 
audibility with changes in position. The same statement is true of all fric- 
tion murmurs and especially such as arise in the excessively mobile "drop 
heart." In dry cases the greatest postural variation occurs in such as arise 
from the right ventricle or at the heart borders. 

Variations in quality or the total disappearance of posturally induced 
marginal murmurs and the advent of wholly new "rubs" upon changing the 
position may be determined in some instances. 

The triple element of the friction sounds, if present, is usually presystolic 
and presumably due to auricular systole. At times the sounds may be 
almost continuous, but usually they are double ("to and fro") distinctly 
separate, and the post-systolic murmur is the louder. 

Absorption of Exudate and Return and Recession of Friction Sounds. — 
As the exudate is absorbed friction sounds may reappear over wide or limited 
areas. In fibrinous pleurisy, as stated, they may disappear through (a) the 
outpouring of abundant exudate, (b) the recession of the inflammation, or (c) 
through the formation of adhesions. 

In the recession of murmurs of this type that of the systolic phase usually 
persists for a longer period than its fellow or fellows though in one or two 
instances the author has seen a persistence of the diastolic element after the 
systolic had vanished. 

Pleuro-pericardial Friction. — It is evident that if pleurisy co-exists, as is 
frequently the case, another element is added which is more markedly affected 
by respiration than the pericardial "rubs" and is usually differentiated by 
the fact that, in general, the pleuro-pericardial friction sounds show inspira- 
tory accentuation, expiratory diminution or elision, and are diminished if the 
breath be held in expiration. 

Other important points in differentiation are: (a) The fact that pleuro- 
pericardial friction occurs chiefly along the lung margins and especially at the 
borders of the notch bounding normally the superficial cardiac dulness, and (b) 
that when pleuro-pericardial friction is present one seldom fails to find indubit- 
able pleural rubs distant from the heart. 



PERICARDITIS 



795 



Resolution and Repair. — If the inflammation stops short with only a 
moderate fibrinous exudate as happens in about 50 per cent, of the cases, 
the affected membrane may undergo a more or less complete regeneration 
with few or no adhesions. 

Ad tics ions. — Agglutination of layers alone may result in a complete 
obliteration of the pericardial sac, the parietal layer of which becomes uni- 
versally adherent to its fellow and in consequence to the heart itself, a 
condition unrecognizable, intra vitam, and, of itself, only occasionally inter- 
fering with the intrinsic circulation of an otherwise normal heart or tending, 
in the absence of preexisting disease, to produce serious myocardial weakness 
and degeneration. If, as so often happens, the heart is the seat of endocardial 
lesions or a myocardial degeneration, whether primary or secondary, the 
lesion becomes a serious complication. 

Progressive heart failure without endocardial lesions, when occurring 
in young people, should always suggest adhesions. As a rule, the heart 
will free itself in large degree from those of the ordinary type located upon its 
more active regions but under certain conditions most extreme manifestations 
occur. 

Polyserositis, Mediastino-pericarditis and Indurative Mediastinitis. — 
It occasionally happens, and with especial frequency in the more chronic 
processes such as tuberculosis, that, starting most frequently in the pericard- 
ium, but nearly as often in the pleura, and more rarely in the peritoneum, 
a polyserositis occurs, involving the mediastinal structures, the pleura, peri- 
toneum, diaphragm and even the cervical fascia. All these are structurally 
continuous to such a degree and in such manner as tends to bring about, 
not only an obliteration of the pericardial cavity, but an" indurative mediastin- 
itis." This may be manifested by visible systolic recession of the seventh 
and eighth left interspaces, diminished, absent or reversed movement of the 
ensiform in respiration, or actual lower sternal, systolic indrawing, with 
epigastric retraction or impassivity in respiration, and decided systolic 
tugging of the lower interspaces or of the ribs themselves anteriorly and 
posteriorly (the latter retraction being wholly unaffected by respiration) 
(Broadbent's sign) with each contraction of the heart. 

In these curious cases the heart, pericardium and mediastinal tissues 
become fused by the chronic inflammatory process; the heart and its envelope 
alike being rigidly anchored to the sternum, the spinal column, the diaphragm 
(itself often wholly or partly immobilized) and the pleurae. 

Thus with each systole the contracting heart pulls in the more yielding 
structures both anteriorly and posteriorly and produces the important events 
just described in whole or part. 

The fixation of the heart abolishes any shifting of the border or apex-beat 
such as ordinarily occurs if one assumes the lateral decubitus and a most 
interesting diastolic vibration or shock of almost pathognomonic significance 
may be felt over the right ventricle. 

If one considers the effect of binding together by adhesions the cervical 
fascia with its venous and arterial sheaths, the diaphragm, the pleura, the 



Partial or 
universal. 



796 



MEDICAL DIAGNOSIS 



sternum, the pericardium and the heart itself, he can readily understand 
that a multitude of subsidiary signs may be associated with this curious and 
slowly fatal ailment. Thus, in addition to diastolic jugular collapse,* para- 
doxic inspiratory filling of the cervical veins, the true paradoxic pulse, 
we may find any of the symptoms due to pressure involvement or inclu- 
sion of the vagus, phrenic and other important structures transversing the 
mediastinum. 

In such cases the veins of the neck may be turgid and the abnormally 
marked inspiratory weakening of the radial pulse {pulsus paradoxus) may be 
manifest and, indeed, finds its best and most typical expression. 

Polyserositis Proper. — Universal polyserositis or what is known as 
"Concato's disease" may begin in the pericardium, pleura, or peritoneum, 
as a wet or dry pericarditis, pleuritis, or peritonitis, usually chronic or slug- 
gish from the beginning. 

Concato's disease is apparently inseparable from Pick's disease though 
the latter laid special stress upon a variant in which an amazingly enduring 
and persisting recurrent ascites constitutes the most prominent feature. 

All varieties should be placed in the one melting pot. 

The pleura may dominate in one case, the mediastinum and heart in 
another, the peritoneum, liver and spleen in a third, and a w T et serositis keeps 
the physician busy draining at short intervals the pericardium, pleural sac 
and abdominal cavity. 

Mediastino-pericarditis and the peritoneal-hepatic cirrhosis type (Pick's 
disease) wdth recurrent ascites are the most interesting clinically. 

The heart may assume enormous proportions in mediastino-pericarditis 
and any and all evidences of progressive myocardial failure may present them- 
selves together with various murmurs due to underlying endocardial lesions 
or relative, secondary or consecutive insufficiency. 

Myocardial Involvement. — To a greater or less extent, and almost 
invariably, the myocardium must be affected in the course of a peri- 
carditis and it would seem probable that in the severer and fatal cases 
such participation of this vital tissue constitutes the most serious element 
in the case. 

As previously stated, pericarditis forms one of the legs of the pancarditic 
tripod pericarditis-myocarditis-endocarditis, especially common in young 
children, in whom signs of acute endocarditis always strongly suggest the 
presence or probable subsequent appearance of pericarditis and, conversely, 
in the case of little children the primary appearance of pericarditis renders 
an ultimate pancarditis wholly probable. 

In all pericardial inflammations a small amount of liquid exudate is 
present and even in the most massive of the exudative forms a complete 
disappearance may take place. On the other hand, chronic effusion particu- 

* Now regarded merely as an unsustained systolic venous pulse, the rapid emptying of 
which is greatly facilitated by the events present in this condition. Paradoxic swelling of 
the cervical veins may occur in inspiration owing to adhesion bands which check the venous 
flow. 



PERICARDITIS - - 

f the tuberculous type may be carried unrecognized and is astonishingly 
well borne, over long periods. 

Calcification. — One of the extremely rare results of pericarditis is that 
of calcification which is seldom recognized except by radiographic means. 

:dus Exudates. — Obviously an inflammation of the pericardiurr 
in the case of other serous membranes, may result in the outpouring of a liquid 
effusion which according to degree and character of the original inflammation 
will be serous, purulent, hemorrhagic or sanious. 

This constitutes the more serious form of pericarditis, even though the 
effusion be of a simple nature, and the most fatal form if it be hemorrhagic 
or purulent. In general, one must distinguish between the effusion which is 
simply blood stained or blood perfused, such as is commonly encountered in Bfaody 
tuberculous and cancerous casts, and those primarily hemorrhagic, such as 
occurs especially in scorbutus, more rarely in purpura and leukemia, which are 
almost invariably fatal. 

In rheumatic cases the effusion is prompt in appearing, the dulness being 
demonstrable usually within three to four days or even earlier. In other 
forms it may be greatly delayed. 

All pericarditis cases should be watched with great care throughout their 
entire course, for at any time the exudate may appear. 

The simple effusions resulting from acute rheumatic pericarditis offer the 
best prognosis and are most likely to disappear with reasonable promptitude 
either spontaneously or in response to appropriate treatment. Persistent 
effusions are usually tuberculous or a part of a "polyserositis." 

In excessively rare instances, as stated, either through the accidental 
introduction of air through fistula? , in the course of exploratory or drainage 
aspiration, or because of the, presence wit bin :he sac of one of the gas-forming 
bacteria, a condition of pneumopyopericardium or pneumohydropericardium 
may result in the bizarre combination of splashes, churning and other mur- 
murs of cardiac rhythm of pathognomonic significance already mentioned. 

Either chronic adhesive or serous pericarditis may result from a chronic 
serositis in which all of the chief large serous cavities may be coincidently or 
consecutively involved. 

C irdiac Outline in Effusion. — With respect to the accumulation of peri- 
cardial exudate and its effect upon the cardiac outline, there would appear 
to be some loose conceptions and it should be said primarily that the peri- 
cardium cannot be held to a rigid and unvarying performance. If the heart 
was diseased and greatly enlarged primarily, the area of dulness may be large 
even if the effusion is moderate. 

An exudate usually accumulates somewhat gradually, but may flood the 
pericardium suddenly and produce serious symptoms of cardiac embarrass- 
ment and possibly sudden death. On the other hand, it may be extremely 
slow and chronic 

In general, as stated, it seeks first the open space and pouches about the 
great vessels at the base of the heart and that represented by the cardiohepatic 
angle at the right sternal margin which it promptly submerges (Ro ten's sign). 



79 8 



MEDICAL DIAGNOSIS 



Complemen- 
tary spaces. 



Epigastric 
fullness. 



Lung 
compression, 



Apex beat. 



Heart sounds. 



In very large effusions it actually may maintain and intensify the angle, 
but carries it far to the right of the sternal border* and usually yields a right 
angle to percussion. 

Large vs. Small Effusions. — In lesser effusions, therefore, the most im- 
portant signs are those of a widening of the left border, obliteration of the 
normal cardiohepatic angle, oftentimes a fairly well-defined area of dulness 
over and about the sternum above the level of the third interspaces, and a 
tendency to progressive extension of the areas of dulness, the last being of special 
significance and value. 

Pressure Effects. — The pressure of such large effusions affects the heart 
in varying degree and chiefly by reason of a direct limitation of the coronary 
blood flow, interference with auricular diastole, and with emptying of the 
superior cava. It may exercise compression upon the various important 
mediastinal structures in close relation to it precisely as would be the case in 
aneurysm or a mediastinal tumor, but much less constantly, and to a lesser 
degree. 

Compression of the Lung and Displacement of the Liver. — The fiver, and 
its left lobe especially, is thrust downward by large effusions, the movements 
of the diaphragm are impaired, and the lungs undergo compression both 
anteriorly and posteriorly. The enlarged pericardial sac thrusts aside and 
compresses the anterior margins and exercises compression upon the base of 
the left lung, which, according to its degree, may produce posteriorly a hyper- 
resonance of relaxation, or, a dulness due to condensation which may yield a 
misleading tubular breathing, save when the right lateral or knee-chest posi- 
tion is assumed, or, be silent from complete atelectasis with blocked bronchi. f 

The lateral lung compression often produces a marginal zone of hyper- 
resonance of the same nature. Egophany is often marked and tubular 
breathing is sometimes heard. 

Paradoxic Variations. — In three respects we find conditions which do 
not seem to fit the conditions present in pericardial effusion: 

i. The apex-beat, though usually lost in massive effusions, is often present 
above its normal site, and in most instances, considerably within the left border 
of dulness, especially in effusions of moderate grade. 

2. The heart sounds themselves may be wholly lost, or, be audible over the 
region of the right ventricle and base, with a lessened intensity suggestive of inter- 
posed liquid, yet oftentimes little more than the laboring weakened heart would 
explain. 

3. It seems obvious that if the heart be completely surrounded by liquid and 
the pericardial sac completely filled all antecedent friction sounds should disap- 
pear, yet even in massive effusions, though friction sounds are always markedly 
lessened in the area of audibility, they may not be wholly lost. 

* This is readily demonstrated by a radiogram or with the fluoroscopic screen and the 
difference between a small early exudate and a fully distended sac should be borne in mind. 

fThe essential thing for the student to remember is the fact that various degrees of 
lung compression must exist in large effusions. Various additional so-called signs are given 
in our text-books but are for the most part inconstant and unreliable as to exact sites. 



PERICARDITIS 



799 



Limiting 
adhesions. 



The Paradoxes Explained. — The reason for these variations, with respect 
to friction, heart sounds and apex-beat alike, is found in the fact that, in 
the case of deep-chested individuals, especially, even a massive effusion need importance of 
not separate the greater portion of the anterior surface of the heart from the diameters, 
chest wall. 

This is well demonstrated by autopsies performed upon such individuals, 
which show a large pericardial exudate with a free heart surface in apposition 
to the anterior chest wall, or, one covered only by a thin layer of fluid, even 
in the absence of such b'miting adhesions as sometimes of themselves limit 
the spread of the fluid. 

If the apex-beat remains visible and if by percussion it is found to lie 
well within a sharply defined left border of dulness, another valuable sign is 
added. 

Furthermore, it may show under such conditions a most prompt and excessive 
mobility in lateral changes of position. 

Diagnostic Value of the Quality of the Percussion Note. — The char- 
acter of the light-stroke percussion dulness in marked effusions is usually use light 
pathognomonic. 

77 represents a marginal area of unusually decided relative dulness togetlier 
with an internal area of extraordinarily large extent which shows superficial Marginal and 
dulness or actual ji at /;-. 

This sign is often much intensified if the patient is able to sit up and lean 
forward; so also the intensity of left border dulness or of that of the right may 
be distinctly increased when the patient turns upon the one or the other side 
respectively. The former procedure is hazardous in bad cases. 

FACTORS FUNDAMENTAL IN DIAGNOSIS.— The diagnosis of peri- 
carditis is greatly furthered by a full knowledge on the part of the physician 
of the etiologic factors which make clear the circumstances under which it 
may be anticipated. 

Especially should he remember its extraordinary frequency as a complica- 
tion of the acute cardiac diseases of children and of acute rheumatism at any 
age. Its relative frequency in severe pncum m terminal tuberculosis 

and in the later stages of chronic Bright' s disease and of scorbutus should never 

. r gotten. 

Dry Pericarditis. — The direct recognition of a fibrinous pericarditis 
depends wholly upon our ability to detect the presence and recognize the 
nature of pericardial friction rubs. There is no other one of the symptoms 
save friction fremitus, which constitutes its direct expression. 

Obscure Pericarditis with Effusion. — In a majority of instances of peri- 
carditis with effusion and in a large proportion of such of the cases as occur in 
private practice, especially, the physician would be able to recognize the 
primary lesion by the presence of a friction sound. In many cases, neverthe- 
and especially those occurring in public clinics amongst the poor, the 
patient presents himself with ajully developed and often extreme effusion and 
the case must be diagnosed on the basis of symptoms heretofore described as 
characteristic of pericardial exudation irrespective of the friction rub. A 



percussion. 



oner zones. 



Postural 
Latensifi cation. 



8oo 



MEDICAL DIAGNOSIS 



Conservatism 
indicated. 



misleading factor peculiarly frequent in public services is the relative lack of 
severe subjective symptoms of any kind in many of these cases.* 

In most instances of large effusion the decided character of the dulness, 
its outline, the extent of its upward projection, and the fact that it passes 
beyond any visible apparent apex-beat, or, the entire absence of the apex 
impulse and marked faintness and remoteness of the heart sounds, suffice 
for diagnosis. Nevertheless, that which seems so simple in written descrip- 
tion may prove difficult and impossible now and then in practice. Recourse 
to the X-ray usually reveals a typical shadow of the outline indicated in our 
illustration and there remains always recourse to aspiration, though this 
must not be lightly undertaken. 

Technic of Aspiration. — In event that this is necessary the needle may be 
introduced most safely into the angle or crevice formed by the ensiform cartilage 
and the rib margin on the right side, the needle being directed toward the point 
of the patient's right shoulder. Very few accidents are reported in relation to 
this procedure, but now and then some highly skilled clinician introduces the 
needle into an acutely dilated heart. 

Many prefer the $th or 6th left interspace at the sternal margin, and some go 
far to the left. 

The matters of chief importance are: 

First. — That the operation actually be necessitated by the urgency of compres- 
sion symptoms. The procedure is not to be entered upon hastily or for slight 
reasons. 

Second. — That the heart sounds are muffled or inaudible at the site chosen. 

Third. — That neither pulsation nor friction be detectable at the point selected. 

Fourth. — That a very sharp needle be used, local anesthesia secured, and a 
steady, unhasty, yet unhesitant puncture made. 

PROGNOSIS IN ACUTE AND SUBACUTE PERICARDITIS.— Crucial 
Factors in Prognosis. — The nature and extent of antecedent or complicating 
ailments, the direct etiologic factors and the character and amount of any 
secondary exudate, constitute the elements of chief importance in the progno- 
sis of this disease. The mortality rate varies greatly in different clinics or 
as between these and private practice amongst well-to-do classes, but is 
relatively high, if the cases are taken as a whole, and may reach 40 per cent, 
amongst the poor. The high death rate is not due to pericarditis itself but 
to the antecedent underlying or complicating conditions together with the 
defective physical constitution and resisting power of the patient, a factor 

* As an example, the author would quote the case of a railroad brakeman who sought 
relief from a slight dry but persisting and irritating cough. He was distinctly cyanotic, 
decided dyspnea was evident on exertion and the cervical veins were prominent. He had 
been on duty, but had experienced some precordial oppression which "slowed him down." 
The cough was almost constant and of that peculiar brazen quality which always suggests 
to the trained ear pressure within the mediastinum and usually aneurysm of the aortic arch. 
In this case, however, a massive effusion was present, its left boundary extending apparently 
nearly to the thoracic wall, its right reaching 8 3^ cm. beyond the right edge of the sternum. 
Three weeks previously this patient had suffered from a follicular tonsillitis and ten days 
before his visit had had a trifling swelling of one ankle-joint. 



PERICARDITIS 8oi 



varying enormously in a great number of determining conditions. Of the 
many symptoms which convey a warning to the attending physician one may 
enumerate the following: 

(a) A tendency to drowsiness, delirium or persistent insomnia. 

(b) An unusually high and resistant fever or a total absence of febrile reaction 
in cases in which feeble resisting power is combined with serious subjective symp- 
toms and extreme physical manifestations of the disease. 

(c) The preexistence of a badly damaged heart or vascular system and ante- 
cedent or concurrent signs of failing compensation. 

(d) Evidence of pancarditis. 

(e) High-grade cyanosis; rapid onset of either cyanosis or pallor, and a 
decided increase of precordial pain or distress, with a stationary exudate, or, one 
persisting after drainage of the pericardium. 

(f) Excessive rapidity of the heart, especially if paroxysmal; the occurrence 
of the pulsus irregularis perpetuus indicative of fibrillation of the auricle or a 
running beat of great feebleness. 

(g) Inability to maintain the obligatory sitting posture even though ortho- 
pnea be present. 

(h) Sighing, Biot, or Cheyne-Stokes, respiration which may indicate renal 
involvement or myocardial insufficiency. 

(i) Decided or rapidly progressive diminution in the urinary excretion, 
after the pericardial exudate is established. 

(j) An excessively rapid and extreme filling of the pericardium. This rare 
event may terminate life in a few hours if unrelieved. 

(k) The presence of a purulent or sanious effusion. As previously stated, 
these cases demand immediate radical surgical relief and only in rare instances 
can recovery take place without it. 

(/) Persistence or sudden onset of extreme pain in a case of established effu- 
sion; great precordial or epigastric distress or oppression, sudden extreme 
physical weakness. These usually indicate decided myocardial involvement and 
inasmuch as the diastole of the heart and its intrinsic circulation are already 
embarrassed by the intrapericardial pressure of massive exudates it constitutes 
a serious and usually fatal complication though under prompt aspiration recovery 
may take place. 
' (m) Syncopal attacks. The gravity of such a complication needs no discussion. 

(n) Manifest hepatic engorgement, excessive turgidity or direct systolic pulsa- 
tion of the jugulars and progressive edema are one and all symptoms of decom- 
pensation resulting from a weakened toxic insufficient myocardium. 

(o) A listless rolling of the head from side to side when the patient is sitting 
propped up on his pillow is sometimes observed in pericardial effusion as it is 
in terminal cases of mitral disease and decompensation and conveys the same 
prognostic meaning, viz., the probability that death is impending or not far 
distant. 

(p) Renal complications chronic or acute. 

(q) The development of valvular murmurs whether these result from myo- 
cardial weakness or an actual complicating acute endocarditis. 
5! 



802 MEDICAL DIAGNOSIS 



The one is a direct indication of threatening myocardial insufficiency, the 
other strongly suggests a pancarditis. 

In general, the murmurs of an established acute endocarditis are louder and 
more definitely transmitted than those of myocardial weakness alone. 

(r) Excessive pulmonary engorgement or the onset of the liquid rales of edema. 

(5) Persistent and exhausting hiccough. 

Finally, if should be remembered that in every case of dry pericarditis, of 
whatever duration, an effusion should be sought for most diligently at each v-isit. 

ANEURYSM OF THE HEART.— This rare condition may be saccular 
and associated with coronary sclerosis, acute or chronic mural (viridans) 
endocarditis or acute myocarditis, or gummata. As a clinical curiosity 
dissecting aneurysm may be encountered. Death occurs usually from rup- 
ture and the disease cannot be diagnosticated antemortem. In almost every 
instance, it represents an antecedent coronary infarct and consequent 
myomalacia cordis. 

RUPTURE OF THE HEART.— This extremely rare condition occurs only 
in persons having a degenerated heart muscle and. in such, may result from a 
fall, strain or other traumatism, such as is apparently insiifficient to produce 
such an accident. Usually it occurs in the anterior wall of the left ventricle, 
rarely in the right, and causes death instantly or within a few moments, pre- 
ceded by severe pain, oppression and symptoms of collapse. This condition 
is medico-legally important. 

FOREIGN BODIES IN THE HEART.— The organ is much more tolerant 
than is generally supposed; exploring needles, sewing needles, hat pins and 
even a knife or bullet may not cause death, indeed a small needle may be 
introduced with a minimum risk of a fatal result and it has even been sug- 
gested or actually employed as a therapeutic dernier ressort for cardiac stimu- 
lation. According to W. G. Thompson, war records show an astonishing ex- 
emption of the heart from bullet wounds, though the statement is based upon 
the Civil war records which antedated the use of high-penetration projectiles. 

NEW GROWTHS OF THE HEART.— New growths, tuberculosis, 
syphilis, various forms of sarcoma and carcinoma, and more rarely the myo- 
mata, lymphoma ta or fibromata may involve the heart. It may be the seat 
of abscess in pyemia, malignant endocarditis and acute myocarditis, or the 
seat of degenerative or cysticercus cysts. 

SITUS VISCERUM INVERSUS.— As a part of the general transposition 
of organs occasionally observed as a congenital phenomenon we may find the 
heart upon the right side, the left ventricle being anterior and the apex in the 
usual relation to the nipple, as in its normal position. Such transposition is 
sometimes complete as regards the other organs, sometimes partial. Apparent 
transposition of the heart is common, but usually proves to be due to a combi- 
nation of Unilateral pressure and lack of support.* As a temporary condition 
extreme degrees of displacement may be associated with pleural effusions. 

* In a case seen with Dr. B. J. Merrill, apparent complete displacement was due to 
almost complete tuberculous excavation of the right lung, with enormous hypertrophy 
of the left. 



CERTAIN RARE CARDIAC CONDITIONS 



803 



DISEASES OF THE ABDOMINAL ORGANS 



THE ABDOMEN. (Abdo, I conceal). — Excepting the brain, this ever has 
been the most obscure region of the human body because of the shifting, air- 
containing, obscurant intestinal coils, its inaccessibility to direct examination, 
and the comparatively slight value of certain of the physical methods so valuable 
in thoracic diseases. 

On the other hand, the recent astonishing development of clinical and 
laboratory methods and especially of the roentgen-ray technic, together with 
a better understanding of the meaning, scope and therapeutic needs of the so- 
called functional disorders of the abdominal viscera, have greatly advanced 
the diagnosis and treatment of the more common and important intra-abdom- 
inal lesions and as a result the legitimate field of the exploratory incision has 
been greatly contracted and careful and painstaking medical methods, both 
diagnostic and therapeutic, are replacing the former all too precipitate ten- 
dency to resort to operation. 

TECHNIC OF ABDOMINAL EXAMINATIONS.— The customary pre- 
liminary cathartic is necessary in advance if the X-ray is to be used or tym- 
panites is present.* It removes misleading fecal masses, but may produce 
a flatulent distention and troublesome peristaltic activity if abundant time 
is not allowed for its immediate effects to subside. 

A thorough flushing by enemata is usually sufficient and preferable save 
in preparation for special forms of roentgenographic examination. 

Measures Preliminary to Palpation. — The head and shoulders both, but 
particularly the former, must be high, the feet firmly placed and the patient 
in an easy and unconstrained dorsal posture. 

To relax the walls, it is usually stated that the knees must be drawn up, but 
oftentimes, as good or better relaxation may be had with the legs extended or 
but slightly flexed and furthermore the flexed thigh and knee are much in the way. 

The breathing of the patient should be deep but easy and natural, with 
the mouth open and his attention should be diverted by conversation and 
inquiry. 

The hands should be warm, the light should be adequate, its source behind 
the patient, and no clothing or other covering should be allowed to obstruct 
or embarrass the examiner. 

In some cases nothing less than a full hot bath or even general anesthesia 
suffices to establish full relaxation. 

Proper Use of the Hands. — The flat of the palm and fingers, not the tips, 
should be. used with a sliding motion. Tender areas should not be immedi- 
ately approached, nor does the discovery of one justify the painful repeated and 
purposeless punching and poking so often inflicted upon the long-suffering 
patient. 

* Many conditions are so frankly shown as to make unnecessary any such preliminary 
procedure and in the usual first examination of the patient it is customary to omit such 
troublesome preliminaries. For the formal and critical examinations proper preparation is 
indispensable. 



Obscure 
region. 



Modern 
advance. 



Lessening 

surgical 

precipitancy. 



Catharsis. 



Enemata. 



Indispensable 
preliminary. 



A common 
imposition. 



804 



MEDICAL DIAGNOSIS 



Respiratory 
mobility. 



Vital points 



Galambro's 
method. 



Useful device. 



A valuable 
maneuver. 



The deep or superficial character of any pain or tenderness developed by 
examination and its precise localization or extent of diffusion should be ac- 
curately determined, but useless and unnecessary maneuvers should be 
avoided. 

In palpating movable organs or growths respiratory movement should be met 
directly by the tips of the fingers at right angles to the free margin, the hand being 
firmly but gradually depressed in deep expiration and allowed to rise laggingly 
and shift slightly upward to meet the descending border in inspiration. 

The fingers should always be relaxed to the utmost, otherwise the tactile 
sense is distinctly blunted. Once the hand is laid upon the abdomen, it 
should remain there and all movements made to intercept a viscus should 
carry the surface tissues upward with the hand. Allowing the hand to glide 
over or to leave the surface is a violation of sound technic. 

// the organ or growth under examination is both movable and capable of 
being grasped bimanually, the opposite palpating hand should be almost motion- 
less as the other brings the organ or tumor to it. 

After tolerance to palpation is established, the palmar surface of the ter- 
minal phalanges may be used to determine consistence and outline. 

Involuntary Abdominal Rigidity. — This common and serious obstacle to 
palpation may be transient and easily controlled by diverting the attention 
of the patient and having him breathe slowly and count aloud the respira- 
tions or it may require the use of Galambro's bimanual technic. This is 
nothing more than an attempt to forcibly overcome the rigidity by upward 
pressure at distance, while the other hand carries out the palpation. 

The Fat Belly. — A very fat abdominal wall, even though in a state of 
maximum relaxation, may interpose most serious or even insuperable diffi- 
culties. These may usually be overcome in considerable measure by the 
double-hand-palpation method of Hausmann. This consists merely in 
laying the otherwise unemployed hand directly upon the palpating hand and 
relieving the latter of all necessity for exerting pressure, to the end that it 
may remain relaxed and maximally sensitive.* 

Dipping. — This special procedure is. of use in detecting the presence of 
tumors or for determining the outline and consistency of the spleen or liver 
under conditions associated with the presence of fluid in the peritoneal cavity. 

It consists of abrupt shallow or deep downward thrusts with the finger 
tips according to the relation of the organ sought to the surface. 

Malingering or Hysterical Patients. — Such may often be misled or 
diverted by conversation and especially by rapid, emphatic interrogation. 
Abruptly directing their attention to some indifferent region which is being 
explored by one hand while the other palpates the supposed tender point, 
and the making of leading or even misleading, positive false statements as 

* These methods are thus named in order that they may be recognized by the student 
when so described elsewhere. 

Both are old procedures which have been employed probably ever since man became 
interested in the physical examination of his sick brethren. At all events the author can 
certify to their common use since the late eighties of the nineteenth century. 



EXAMINATION OF THE ABDOMEN 



So: 



to the necessary or anticipated effect of pressure, forced respiration, and the 
like often exposes spurious symptoms. 

The dorsal posture is the best for general purposes, but the lateral is of 
value for palpation of the spleen, the detection of movable fluids and floating 
kidney, or for the purpose of " spilling" " the intestines of a large-bellied 
person and rendering more accessible the lateral region under examination. 

The patient sometimes with advantage maybe placed upon the hands and 
knees or in the knee-chest position to bring a growth forward against a thin 
and relaxed abdominal wall or to demonstrate the otherwise obscure effusion. 

All portions of the abdomen shoul-d be thoroughly examined, not forgetting 
the hernial openings, the stretching or patency of which no less than actual 
hernias may be the cause of much obscure pain, usually absent when the 
patient is recumbent and increased by standing and by cough. 

POINTS TO BE DETERMINED.— a The conditions of the organ under 
observation (size, outline, condition of surface, mobility, tenderness). 

(b) The presence of swelling or tumors ''intra- or extra-abdominal, size. 
outline, surface, mobility, tenderness, associated symptoms). 

(c) Presence of pain or tenderness (true or false, intensity and character, 
exact location, superficial or deep, and the effect of pressure; . Pain increased 
on pressure ordinarily suggests inflammation, but the utmost care and cau- 
tion are necessary to avoid being misled by spurious or referred pain, tender- 
ness and even an apparent defensive rigidity, the true source of which may be 
an inflamed pleura or a diseased heart. 

General Inspection. — -The nutrition, musculature and abdominal outline 
are first noted. 

General distention may be due to tympanites, ascites, chronic tuberculous 
peritonitis, great dilatation of the stomach or colon, advanced pregnancy 
or large ovarian tumor. 

Localized distention or swelling suggests hysteria (phantom tumor), 
ventral hernia, abscess, intestinal obstruction, new growths, dilatation or 
displacement of the stomach. 

Abdominal Flaccidity. — One of the most important of the stigmata of 
congenital asthenia and its associated visceroptosis is the decided loss of tonus 
in the abdominal musculature. The degree of flaccidity depends upon the 
grade of the constitutional defect primarily, and secondarily upon the general 
state of nutrition at the time of examination and the occupation of the 
individual.* This is a condition apart from that noted below. 

The flaccid pendulous abdominal wall of middle-aged women who have 
borne children may reach an extreme degree of relaxation and if nutrition 
has become impaired the tissues may literally hang in a fold. In such cases 
diastasis ''separation; of the recti is frequent. 

In all cases the tonus and structural continuity of the abdominal muscles 
should be tested by asking the patient to raise the head and shoulders alone, while 
lying in the full dorsal recumbent posture. 

* One should note particularly the absence of a good musculature in hard working meD 
and women who should show, normally, decidedly firm muscles. 



Lateral 
posture. 



Knee-chest. 



Hernial 

opening's 

important. 



An important 
stigma. 



"Hanging 
belly." 



Useful test. 



8o6 



MEDICAL DIAGNOSIS 



Lineae 
albicantes. 



Linea nigra. 



Caput 
medusae. 



How to in- 
crease it. 



Obstructive. 



"Ladder 
pattern." 



Surface Appearances. — The skin may show an acute exanthem, syphilis 
or skin diseases, areas of pigmentation, atrophy and the various hues and 
discolorations already discussed under the "outward signs of disease." 
The white or bluish striae may indicate respectively past or present disten- 
tion by tumor, pregnancy, ascites or excessive fat, or the linea nigra, a dark 
median vertical line, may indicate a pregnancy existent. 

Enlarged Superficial Veins. — As stated previously, the superficial veins may 
be enlarged in the case of portal or caval obstruction, the former indicating 
hepatic cirrhosis, tumors or prolonged ascites; the latter, thrombosis or the 
pressure of abdominal growths. 

If the superior cava be obstructed, the direction of the blood flow in the 
enlarged lateral superficial veins (readily determined by emptying one and 
watching its refilling) will be downward; in other conditions it is upward. 
In hepatic cirrhosis and portal thrombosis, large veins may radiate from the 
umbilicus {Caput Medusa) and the blood flows from that as a center. 

In obstruction of the inferior vena cava the lateral superficial veins of the 
abdomen are chiefly affected. 

If the visible venous distention is most marked in the pubic surface-segment^ 
obstruction below the liver is suggested. 

Congenital Occlusion of the Aorta below the Ductus Botalli. — This con- 
dition, indicated by enlargement, prominence and pulsation of the epigastric, 
scapular and internal mammary arteries, is a clinical curiosity, but usually 
should offer no great diagnostic difficulties. The collateral circulation may 
be easily and well maintained because the block lies beyond the area of origin 
of the great aortic branches. Over the arteries named one may hear mur- 
murs and a palpable thrill may be present.* 

The contrast between the strong full pulse in the upper extremities and the 
faintness or entire impalpability of that of the lower extremities is usually very 
striking. 

Visible Peristalsis. — In the presence of emaciation and -a thin and relaxed 
abdominal wall, peristaltic movements may be noticeable and are readily 
made more pronounced by snapping the surface with the finger-nail or wet 
towel, splashing upon it a little ether or applying the faradic current. 

Normally the movements are deliberate and wave-like and occur usually 
without borborygmi; but in acute obstruction they may seem to be fiercely attack- 
ing the stenosed region. 

Normal stomach peristalsis runs from left to right; that of the transverse 
colon from right to left, a point slightly diminished in value because of occa- 
sional reversed gastric peristalsis in marked pyloric obstruction. In relation 
to obstruction of the bowel, acute or chronic, the sign is of distinct value; 
that of its commonest forms, the "ladder pattern" peristalsis, running from 
one region of the ileocecal valve toward mid-abdomen, f In sigmoid obstruc- 

* See " Congenital Heart Lesions." 

f In two such instances observed by the author marked obstruction due to appendicitis 
existed for a period of thirty years, the diameter of the tube having been reduced to that 
of a crow quill. In one case the recurrent attacks had been so violent as to have led to 
an operation for gall-stones, the pain being to some extent referred to the hepatic region. 



EXAMINATION OF THE ABDOMEN 



807 



Hon there is increased violent peristalsis along the course of the colon and a 
cooing or loud rumbling associated with any disappearance of distention which 
at times sharply localizes the point of constriction. 

One of the commonest causes of increased visible peristalsis is stenotic 
dilation of the stomach. 

TOPOGRAPHY AND REGIONAL DIVISIONS.— Boundaries— The 
spine, inferior costal margin, iliac crest, Poupart's ligament and the pubic 
symphysis bound the abdomen and the diaphragm roofs its cavity and im- 
parts respiratory movement to the liver, spleen, and, less directly, to the 
kidneys and stomach. A transverse line at the level of the base of the ensi- 
form roughly bounds the abdominal cavity above; the brim of the true pelvis, 
below. 

The Abdominal Quadrants. — A median vertical intersecting a horizontal 
line at the navel divides the abdomen into four quadrants. 

In describing the contents of the abdomen with relation to these arbitrary 
divisions, one can take account only of normal conditions. 

These may be and commonly are greatly modified in the cases of viscerop- 
tosis so frequently present in sick and well alike. 

The upper right quadrant contains the liver, gall-bladder, head of pan- 
creas, kidney, the hepatic colonic flexure, a portion of the transverse colon 
and the pylorus. 

The upper left quadrant includes the left extremity of the liver, the spleen, 
splenic flexure, a part of the transverse colon, left kidney, the fundus of the 
stomach and most of the pancreas. 

The lower right quadrant contains the ascending colon, cecum and the 
vermiform appendix. 

The lower left quadrant covers the descending colon and the sigmoid 
flexure. The uterus and ovaries are anatomically pelvic and not 
abdominal. 

The Bony Landmarks. — The anterior-superior spine of the ilium, iliac 
crest, pubic spine, lower ribs, costal margin, and the ensiform, are the chief bony 
landmarks. 

External Landmarks. — The linea alba and the navel are always in evidence 
and the rectus muscles, which are divided into segments by the linece trans- 
versa and bounded externally by the linece semilunares, are easily distin- 
guishable in thin muscular abdomens. 

The umbilicus usually lies from ij^ to 2 inches above a line connecting 
the anterior-superior iliac spines, being opposite the tip of the third lumbar 
spinous process. 

The tenth and twelfth ribs and the projection representing the ninth cartilage 
are also important landmarks. 

The abdominal aorta bifurcates opposite the fourth lumbar vertebra % 
of an inch to the left of and below, the navel. 

The ileum and jejunum occupy chiefly the center and lower portion of the 
cavity, the ileum largely on the left and the jejunum on the right and below. 

The colon, somewhat less movable, passes from the cecum upward and 



Arbitrary 

boundaries 

impossible. 



Linese trans- 
versa and 
semilunares. 



Opposite 3rd 
lumbar. 



Bifurcation of 

aorta. 



-- 



MEDICAL DIAGN" 



Usui: Wilt , 



Vermiiorm 
appendix. 



McBumey's 
point. 



: :he right, then turning (hepatic flexure), runs transversely above th.e 
umbilicus (transverse colon) under the left costal margin; then passing 
(splenic flexure) downward and inward (descending colon and sigmoid flexure) 
: : terminate in the rectum. 

The hepatic flexure lies under the arch of the liver, the splenic even higher 
under the left ribs. 

The transverse colon, sigmoid flexure and cecum are relatively superficial 
and the vermiform appendix lies with its base at a point representing the inter- 
section of the outer edge of the right rectus with a line drawn from the anterior- 
superior iliac spine to the umbilicus McBurney's point . It lies behind and 
to the inner side of the cecum with its apex downward, outward, inward, or 
rarely upward. 

The position of the transverse colon especially is very variable and it may 
dip as low as the true pelvis in cases of marked visceroptos 

The transverse colon, cecum, and sigmoid flexure are accessible to pal- 
pation by the method referred to under palpation of the stomach. 

J ; r the transverse colon the ringers should be directed upward at various 
levels for it may lie as low as the h}-pogastrium in visceroptotic patients. 

It does not move with respiration, but is quite freely movable and feels 
like a cord under the fingers. 

The cecum is palpated by passing the fingers deeply downward along the 
inner aspect of the ilium at the anterior- superior spine and pushing toward 
the navel and backward with gliding movements. 

It is somewhat easily palpated and is quite often movable ("cecum 
mobile"). A characteristic gurgle usually attends its manipulation and severe 
pain elicited by moderate but firm deep pressure upon the gut, toward the 
navel, raises at once the question of chronic appendicitis. 

The sigmoid flexure may often be palpated as a thin somewhat tense cord 
just above the fold of the left groin. Its tumors ordinarily He too low to be 
reached by the fingers. 

The Liver and Gall-bladder. — The normal percussion outline of the liver 
is shown by the following table.* 



MlL'lr LlH: 



Af ftm miliar y line 



:•:;-- 



Lzt j:i::.i: Lire 



Dee; 
dulne!: 

Surerzzial 



Upper 

ii~i: 



Lower limit j 



F;ur:b srize 



Seventh space Xinth space 



Blends with. Sixrh rib 
heart duliiess 



Eighth rib _er.:b rib 



Hand's breadth below Costal margin or Tenth space Blends ~i:b 
base of xiphoid 



somewhat above 

: : :el:~ :: 



kidney dul- 
zer~ 



Left lobe and 
notch. 



It should be noted that the left lobe extends nearly to the left nipple line, 
the interlobar notch lying in the median line. In children the liver lies lower, 
in old persons either higher or lower. 

* Hutchinson and Rainv: "Clinical Methods." 



EXAMINATION OF THE .ABDOMEN 



809 



The Gall-bladder. — This lies just without the right rectus under the 
projection of the ninth costal cartilage. 

The Spleen. — This important organ lies just outside the spine in close 
relation to the diaphragm above the left kidney, posteriorly, and the colon, 
stomach and small intestines below. 

It is oval, flattened, from 3 to 5 inches in length and lies parallel to and 
within the area of the ninth, tenth and eleventh ribs, its anterior margin 
reaching normally a line dropped from the stemo-clavicular joint to the point 
of the eleventh rib, two-thirds of its outer surface being parietal and lying 
between the posterior and mid-axillary lines. 

The Kidneys. — These lie behind the peritoneum upon either side of the 
spinal column on the muscular bed formed by the lumbar muscles. They are in 
virtual contact above with the liver on the right side and the spleen on the left 
and move laggardly and to a slight degree with respiration. 

The right kidney is slightly lower than the left because of the overlying 
and impinging liver and each lies two- thirds within the mid- clavicular line. 
The lower border of the right is 1 inch and that of the left 1^ inches above 
the level of the navel. 

Posteriorly, they lie within a parallelogram represented by two verticals 
drawn 1 inch and 2% inches respectively, from the spinous process, and con- 
nected by two horizontals representing the eleventh dorsal and third lumbar 
spines. 

Therefore, about one-third of their surface is covered by the eleventh and twelfth 
ribs. Their lower extremities lie from 1 to tj^ inches respectively above the 
crest of the ilium. 

THE LIVER. — Inspection sometimes shows a lower-border shadow de- 
scending with deep inspiration, a very definite bulging if the enlargement be 
great, and not infrequently, in malignant disease, the respiratory descent and 
ascent of nodules upon its surface. The normal percussion outlines have 
already been given. Simple auscultation is of little value save in the detec- 
tion of peritoneal friction in inflammatory lesions or abscess, and the most 
useful physical method is palpation. 

Palpation. — The normal liver can often be palpated easily if the abdominal 
wall is relaxed and the liver edge is met by the fingers as the firmly depressed 
hand rises laggardly with the wall in deep inspiration. 

Directness and immediateness of imparted vertical movement in response to 
forced inspiration are characteristic of the liver as compared with the slightly 
delayed descent of the movable kidney or pyloric growth, or the diagonal descent 
of the spleen. It is absent only when adhesions exist or diaphragmatic descent 
itself is limited or absent. 

A firm resistant liver edge suggests cirrhosis, chronic congestion, amyloid 
disease or tumors, and is found in many of the diseases associated with chronic 
enlargement and induration of the spleen. Rarely in adults and more often 
in children, the liver may pulsate directly and expansively from tricuspid 
regurgitation, and yet more often there appears a transmitted pulsation due 
to a dilated overacting right ventricle. 



Border of 
rectus and 9th 
cartilage. 



Anterior 
relations. 



Posterior 

relations. 



Technic. 



Type of 
mobility. 



Fixation. 
Consistence. 



Expansile 
pulsation. 



8io 



MEDICAL DIAGNOSIS 



Percussion. — A reduced area of percussion duhiess is especially significant, 
if it involves the region of the left lobe, as this is earliest affected in atrophic 
cirrhosis. 

Diminution of the upper (thoracically sheltered) liver area may indicate 
hepatic contraction but is more often due to changes outside of the liver itself, 
such as emphysema of the lung, pneumothorax *or, very rarely, diaphrag- 
matic hernia. 

By reason both of the respiratory mobility of the liver and the descent 
of the lung border this area varies with deep breathing. 

Auscultatory percussion is especially valuable in outlining the left lobe or 
in deciding the origin or attachment of a tumor. The stethoscope is placed 
over the thoracic area of superficial hepatic dulness while the finger taps the 
surface in radiating lines until the decided change of note indicates that 
hepatic tissue has been passed.* 

Attached tumors will usually yield the hepatic note. 

Under certain conditions great enlargement of either the spleen or liver 
may be overlooked if palpation is not commenced well below the normal 
boundary. 

Conclusions. — Upward extension of dulness in the hepatic area 
suggests not only enlargement of the liver, but also pleural effusion 
or adhesions, pulmonary consolidation, hepatic or subphrenic abscess or 
displacement due to upward pressure and thrust of gas and liquid in the 
abdominal cavity. 

Diminution of upper boundaries suggests not only hepatic atrophy but 
asthma, emphysema, pneumothorax, gaseous distention of a subphrenic 
abscess, hepatic ptosis and rarely, massive pericardial effusion or extreme 
cardiac dilatation. f 

General enlargement may be due to passive congestion of cardiac 
origin, the commonest cause, to hypertrophic cirrhosis, leukemia, erythremia, 
Banti's disease, fatty liver, amyloid disease, syphilis, cancer, abscess, or 
pyemia. 

General shrinkage suggests atrophic cirrhosis, the commonest cause, with 
acute yellow atrophy as a rare possibility. 

It is obvious that either ascites or tympanites may force the liver upward and 
prevent any true and exact delimitation of its actual boundaries or proper 
examination of its surface. 

Irregularities in Surface Outline. — Such may be due to congenital de- 
fects, various enlargements and displacements, atrophic cirrhosis and indeed 
practically all of the conditions noted in a preceding paragraph. 

Of special significance are the nodular irregularities (sometimes showing 

* The reversed method, i.e., percussing toward the organ is preferred by many and 
one should use the one to confirm the results of the other. 

f Often, a downward displacement of the liver itself is associated with the two latter 
conditions, although this may be detectible only through the position of the lower border. 

The author has seen three cases of enormous aneurysm of the ascending portion of the 
aortic arch which blended their anterior duhiess with that of the liver. 



EXAMINATION OF THE ABDOMEN 



8ll 



crateriform depressions) associated with secondary carcinoma or a tertiary 
syphilis. 

Glissonian cirrhosis may produce marked shrinkage and deformity, 
whereas the tiny granular elevations of atrophic cirrhosis can be palpated 
only under exceptional conditions, as when the wall is thin and lax, though 
the sharp resistant liver edge of an advanced lesion is striking. 

Fluctuating or elastic swellings or tumors modifying the outline are due 
usually to a distended gall-bladder, associated perhaps with a Riedel's lobe. 
Abscess or hydatid cyst are among the unusual findings, the last yielding 
sometimes a peculiarly exquisite thrill (hydatid thrill), echoing the percussion 
stroke. 

It should be remembered that a greatly enlarged liver, easily- palpable, with 
a smooth hard surface, suggests leukemia and many other splenomegalic condi- 
tions, amyloid disease, passive congestion of long duration, hypertrophic cirrhosis, 
fatty liver, certain tropical diseases and interstitial forms of hepatic syphilis. 

Roughening suggests cirrhosis or tuberculosis and decided nodulation repre- 
sents usually carcinoma or syphilitic gummata. 

Finally it will be noted that mere increase or diminution in the hepatic 
area yields no information as to the actual size of the organ unless checked 
carefully with the conditions present in contiguous structures. 

Friction Sounds. — If any condition causing perihepatitis exists friction 
sounds may be audible upon auscultation. 

THE GALL-BLADDER. — Palpable only when distended, it may then form 
a pear-shaped tumor, smooth and elastic, anchored above but more or less freely 
movable from side to side, and, in the absence of adhesions, rising and falling in 
respiratory rhythm with the liver itself. 

Though seldom larger than the fist, these gall-bladder tumors may some- 
times extend as low or lower than the level of the navel and are often mis- 
taken for other conditions.* 

One often feels a depression or groove corresponding to its emergence 
from beneath the edge of the fiver and a narrow tongue-like projection of 
hepatic tissue may overlie it or be manifest when the distended gall-bladder 
itself is not palpable. This is the so-called Riedel's lobe and its presence may 
prove of value when a loop of gut obscures the outline of the gall-sac itself. 

Rarely a palpable crepitation may be obtained bimanually if gall-stones 
are present and the viscus may be nodular from malignant disease or, in long- 
standing cholecystitis, may undergo atrophy. 

In cholecystitis, quite apart from sensitiveness and defensive rigidity over 
the gall-bladder or liver itself, a zone of distinct tenderness may extend from 
a point 2 to 3 cm. to the right of the vertebral column at the level of the 
eleventh or twelfth dorsal vertebra across the infrascapular region and some- 
times into mid-axilla. 

THE SPLEEN. — A greatly enlarged spleen and more rarely one scarcely 
more than palpable may be seen to move with the respiration and, further- 

* These tumors in rare instances attain an enormous size. Alban Doran has reported 
one simulating ovarian cyst (British Medical Journal, June 17, 1905). 



Riedel's'lobe. 
Hydatidlthrill. 



Excessive 
enlargement. 



Roughened 
surface. 



Caution. 



May form 
large tumors. 



Source of 
error. 



A rare finding. 



An occasional 
finding. 



812 



MEDICAL DIAGNOSIS 



Chronic 
splenomegaly. 



more in any case of splenomegaly, a marked prominence of at least the left 
upper abdominal quadrant is produced.* 

As in the case of the liver, auscultation may reveal friction sounds in the 
presence of perisplenitis, or the organ may be anchored by adhesion, but it is 
ordinarily freely and directly movable with respiration, and palpation is the only 
method yielding dependable and accurate results. 

The position of the patient should be right lateral if minor enlargements 
are to be noted, as in typhoid fever or other acute infections, and the one 
hand should make pressure over the lower ribs in the post-axillary line while 
the other makes palpation. 

Abdominal distention defeats palpation save in great enlargment and, 
except in splenoptosis, the normal spleen is not palpable save in the rarest 
instances even when the left cup of the diaphragm is forced downward by liquid 
of serous effusion. 

If greatly enlarged, the dorsal position is to be preferred and it would seem that 
the condition can hardly be overlooked,^ unless, with a tense wall, the careless or 
hurried examiner fails to get below the actual border or to distinguish between 
muscular resistance and the splenic mass. In these cases the chief notch in 
the anterior border is sharply defined and quite distinctive. 

Students at first palpate too deeply and let the hand rise too slowly with inspir- 
ation to detect the minor enlargements. 

In the examination of both the spleen and kidney many prefer to grasp 
the flank with one hand rather than employ bimanual palpation. 

The student should use both methods and note and compare the results 
attained. 

Differential Factors. — In all cases where doubt arises as to the nature of a 
large tumor in the splenic area it should be remembered that a splenic growth 
or tumor is peculiarly superficial {in close apposition to the abdominal wall) 
and so accurately applied to the thoracic edge that the finger cannot be thrust 
between. Its dulness is marked and can be carried directly back to its normal 
area behind the ninth, tenth and eleventh ribs; it ordinarily moves directly with 
respiration, and, if the colon be inflated, splenic tumor dulness is not lost. 

Renal tumors extend more deeply, are relatively fixed or immovable, are 
likely to be reniform or nodular and in nearly every instance will be crossed 
by an area of resonance if the colon be distended artificially. 

Emphysematous lung or a pneumothorax may cause an apparent diminu- 
tion in the upper percussion area of the spleen or the pressure of tympanites, 
ascites, or even a widely dilated stomach or colon, may confuse the findings 
save in massive enlargement. 

Causes of Enlargement. — Excessive chronic enlargement may be due to 
chronic malaria ("ague cake"), the leukemias, splenic anemia, a splenic form 
of Hodgkin's disease, the Gaucher type of splenomegaly, congenital hemo- 

* In a case shown by the author to the Minnesota State Society a leukemic spleen 
filled the entire abdomen, actually reaching the right anterior superior spine of the ilium, 
and, as in many similar cases, the patient showed then no impairment of the general 
health, pallor, or malnutrition, and declined to cease work to take treatment. 

f As a matter of fact it is quite often overlooked or mistaken for some other form of 
abdominal tumor. 



EXAMINATION OF THE ABDOMEN 813 



enlargement. 



engorgement. 



lytic jaundice, Banti's disease (splenomegaly with hepatic cirrhosis 1, chronic 
tuberculosis, syphilitic hepatitis, amyloid, certain cases of atrophic or hvper- 
trophic cirrhosis, sarcoma, carcinoma, kala-azar, rarely echinococcus cysts 
or the Vaquez-Osler "erythremia.'' 

Lesser degrees of enlargement may be encountered in ordinary atrophic Lesser 
cirrhosis of the liver, rickets, pernicious anemia, passive congestion or actual 
portal obstruction. 

Acute enlargement is most often encountered in septicemia, acute lym- 
phatic leukemia, malarial fever, typhoid and typhus, erysipelas, acute miliary Acute 
tuberculosis, tuberculous peritonitis, cerebro-spinal meningitis, smallpox, 
diphtheria, scarlet fever, relapsing fever, infarct, plague and certain other 
tropical diseases. 

Enlargement of the spleen is nearly always uniform, abscess being an occa- 
sional, and hydatids or carcinoma an excessively rare cause of irregular outline, outline. 

Splenoptosis. — As a part of extreme visceroptosis, the spleen may be 
quite freely movable or actually "floating " and readily displaceable through "Movable 
change of posture or manipulation. 

Its notched border, peculiar soft consistency and oval contour when 
normal but displaced serve for its identification. 

KIDNEYS. — The normal kidney yields no results to inspection or ausculta- 
tion and indefinite ones to percussion. 

When enlarged by disease, it may be present itself in the anterior or pos- 
terior-lumbar region and be readily accessible to percussion and palpation. 

The sarcomata in children and cystic, tuberculous or hydronephxotic 
kidneys in the adult, are the most frequent causes of enlargement. 

Palpation. — The dorsal and semidorsal* postures are the best, and, in the Posture. 
latter, relaxation is assisted by supporting the shoulders and buttocks and 
bringing the hand and arm of the side under examination obliquely downward 
arid forward to hang relaxed across the abdomen. 

One hand of the examiner makes pressure over the floating ribs or just Technic. 
below them posteriorly, while the other is pressed deeply downward and 
slightly upward, outside the rectus border at or below the level of the umbili- 
cus and rises laggingly and slightly with each forced inspiration or cough. 

If the kidney is abnormally movable, it will slip downward in deep inspira- Degrees of 
tion oftentimes so as to be grasped between the tips of the apposed fingers 
of the two hands. 

The normal kidney yields to palpation only its lower pole and this only under 

>able conditions. Any greater degree of mobility constitutes movable kidney. 

If the organ is so movable and displaceable as to suggest a mesonephron, Floating 
it is a "floating kidney.'' Such are often overlooked because at the moment 
they occupy some distant portion of the abdomen and may fail to move with 
respiration. 

In extremely rare instances such a kidney may become fixed in its abnor- Sources of 
mal location. Floating kidneys have been reported as occurring in hernial 
sacs and, rarely, they may cross the median line. 

• The patient lying obliquely on the side opposite the one under examination. 



error. 



814 



MEDICAL DIAGNOSIS 



A useful 
posture. 



Albuminuria of 
manipulation. 



It is sometimes advisable that examination should be made with the 
patient leaning forward in the standing posture with the elbows or hands 
supported on a chair or table. 

This method sometimes reveals a far greater mobility than had been 
demonstrated by the usual technic. 

One oftentimes may approximate the tissues even above a movable 
kidney and feel its upward movement as it slips between the finger and thumb 
in expiration or when the patient slowly assumes the dorsal position. 

The head of the patient must be sharply flexed upon the chest if full relaxation 
is to be secured. 

Ballottement Renal. — (Guyon). — This special bimanual maneuver may 
bring the kidney into touch when other methods fail. 

Technic. — With the two hands in the usual position the ringers of the 
posterior (inferior) hand dip sharply into the loin and thrust the kidney for- 
ward on its muscular bed and within the reach of the finger tips of the 
anteriorly placed hand. The short, rapid, regular thrusts, recur in quick 
succession in order to permit determination of the kidney outline. 

The maneuver need not be excessively uncomfortable to be effective, 
but as in most instances of renal palpation albumin will appear in the next 
voiding of urine and should not mislead the observer. 

Twelfth Rib Pressure Point. — Firm pressure over the twelfth rib made 
whilst the patient is sitting erect or dorsally recumbent with relaxed muscles 
will often elicit a pain response or only an abrupt marked defensive rigidity 
of the overlying muscles, if the kidney is the seat of active irritation or inflam- 
mation acute or chronic. The sign often occurs in renal calculus lacking all 
active symptoms. 

It is well to bear in mind, however, that this particular area is normally 
more sensitive than the regions about it. 

Percussion. — The semidorsal position is best adapted for percussion which 
is usually superfluous, uncertain and often misleading. Occasionally displace- 
ment is suggested by the substitution of tympany for normal dulness or an 
unusual extension of the latter may point to diseased conditions but the 
region is ill adapted to dependable percussion results. 

Characteristic Features. — The reniform shape and peculiar consistence of 
the palpable or movable kidney are readily recognized unless the organ be mark- 
edly inflamed or the seat of a new growth. 

Under these latter conditions the tumor is readily palpable usually and may 
be relatively or absolutely fixed, regular or irregular in outline, smooth or nodu- 
lated, according to the nature of the morbid process. 

If the organ be merely movable, as is so often the case, its maximum displace- 
ment occurs near the end of full inspiration, a fact readily explained by its rela- 
tion to the diaphragm and the directly movable spleen or liver. 

Furthermore, such displaced kidneys are replaceable into the flank or normal 
kidney position and, as stated previously, infixed renal tumors artificial inflation 
of the colon usually establishes a band of resonance crossing or wholly obscuring 
ihe percussion dulness anteriorly. 



Of little value. 



Form. 



Surface. 



Lagging 
descent. 



Replaceability. 



EXAMINATION OF THE ABDOMEN 



815 



Secondary abscess in the renal region is not uncommon as a sequel of neglected 
appendiceal abscess, empyema, subdiaphragmatic abscess, caries of the vertebrce, 
etc. 

One must consider also the globular elastic or possibly fluctuating tumors of 
hydro- or pyonephrosis; the irregular cystic tumors; the denser more nodular 
malignant growths and the bogginess or induration of the perinephritic suppura- 
tions which tend posteriorly rather than anteriorly, in contradistinction to renal 
tumors. 

Chemic and microscopic examination of the urine, careful considera- 
tion of primary factors and the rtional use of tahe aspirating needle assist 
diagnosis. 

THE PANCREAS.— Only in the rarest instances can the head of the fixed, 
deep-seated, normal pancreas be detected at a point 3 to 4 cm. to the left 
of the navel, and this only by palpation in those carrying an extremely thin 
and relaxed abdominal wall and extreme downward displacement of the 
stomach. 

HELPFUL DATA RELATING TO ABDOMINAL TUMORS.— Certain 
special points of diagnostic value may be stated here with propriety even 
though the main characteristics of tumors with relation to physical diagnosis 
are given in the discussion of individual viscera or their diseases. 

Fecal Impaction. — If impacted fecal matter is palpably of soft doughy 
consistence, this fact alone suffices usually for its recognition. Unfortu- 
nately this is not always the case and frequently masses of almost stony hard- 
ness are encountered and may and do cause serious and damaging diagnostic 
error in many instances. 

These masses may present themselves in any portion of the great gut from 
the cecum to the anus. 

In form, feel and consistence they may exactly simulate malignant 
growths. 

They may be present as channeled masses in patients reporting one or 
more daily bowel movements though constipation is the rule. 

In some instances they resist to an extraordinary degree the action of 
ordinarily efficient cathartics. 

Co-existing with actual new growths of the intestines they may lead to 
erroneous conclusions as to the form, size and consistence of the true growth 
itself. 

They may or may not be quite freely movable. This rather common 
mobility should not be considered as an absolute finding. Mobility depends 
upon the segment of gut involved and the presence or absence of marked 
visceroptosis. Cecal impactions, for example, are usually immobile but may 
be quite freely movable if the u cecum mobile" exists. 

The following points aid greatly in the differentiation of fecal masses: 

(a) There is usually a history of constipation. 

(b) The tumors are as a rule of doughy consistence and take slowly the 
forcible sustained impress of the finger much as does the " leathery edema" of the 
legs in certain cardiovascular cases. 



Abscess. 



Points of 
importance. 



"Stony" 

masses 

misleading. 



Channeled 
impactions. 



Mobility 
variable. 



8i6 



MEDICAL DIAGNOSIS 



Unfortunate 
precipitancy. 



Segmental 
spasm. 



Significant 
associations. 



Crucial test. 



Confused 
definitions. 



(c) The most frequent sites are the hepatic, sigmoid, and splenic flexures and 
the colon. The impactions are often multiple, tend to follow the known anatomic 
direction of the portion of the gut involved and to assume a cylindrical form. 
This point is subject to many exceptions but of value nevertheless. 

(d) Hard impactions may crumble under a persistent manipulation. 

(e) They, as a rule, are less tender than either benign or malignant new 
growths. Exceptionally they are extremely sensitive but in such cases there is 
likely to be a history of overmuch manipulation antedating the examination. 

(f) They seldom wholly resist free catharsis alone. 

(g) They may show decided change of form and consistency following re- 
peated oil injections or the usual enemata, even if not wholly removed. 

(h) If heavy pressure is made over the mass and gradually released, one may 
feel the release of the wall from the contained fecal mass. 

This is Gersuny's " adhesiveness sign" ( u klebs Symptom"). It is far from 
impeccable. 

(i) However intractable primarily, such tumors disappear almost invariably 
under such repeated use of enemata and catharsis as is proper in any doubtful 
case of intestinal tumor, especially if this be combined with the free use of oil 
injection by mouth and gentle massage. 

Finally. — Many bellies have been opened only to find a fecal impaction 
instead of the new growth expected. All cases of obscure tumor within the 
abdomen which resemble new growths but are unassociated with cachexia 
demand that the measures outlined above be carried out before any positive 
diagnosis is made. 

Indeed an appearance strongly suggesting the cachectic state of malig- 
nancy may be present in long-standing cases of fecal impaction. 

Phantom Tumor. — Segmental muscle spasm especially of the rectus 
abdominis is sometimes astonishingly like an intra- or extra-abdominal new 
growth in appearance and, yet more often, a milder transient contraction 
may falsely suggest localized defensive rigidity. 

This rare form of phantom tumor is much more deceptive sometimes than 
the description would indicate, but to the eye and touch of the experienced 
observer it does not " conform." There is that in its appearance that excites 
a suspicion which is usually strengthened by its common association with 
psychasthenia or actual hysteria. 

Its anatomic situation and limitations are suggestive and helpful, its extra- 
abdominal nature is usually easily established by the maneuvers already 
described under "abdominal palpation" and if doubt remains, a few whiffs 
of ether or chloroform, sufficient merely to produce relaxation, at once re- 
moves it. 

It is seldom necessary to push anesthesia beyond that early and harmless 
stage when the arm of the patient, kept steadily at the vertical by repeated 
command of the physician, drops inertly down. 

Much confusion seems to exist in the minds of medical writers as to what 
constitutes " phantom tumor" for there are many transient swellings 
associated with muscular spasm to which that term may be applied, 



EXAMINATION OF THE ABDOMEN - : 7 



sr:"ir 



Vi- 



and individual choice seems to determine the descriptions given by the 
authori: 

Spasm of intestinal segments and coincident gaseous distention may ac- 
count for certain phantom swellings of considerable persistence and a 

Mere disorders of peristalsis produce at times a small knob-like projection 
which may last for several minutes. 

Sometimes the name is applied, wrongly one would believe, to extreme 
but transient general gaseous distention of the abdomen sue: rn often 

in the psychasthenic and hysterical or psychasthenic an 5 

We all swallow air, but the " aerophagi" swallow it excessively and against 
increasing pressure and may attain thereby alarming abdominal proportions The 
or merely such distention as keeps them uncomfortable, and still swallowing 
unless corked up. As stated elsewhere this may actually be accomplished 
by having them hold between the teeth a large cork, which makes effective 
deglutition difficult or impossible. 

Idiopathic dilatation of the colon has been described as "chronic phantom 
tumor," a manifest misnomer, for this condition could never be described 
as chronic without at least the addition of the words " remittent"' or "inter- 
mittent." 

A not uncommon phenomenon, sometimes described with dubious pro- 
priety-, as phantom tumor, consists in the protrusion of certain gas-filled 
intestinal coils without evidence of marked intestinal spasm, but to such 
a degree and in such locations as may produce a striking and bizarre 
appearance. 

In some such cases voluntary or involuntary diaphragmatic action seems 
to initiate and maintain the tumor. 

The type first described is that to which the term is applied most fittingly. 

Nearly all of the forms described occur in nervous or hysterical women 
and usually in such as are congenitally asthenic, badly nourished and carry 
a thin, relaxed abdominal wall or are afflicted with actual diastases of 
the belly muscles. Most of the swellings of intestinal origin are easily 
recognized as ephemeral and in any event all that are due to spasm yield t : 
anesthesia. 

Hypogastric Tumor. — Retention of urine produces hypogastric tumor 
which may reach large dimensions and have the elasticity and, perhaps, the 
fluctuation characteristic of accessible encysted liquid accumulations. The 
introduction of a catheter resolves all doubt, which is seldom great. 

In stuporous or unconscious patients it must be anticipated. se.::- 

Enlargement of the uterus produces a solid tumor in the same region and 
its nature is readily established by bimanual vaginal examination. 

Ovarian Cyst. — If large enough this may be detected in the same area as 
an elastic round tumor showing fluctuation, but it is usually obviously one- 
sided as to origin and attachment until it attains large dimensions and simu- 
lates ascites. It lacks, however, the bulging in the fla n ks and the change 
in percussion resonance and abdominal outline, attending changes of p : 
tion, and characteristic of free ascitic fluid in the abdominal cavity. 



MEDICAL DIAGNOSIS 



Violent 
pulsation. 



Lacks other 
aneurysmal 
signs. 



Value of 

inflation. 



Direct 
movement. 



Hesitant 
descent. 



•Tagging. 



Fixation. 



Pseudo-abdominal Aneurysm. — True aneurysm of the abdominal aorta 
is extremely rare. A more or less violent or prominent pulsation of an ob- 
trusively palpable aorta is very common in exophthalmic goitre cases or in 
congenital asthenics who are poorly nourished. 

In these the aorta shows no such bulging or change in the uniformity of 
its outline as could be regarded as a true sac or genuine dilatation. 

In such patients the subjective sense of. pulsation is often troublesome 
and becomes a source of complaint. 

Misinterpretation of a Palpable Pylorus. — If in the upper abdominal 
palpation the contracted pylorus is encountered as a firm, short tumor-like 
body, it may lead to mistaken conclusions. 

Its relaxation will promptly follow unless it is the seat of spasm, the rhyth- 
mic alteration in consistence persists and error is rare if both its normal 
position and enteroptotic modifications of site are remembered. 

If spasm actually exists the relation of the mass to the stomach may 
readily be determined by inflation and evidence of ulcer or erosion should be 
sought. 

DIFFERENTIAL POINTS RELATING TO TUMORS.— Abdominal 
tumors, apart from mere enlargements, are usually malignant or tuberculous. 

Nodular hard tumors are almost invariably carcinomata. 

Sarcomata are uncommon and usually present a firm smooth surface 
offering perhaps, areas of softer consistency. 

Benign growths, when such occur, are usually hepatic in seat, though this 
must not be taken as meaning that the liver is not a frequent source of sec- 
ondary carcinomatous new growths. 

In establishing the anatomic site of a tumor, aside from cases of evident 
organic connection, its range and type of respiratory movement, fixation, or 
passive mobility are of chief importance. 

But two abdominal viscera, the liver and spleen show respiratory move- 
ment so immediate and direct as to be practically coincident with the inspira- 
tory and expiratory phases of respiration. Such movement in tumors dis- 
tinctly suggests an hepatic or splenic origin. 

The stomach shows a definite respiratory change of position, less marked 
if visceroptosis is present, and to a somewhat less degree this is true of the 
colon. 

The kidney shows a lagging displacement which, as to extent, varies 
greatly with the conditions surrounding its anchorage in the individual, 
though even a normal kidney may slightly increase its range if it becomes the 
seat of a growth of considerable size. 

Kidney tumors, however, whether new growths or of inflammatory origin, 
show a strong tendency to become fixed. 

Pancreatic tumors are fixed at all stages. 

True aneurysm, enlarged retroperitoneal glands, bone tumors and the cold 
abscesses resulting from caries are one and all immovable. 

Bilateral kidney tumors associated with urinary findings resembling those 
of interstitial nephritis are almost certainly cystic. 



EXAMINATION OF THE ABDOMEN 



819 



Bilateral or unilateral chronic renal tumors associated with pus in the urine 
are often tuberculous and the tubercle bacillus may be demonstrated readily 
if this condition is present. 

The diagnosis should be possible usually and by the same means before 
any decided tumor is present. 

Passive mobility of varying degree is found in tumors of the kidney, trans- 
verse colon, small intestine, hepatic, splenic and sigmoid flexures, omen- 
tum, stomach, and in growths involving a cecum mobile, always provided that 
such tumors have not been rendered fixed and immovable by adhesions. 

A gall-bladder tumor not only moves with the liver in respiration, but 
characteristically limits its passive mobility to lateral pendulum motion which 
is lost if adhesions are extensive. 

Tumors of the pylorus may show an extraordinary displacement and 
passive mobility especially in visceroptotic cases. 

Expiratory Fixation. — These growths, together with other accessible gas- 
tric tumors, may be held fast against their tendency to ascend in, expiration. 
This, in contradistinction to the positive determined expiratory ascent of 
the liver and spleen and their tumors save in profound visceroptosis. 

The Differential Value of Inflation of the Stomach. — It is obvious that 
the condition of the stomach, with relation to distention and collapse, must 
influence greatly the accessibility and position of growths attached to it and 
also affect in some degree the position of tumors involving neighboring vis- 
cera if these be movable. This maneuver is especially valuable in the 
differentiation of pyloric tumors from those of the liver. 

Upon inflation, a pyloric tumor, in the absence of adhesions, moves to the 
right and downward; those of the lesser curvature, upward usually, some- 
times backward and out of reach. 

Under the same procedure tumors of the liver directly ascend; those of 
the transverse colon directly descend; those of the ever-fixed pancreas become 
obscured; and those of the spleen move somewhat to the left. 

Value of Colon Inflation. — This is chiefly of value in relation to its effect 
when colonic tumors are in question or in cases demanding differentiation 
between massive renal and splenic tumors. 

Usually, as stated, the inflated colon casts a band of anterior resonance 
over a renal growth whereas the spleen remains unaffected. 

Chronic Peritoneal Tuberculosis. — This must be borne in mind always in 
the presence of tumor crossing the abdomen at or somewhat above or below 
the level of the umbilicus. 

The great omentum may form a thickened contracted rounded " bar-like" 
tumor fixed by adhesion to the intestines and to the abdominal wall itself. 

The mesentery may also become thick and contracted and the small 
intestines may become massed in the middle of the abdomen or to the right 
side. 

Such a mass is sometimes mistaken for the lower border of an enlarged 
liver but a zone of resonance can usually be outlined between them and the 
hepatic respiratory movement and the true feel of the liver edge is lacking. 



Pyloric tumor. 



General rules. 



Kidney vs. 
Spleen. 



Mesenteric 
masses. 



Occasional 
source of error. 



820 



MEDICAL DIAGNOSIS 



Pockets. 



Important 
point. 



An important 
region. 



Less important 
than small 
intestine. 



Important r6le. 



Normal 
capacity. 



In such cases the intestines, omentum and mesentery may be adherent 
to each other and to the abdominal wall and various pockets may be found 
containing fluid. exudate. 

The autopsy picture is oftentimes one of practically universal adhesion. 

Fixation of Liver and Spleen. — These organs obtain their movement from 
the diaphragm and are dependent upon that structure and freedom from 
immobilizing adhesions for their peculiarly direct immediate and powerful 
descent in full inspiration. 

Fixation by adhesion is not uncommon in chronic inflammatory condi- 
tions, but one may forget that a decided lack of motion may result from exces- 
sive abdominal distention especially when due to ascitic accumulations under 
great pressure. 

THE STOMACH 

General Considerations. — Not only has modern research developed a 
remarkable increase of positive knowledge in regard to the capacity, dimen- 
sions and normal limitations of position of the human stomach, but it has 
greatly extended and modified our conceptions of the vagaries of its secretory 
activities in health and disease. 

To just what extent its functions of digestion and absorption enter into 
the digestive process is still undetermined, but, in the light of modern in- 
vestigations, the chief role must "be assigned to the small intestine. 

Indeed gastrectomy and cases of achylia taught us long ago that the 
stomach is not absolutely indispensable to life; yet it plays a most important 
part in human existence. Nor is its role confined to its functions in relation 
to digestion, absorption and the preparation of food substances for the action 
of the intestinal ferments. To a considerable extent it is protective in its 
ability to inhibit the growth of, neutralize, or actually destroy, many kinds 
of pathogenic organisms and their toxins, or so weaken others as to facilitate 
anti-bacterial activity of the intestinal ferments. 

Capacity. — The stomach of the new-born baby has a "voluntary" capac- 
ity of but i or i }/2 ounces, yet in from six to eight years this is increased to 
i quart, and in the adult stomach varies from i to ij^ quarts. 

Types of Stomach.- — We are interested chiefly in the form and position of 
the stomach in persons standing erect, and a wide divergence of opinion exists 
as to what constitutes the normal. In individuals wholly free from symptoms 
of gastric disturbance two chief types are observed, viz: (i) the "steerhorn," 
carrying its lower border well above the level of the iliac crests, between the 
umbilicus and the ensiform cartilage, and (2) the "fish-hook" stomach. 

The Steerhorn Stomach. — This is the normal type according to Holz- 
knecht, but might more properly be designated the "ideal," as it occurs in 
only about one-third of all adults, almost wholly in men, and in such of these 
as are powerfully built and carry a large nutritional reserve or actual pannic- 
ulus. Holzknecht maintains, nevertheless, that it represents the normal 
and necessary form with respect to the functional optimum and the type from 
which other forms are logically deducible. 



EXAMINATION OF THE ABDOMEN 



821 



Support for his view is found in the fact that well nourished, strongly 
built children carry such stomachs, whereas undernourished, slender 
youngsters show the type described below, with the many modifications with 
respect to latent or demonstrable atony and ptosis, more or less closely 
reflecting congenital defects of structure and the grade of subnutrition pres- 
ent in the individual case. 

The "Fish-hook" Type. — Rieder maintains that the normal is found in 
the "fish-hook" stomach, present in some form in about two-thirds of adult 
individuals. In this type the long diameter is vertical, the caudal pole 
sac-like, and ascending to the right in such a manner as to make the pars 
pylorica the terminal of what appears like a syphonage system. 

Conditions Influencing "Type." — There would seem to be little doubt 
that our primitive ancestors carried steerhorn stomachs, but their descend- 
ants have developed congenital and acquired defects of structure through the 
subtle ravages of disease. 

It is interesting to recall the fact that 80 per cent, of civilized adults will 
react to tuberculin or show evidence of this disease at autopsy, and that 
the type of individual ("congenital asthenic") showing the exaggerated 
degrees of "fish-hook" stomach in the form of actual gastroptosis or atony 
in its more readily demonstrable and extreme forms, is identical with that 
which offers in its tissues the best living medium for the development of 
the tubercle bacillus. 

In sucklings the steerhorn type is nearly always present. Between the 
ages of five and ten it constitutes the type present in two thirds of all children 
Between the ages of ten and twenty it is found in about 50 per cent. These 
figures closely parallel the positive results of tuberculin tests for the same 
age groups. For practical purposes the views of Holzknecht and Rieder 
both may be accepted if we modify the term "normal" of the former and call 
it the "ideal normal." In the opinion of the author no such term may be 
applied properly to any "fish-hook" stomach whose caudal pole sags below 
the level of the iliac crests, though unquestionably such stomachs, or even 
lower ones, may be carried without serious symptomatic disturbances in the 
presence of an adequate general circulation and a balanced nutrition. 

The "steerhorn stomach," the powerful build, strong abdominal muscles, 
ideal normal heart, well developed musculature, wide thoracic aperture, and 
superabundant nutritional reserve, go together. 

The "normal" "fish-hook" type is the commonest one in adult life — may 
carry its possessor through life without a serious gastric symptom or show 
extreme degrees of sagging with or without peristolic atony under conditions 
of nutritional deficit. 

This does not mean that individuals with "fish-hook" stomachs must die 
of tuberculosis or even show or ever have shown clinically active symptoms 
of the disease. 

It does suggest the basic importance of congenital defects of structure 
and the after effects of acquired infections with associated toxemia and im- 
paired nutrition. 



Tuberculosis. 



822 



MEDICAL DIAGNOSIS 



Cardinal 

differential 

points. 



Fundus. 



Cardia and 
pylorus. 



Lower limit. 



Growths. 



Peristalsis. 



The close association of gastroptosis and cardioptosis observed by the 
author is dealt with elsewhere. (See Fig. 386, "The Drop-Heart," 
" Gastric Atony," " Congenital Asthenia," etc.) 

Position and Dimensions. — The older views relating to the position of the 
stomach have been corrected and greatly modified by the result of X-ray 
work. When the patient is recumbent and in the dorsal position or erect, with 
the stomach fully distended, more than jive-sixths of that viscus lies to the left 
of the median line. And the lateral distance between the pyloric and. cardiac 
orifice of the uninflated normal organ is but ij^ inches. 

The fundus, when distended, lies in the left cup of the diaphragm; hence 
the upper limit of percussion resonance normally extends to the fifth left in- 
terspace in the parasternal and mid-clavicular lines, while the lower may run 
from several inches below, to 1 or 2 inches above the level of the iliac crest. 

The pylorus of the empty normal stomach lies in the median line. When the 
viscus is distended, the pyloric opening should be midway between the right 
sternal and parasternal lines 1 or 2 inches below the level of the xiphoid. The 
cardiac orifice lies, therefore, about 1^2 inches to the left of the median line 
opposite the ninth dorsal vertebra posteriorly and the seventh costal cartilage 
anteriorly. The lesser curvature lies normally deeply under the liver border. 

Absolute lines cannot be drawn for the limitations of an organ so dis- 
tensible, so freely movable and so often ptotic. 

In general, it may be said that a stomach whose lower border reaches the 
navel is abnormal, either in size or position. 

PHYSICAL EXAMINATION.— Inspection— This yields valuable results 
more often than is generally supposed, and, especially in cases with thin, 
relaxed, abdominal walls, the outline of a distended stomach may be clearly 
defined. 

Growths, especially of the pylorus, are often seen to move with respira- 
tion, and normal (left to right), or very rarely, reversed (right to left), peri- 
stalsis may be present, the latter often affording valuable corroborative evi- 
dence of pyloric obstruction. The normal gastric waves are large and 
deliberate and take from one-fourth to one minute to pass across the field. 

In cases of gastric dilatation with hypertrophy of the wall due to pyloric 
stenosis, the condition of intermitting stomach rigidity ( u magensteifung") 
may be manifest to the eye as well as to the hand. 

As the pylorus intermittently yields, one may hear and feel in many 
such cases the squirting, spurting or gurgling of expressed fluid ("spurting 
murmur"). 

In the congenital pyloric obstructions of children and in carcinoma of 
the adult stomach* the tumor is often readily seen. 

Importance of General Inspection. — The facies of the patient and his 
general nutrition are matters of cardinal importance in many instances. 

A good color and a well-nourished body often go far to aid the physician 
in excluding organic disease of the stomach. The asthenic habitus points 
to the existence of visceroptosis and the many functional gastric disorders 
which are associated with the constitutional inadequacy of such patients and 



EXAMINATION OF THE STOMACH 



823 



Artificial light 

sometimes 

preferable. 



Bismuth. 



oftentimes with an outward appearance of suffering and a degree of emacia- 
tion which may be most misleading. 

On the other hand, it must be remembered that congenital asthenics 
may carry gastric ulcer or cancer. 

Light. — A proper light is indispensable to thorough inspection and 
sometimes an artificial light is better than daylight for the detection of 
peristaltic movement and the shadows produced by the respiratory dis- 
placements of organs or growths. 

Teeth and Naso-pharynx. — The condition of the gums, teeth, tonsils 
and naso-pharynx should invariably be determined and the odor of the breath Tonsillar and 
will often prove suggestive. Loss of the means of mastication may lead j infections, 
ultimately to partial or complete loss of function of the glands which furnish 
certain important digestive hormones. 

Chronic infections no less than imperfect mastication may play a large 
part both in relation to gastrointestinal disturbances and to general health. 
Peridental abscesses, a persisting sinus infection or chronically infected tonsils 
may be of fundamental etiologic importance. 

The various pictures presented by the tongue have been described 
elsewhere. 

Fluoroscopy and TransiUumination. — By giving the patient massive doses 
of bismuth subcarbonate (20 to 30 grams) suspended in mucilage of acacia 
porridge, kefir or some similar substance, fluoroscopic or skiagraphic evidence 
may be obtained. * Occasionally Einhorn's method of transillumination (gas- 
trodiaphany) may slightly assist inspection, if better means are not available. 

In testing the position of the stomach whether by inflation or other 
methods the patient should be standing. 

One of the valuable qualities of the bismuth meal is its weight. We 
get the position of the stomach as in actual digestion of a full meal. 

Gastrodiaphany. — The gastrodiaphane is merely a moderately rigid 
bougie or soft tube carrying an electric light. The patient, who is placed 
in a dark room, drinks two glasses or more of water, after which the instru- 
ment is introduced and the electric circuit completed. In a normal stomach 
the illuminated surface zone thereby produced indicates the position of the 
left lower segment of the fundus and is triangular in form, the apex being 
downward and slightly above the umbilicus. It naturally follows that 
in gastroptosis or dilated stomach (gastrectasia), the illuminated area is 
lower and larger. 

The information gained through simple inflation of the stomach or 
fluoroscopy is usually so much greater that the method is seldom required 
and fluoroscopy and skiagraphy, when available, replace all such inefficient 
and insufficient methods. 

Tiirck's Gyromele. — This ingenious old device lends itself to inspection, 
palpation and auscultation. It consists of a flexible piece of steel, such as a 
piano wire, inclosed within a rubber tube and bearing a soft sponge. Being 
introduced into the stomach, it is attached to a little hand instrument which 

* See "Roentgenography" and "Roentgenoscopy." 



Of slight value. 



Better 
methods. 



Ingenious. 



824 



MEDICAL DIAGNOSIS 



Not wholly 
safe. 



Old method. 



Best method. 



Ectasia and 
ptosis. 



A misappre- 
hension. 



The sound. 



Accessibility of 
esophagus. 



causes rapid revolutions and will distinctly indicate the position of the sponge 
as it passes along the lower gastric border. Its inventor uses it not only 
for diagnostic, but for therapeutic purposes, but at the present time its 
diagnostic value is not so great, nor is the procedure so safe, in the opinion 
of many, as to justify its preferential use. 

Inflation of the Stomach. — Methods. — (i). The oldest and simplest 
involves the administration of i dram of sodium bicarbonate in a wineglass 
of water, followed promptly by an equal amount of tartaric acid similarly 
dissolved. 

Theoretically, it is open to the objection that serious danger from over- 
distention may result, especially in ulcer; practically, this danger is slight, 
yet the method is decidedly inferior to the following one. 

2. After introducing the stomach tube, air is pumped into the stomach 
with a Davidson syringe, or, if the patient be tolerant and the physician 
courageous, the inflation may be accomplished by blowing into the tube. 
As the degree of inflation is wholly under control under this method, the 
procedure has almost wholly superseded the older one. The distention 
should not be great and the patient's facial expression quite accurately 
indicates the safe maximum. 

Inflation brings into prominence tumors of the anterior wall and obscures 
those of the posterior wall. In general, gastric growths are cylindrical at 
the pylorus, broad and flat at the fundus. 

Interpretation of Outline. — The normal boundaries have already been 
given; if abnormal, one should Carefully note whether, in the outline estab- 
lished, there is merely a normal or approximately normal area in an abnor- 
mally position (gastroptosis) ; both abnormal position and increased area 
(gastroptosis with ectasia), or, finally, general enlargement without marked 
displacement (simple dilatation). 

DIRECT INSPECTION 
THE ESOPHAGOSCOPE AND GASTROSCOPE 

Preliminary Comment. — The diseases of the esophagus are surgical for 
the greater part and neurologic for the lesser, and can be given only slight 
attention in this volume. 

It would appear that some misapprehension exists, however, both as 
to the best means of direct diagnosis and the relative ease and safety of its 
application. 

In diagnosis the esophageal sounds are serviceable chiefly as a means of 
determining the presence or absence of an obstruction and, approximately, 
the caliber of a constricted esophagus. 

As generally employed, they are doubtless far more dangerous than is the 
esophagoscope, in the hands of anyone of average skill. 

As Lerche says, "through the aid rendered by a proper type of esophago- 
scope, the gullet, instead of being an organ difficult of approach becomes the 
most accessible, barring none" He further states that no matter how many 
cases may have been- seen, if the esophagoscope has not been employed 



EXAMINATION OF THE STOMACH 



825 



so many mistaken diagnoses will result that any reports made will lack 
all scientific value and " merely emphasize the frequency of esophageal 
disorders."* 

The Esophagoscope. — There are many esophagoscopes in successful use 
and the best modern instruments have a rigid tube and a source of illumi- 
nation distal to the operator and as near as possible to the surface under 
investigation. 

This latter desideratum is achieved by the use of the electric bulb, but 
its position as the distal extremity of the tube ordinarily involves the incon- 
venience of soiling, with resulting dimming of the light by accumulated 
mucus and blood, if the latter be present, and the remote danger of lamp 
breakage. 

The instrument here shown carries a suction tube which can at will be 
extended by the operator, not only to cover, but to extend far beyond the 
lamp. 




Fig. 428. — Patient in correct position with the esophagoscope introduced and the suction- 
pump at work. 

For office or hospital work the attachment of the simple Chapman suction 
pump keeps the field of operation itself entirely dry. 

The tip of the instrument is provided with a blunt protective lip and 
enables the operator to introduce it without an obturator and inspect the 
entire tract traversed by the instrument. 

In its introduction the suction tube is drawn back and the instrument 
entered with the outer surface of its lip facing the epiglottis and the anterior 
wall of the esophagus, thus bringing its greatest diameter into relation with 
the most distensible diameter of the canal it traverses. 

The detachable handle, if used at all, should be on the side of the instru- 
ment which carries the lip if the patient is to be examined in the sitting 
posture and on the opposite side if the posture is that of recumbency. 

Technic of Introduction. — If, in a case to be examined, there is a large 
quantity of fluid and remnants of food retained in the esophagus, this material 
must first be drawn off by the stomach tube and the esophagus washed out 

*" Diseases of the Esophagus," Wm. Lerche, N. Y. Med. Journal, June 19, 1915. 



Chief 
requisites. 



Lerche's 
esophagoscope. 



Keeping the 
field clear. 



Safety tip. 



Technic of 
introduction. 



826 



MEDICAL DIAGNOSIS 



Posture of 
patient. 



Ease of 
introduction. 



Tubes 
required. 



before the esophagoscope is introduced. The suction tube is for the removal 
of fluids accumulating during the operation. 

Esophagoscopic work in adults is done usually under local anesthesia with 
10 per cent, solution of cocain and with the patient in the sitting position. If 
a general anesthetic is used the patient is examined while lying on the back 
or on the right side. In children general anesthesia is always required. 
Fig. 360 shows the patient in the correct position on a low chair with 
straight back and with the head supported by an assistant. The esophago- 
scope is shown in position and the suction tube A is connected by a long 
rubber tube with the Chapman suction pump attached to the water faucet 
and having a Wolff's bottle interposed for the reception of the mucus and 
blood. 





Fig. 429. — Lerche's esophagoscope. A, Indicates suction tube; B, light carrier, running 
in the grooves C; E, detachable handle to fit in groove D. 

The introduction of this instrument is easy. The operator stands in 
front of the patient, and, holding the illuminated esophagoscopic tube near 
the proximal end with the right hand, places the lip of the instrument on the 
back part of the patient's tongue pointing somewhat toward the patient's 
right. While the operator now looks through the instrument it is passed 
over the epiglottis and down to the inlet of the esophagus. On gentle pres- 
sure the cervical part is entered and the open thoracic part of the esophagus 
soon comes into view. 

No lubricant need be used on the instrument and one does not guide the 
instrument by inserting a finger into the patient's mouth. A dry cell-battery 
is required for the lamps. The street electric current should not be used when 
the instrument is connected with the water faucet. 

Three tubes are required. One 10 mm. diameter and 50 cm. long, and 
one 10 mm. diameter and 25 cm. long, both for adults; one 8 mm. diameter 
and 35 cm. long for children. 

THE GASTROSCOPE 

This, the newest of the specific instruments devised for the exploration 
of the stomach is capable of yielding most interesting results, but only in 



ESOPHAGOSCOPE AND GASTROSCOPE 



827 



the hands of a thoroughly experienced and practised operator, and, in most 
instances, under profound anesthesia. This last procedure is doubtless to 
some degree avoidable under the skilful technic of a past master of the art. 

The difficulties in gastroscopy also are manifestly greater than those of 
esophagoscopy by reason of the obstacles to be overcome in bringing the part 
to be examined into view. The path from the teeth to the stomach must be 
made direct and hence the normal curves must be straightened. Obviously 
the head must be thrown far back to raise the level of the upper jaw and over- 
come the curve normally present and considerable delicacy of technic is 
required to secure the entrance of the instrument into the cardia and beyond 
that point as is actually accomplished by the expert. 

It occasionally happens that in individuals with a very prominent upper 
jaw and short thick neck the introduction of the tube may be well nigh impos- 
sible. The passage of the tube from the esophagus into the stomach may 




Fig. 



430. — Usual gastroscopic field. It is manifest that the accessible area will be greatly 
increased in ptotic stomachs. 



also be blocked by reason of great deformity of the spine, abnormalities of 
the gastric musculature itself, large aneurysms of the thoracic aorta, or 
existing heart disease greatly distending the left auricle and producing com- 
pression upon, and stenosis of, the esophagus. 

Some of the modern forms of the gastroscope have largely overcome any 
danger inherent in its use by dispensing with the uniformly rigid tube such as 
easily led to perforation of the esophagus in clumsy or inexperienced hands 
when the attempt was made to traverse that structure at its lower portion 
opposite its point of passage through the " hiatus esophagus" of the dia- 
phragm. The use of a flexible tip which in its passage conforms to the 
curves of the esophagus offers an advantage, though adding somewhat to the 
complication of the instrument. 

Much difficulty has also been experienced in devising an instrument 
which would secure a clear field of vision and freedom of the area under 



828 



MEDICAL DIAGNOSIS 



examination from obscuring secretions. This is accomplished by the newer 
instruments of Jackson and of Eisner. 



,4 ft" 




<-! 



it 




Fig. 431. — Eisner's gastroscope. AA, Outer tube (11 X 76 cm.); Oe, objective lens; 
KK l K 2 , air passage; T, mark to indicate distance tube should be passed (40 cm.) to just 
enter stomach. 

The greatest difficulty of all doubtless lies in the limitation of the working 
field and the difficulties encountered in bringing into view all portions of the 
stomach and this is emphasized by the many variations in form and position 



::•: 



:i:i ::zn ~i iii-^i: i: .::: :in :y :ie i-~ :•?: : :i5tii : - r:;>:j..-„: 

-:-.t~:::i ...:.: i:t _..r'.y :: t ::ti.ti: 

r.-i-v.ii:.:- .: -i : -- ..-•.-..::._•'.-.:- -:-t :: ::i:.i-t ::: ;:;it: _:t :':: ~::t 
than a few minutes and during that period only the expert operator can 
secure much information. He most work rapidly, intelligently and with the 

fill kzi:-".tizt :: -•:"— --- iiii::—'-^ 11: --n.n:::ii :: :zt .1:; i:ti: 

i— ^-~-~ "--: : i=ii::-z 
::' :-e rlr.i rile = z:z. ii :n: irviici 111 liti — " :i t.-:t'.lti: ::-.;• '-. - 




It r-tvijt: y:^:: ii: it::i: ±2: :ii:tsc-:ci :y —t Lz.5::_zj.ti: : 
HL Eiizt: 5- :^~ -err. — ii:- : :~ lints 11 1 r.zii :-':-e : :<iy ~Ai. 1 ::~:.: ::; 
Dr. Jackson's instroment has its light at the distal end of the tube on a 

n~.t: --ii:'- :::~ := :ii .: :tn :- "il ::: :e:::.:: 51: A: :i - :t it:tt5i: 
:i": i~ tim ."::. :i 

By lit .:.:-:..: :i itvAt :: ;;:.:.: ±t Izz: - .-,.: 1: it y.it : ±t 
visual orifice, the very considerable advantage of obEqne iThrminaHon is 

;c :.::: 

A iziiznzt it i:t ii ;::i:t: in :it: ±2: -Jit it : ::' ^1:1:1:.::. -1 
:e it". :.ti: A Aim :: n - : 1 = 11 : :i:i :: i .nzt :. it trt "J my : t :t; ii:t : 
ind rt~:vti :y n::At: ir :ti.:t: 

An : ::_:i: : i :Ai7_Ait: :: i.i :it ;i- ; iizt ::' Jit : -it Airiizi \Lt ::r- 
5nrl::t-i i:tii 

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seize 11: ::iii.i ::' 11 : nt: :_:t ::i:i:i„iz :zt :;:::i. 11:1:1.-5 :i 15 
rrtr'.y ~ : 1 t i:n :.i ii: :it mil :y::i ii:i:i:_i 11: ii :_:t: :A:e 
Tit :— : :A:ti i:t -: :'.i:t-: 1- :: .ti" t :c:~tti iit~ 1 111-1. :•: i--..i:t : 



MEDICAL DIAGN SIS 



passage. This last serves as a canal for the introduction of air and likewise 
carries the light conducting mechanism. The light is carried upon the lower 
end of the main tube, is fully protected and the instrument carries a flexible 
tip which Eisner believes greatly facilitates its primary introduction. Of the 
same caliber as the gastroscope and carrying an elastic spiral within, this 
tip is intended to fulfill the double purpose of meeting gently and passing 



rf 




9 



: I : - : — Eisner's "astroscope. A sponge carrier and a metallic sound are shown at the 
right. Outer tube and that containing the optical apparatus are shown on the left. 

easily the diaphragmatic junction point and also of preventing any pos- 
sibility of perforation of the stomach attending the actual introduction of the 
tube. With such an instrument in many cases it is possible for the 

serve directly the more important regions of the stomach as is indicated 
by the figure, viz., the anterior wall, the region of the pylorus, the entire 
fundus and the greater part of the lesser curvature and posterior wall. This 
procedure, of course, demands the proper handling of the light both through 
the manipulation of the movable shaft governing it and the proper raising and 
lowering of the tube itself. The pyloric antrum is clearly seen but unlor- 
tunately the pylorus itself is usually unattainable. Only when the pylorus 
is greatly lowered or unusually high does it come into the gastroscopic held. 



THE GASTROSCOPE 



831 



palpable. 



The introduction of the gastroscope should be preceded by a most thor- 
ough and careful physical examination of the patient and especial attention 
should be paid to the possible presence of aneurysm or mitral disease or 
advanced arterial sclerosis, especially if this be associated with high arterial 
tension. The question of possible deformities will usually be determined and 
the constitutional type of the patient may or may not be such as is favorable 
to the introduction of the instrument. 

Victims of congenital asthenia furnish the very best material on account of the 
general slackness of their tissues and ligaments and in them one is frequently 
able to see the pylorus itself. 

The author deals thus briefly with this ingenious device for the reason that 
he considers it wholly unadopted to general use and, assuming equality in skill 
and perfection of technic, more dangerous than exploratory incision. 

Palpation of the Gastric Area. — This is chiefly used to determine three seldom 
points: (1) The presence of tumor. (2) Localized tenderness. (3) Succussion. 

The palpable tumors of the stomach oftenest involve the pylorus and lie 
to the right of the median line between the margin of the ribs above and the 
navel below. 

Areas of thickening over the distended stomach, often plaque-like in feel, 
may be encountered in rare instances and indicate an old ulcer base. 
Adhesions frequently occur, anchoring the stomach to adjacent organs 
and greatly complicating and obscuring diagnosis. Accessible tumors ordi- 
narily move freely and indeed may be so far from their usual site as to 
suggest growths of distant organs. Their movement and position in con- 
nection with inflation then becomes of special importance. In very thin 
flabby abdomens one must be on his guard against mistaking other structures, 
perhaps normal, for gastric growths. 

Intermittent stomach rigidity as described under "palpation" over the 
fundus may be encountered in cases of pyloric stenosis. 

Through relaxed thin abdominal walls such as are encountered often in 
cases of visceroptosis or "hanging belly" the pylorus may sometimes be 
directly palpated as a cylindrical body 4 to 5 cm. long and felt to harden and 
relax with an associated ''''squirting'' sensation (already mentioned) and if a 
soft tube be used the point perhaps may be distinctly felt as it is coaxed along 
the lower border to the pylorus. If pylorospasm occurs, the "fed" is that of 
a hard egg-shaped mass. 

If bimanual palpation be employed over a thin, relaxed abdomen with the 
tips of the fingers deeply pressed against the posterior wall of the abdomen at 
an angle of 45 with the external surface, one may sometimes feel the dupli- 
cated lower edge of the collapsed stomach as it passes upward at the end of 
deep expiration. It gives the impression of a cord rolled under the fingers 
and may be associated with a gurgle if any fluid is present in the viscus. A 
slight downward glide of the finger-tips at or immediately preceding the height 
of expiration is necessary to the success of the maneuver. 

Below the stomach one may feel the transverse colon as a similar cord, 
unaffected by respiration. 



Old ulcers. 
Adhesion. 



Tumors. 



Useful method. 



Pylorus. 



Pylorospasm 



Palpating 
border. 



Transverse 
colon. 



83 



MEDICAL DIAGNOSIS 



Of slight 
value. 



Overesti- 
mated sign. 



Slight value. 



The procedure is interesting and constitutes an excellent exercise for the 
development of the tactile sense, but otherwise its value is almost nil. 

The levels of the visceral borders will vary with the grade of any viscerop- 
tosis present and palpation is seldom successful with a normally placed 
stomach. 

Succussion. — Any splashing sound suggests dilatation or gastroptosis 
with marked atony if it occurs more than six or seven hours after a meal. 
The value of this sign has been overestimated and is practically limited 
to its occurrence before breakfast or on a fasting stomach. 77 may be present 
in wholly normal individuals and, in general, merely indicates slight motor in- 
sufficiency, or, if it be obtained within narrower limits but by very gentle tapping, 
it strongly suggests decided gastric atony * 

In asthenic dyspepsia the sign is undoubtedly in a large degree dependent 
upon the condition of the abdominal wall itself and is peculiarly common in con- 
nection with the relaxed abdominal musculature and visceroptosis of asthenic 
individuals. 

Finally, rarely, actual dilatation of the stomach may occur without superficial 
splashing. 

Succussion is obtained by placing one hand over the left ribs posteriorly 
while making sharp dipping movements anteriorly. 

Precautionary Pelvic and Rectal Examinations. — Many disastrous errors 
in diagnosis would be avoided if physicians would adhere more scrupulously 
to the rule which demands that in married women such examination be made 
if any substantial reason exists for suspicion. Pelvic growths or abscesses 
especially are potent causes of obscure gastric symptoms. 

The author does not wish to be understood as advocating routine pelvic 
examinations. Sound common sense is necessary. In young girls especially 
these should be made only when clear indications are present. 

Percussion. — Ordinary percussion is of little use and need not be dis- 
cussed. It was formerly the custom to introduce a pint or more of water 
and percuss the dull area produced, but both the boundary and the muscle 
tonus are better established by inflation. 

To attempt to outline the stomach by percussion or even to differentiate 
the stomach tympany from that of the intestines, in the absence of for- 
tuitous or artificial inflation, is absolutely futile. f 

Auscultatory percussion is distinctly useful though nevertheless fallible ; 
useless if not preceded by inflation. Normal gastric tympany, as heard 
over a moderately inflated stomach, is represented by the segment of a circle. 
It is limited above by left lobe hepatic dulness, but includes Traube's space and 
has a curved border below, which normally should not reach the navel. J 

* Sahli quite properly distinguishes between "deep splashing" and "superficial splash- 
ing," for these differences are quite readily recognized by the examiner. 

f The empty stomach is, in fact, often practically inaccessible to percussion because 
of the overlap of the liver and left lower thorax. 

Furthermore, the stomach tympany varies greatly with the amount of food or gas 
content and the same statement applies in the case of the hollow viscera surrounding it. 

% The word "not" is given emphasis because of a present tendency to be misled by 



EXAMINATION OF THE STOMACH 



*53 



Contraction of the left lobe of the liver, shrinkage of the left lung, gas- 
troptosis, and marked distention of the stomach tend to enlarge it. By 
careful auscultatory percussion, the upper right and left limits may be some- 
what extended though the change of note due to the lung and left hepatic 
lobe will be distinctly marked. 

Technic. — The bell of the stethoscope is placed just below and to the left of 
the ensiform cartilage and light percussion is carried from it in radiating lines , 
in accordance with the boundaries outlined above, either from the stethoscope out- 
ward until the note changes, or from the surrounding negative areas toward that 
of gastric resonance. 

It is well to shift the position of the stethoscope and repeat the percus- 
sion in order to check results. So also in the case of a growth, if the stetho- 
scope be placed over it and a similar method employed, one may often deter- 
mine its connection with the stomach. An elaborate description of the tones 
is unnecessary as the veriest tyro can distinguish the abrupt change that indi- 
cates that the border of the inflated stomach has been passed. f 

Auscultation. — Aside from the procedure mentioned below, this method 
finds its only usefulness in the detection of esophageal "swallowing sounds" 
"the succussion sound" already referred to, the "sizzling" or "fizzing" of 
active fermentation, and the test for hour-glass (bilocular) stomach. 

Auscultation of Inflation Murmurs. — While the stomach tube is in the 
stomach the outline of that organ may be determined sometimes with con- 
siderable accuracy by forcing jets of air into it with the bulb and noting the 
limits of audibility of the bruits produced during the process of inflation, but 
the value of this procedure is very limited. 

Revidtzefs Sign. — It would seem that this might well replace the older 
method of noting delay in the second element of the double pharyngo-eso- 
phageal sound attending deglutition. 

Revidtzef points out the fact that in stenosis of the esophagus the retained food 
requires more than one act of swallowing for its complete removal and that in 
such instances the normal double sound will be duplicated, or repeated several 
times, if the patient attempts to complete the act of swallowing without taking 
more into the esophagus. 

If the interval between the primary and secondary sound exceeds the 
normal limit the older test gives added information but cases of stenosis 
may present a normal interval (five to seven seconds) and the newer test 
would seem the more reliable. 



the frequency of gastroptosis into the belief that a decidedly low stomach is a wholly negli- 
gible condition. 

Its chief importance lies in its definite assignment of its possessor to the congenitally 
asthenic group, a matter of no little importance in many instances, whether as a contrain- 
dication of all major surgery save that of genuine need or actual emergency, or, as clearly 
indicating the proper line of medical treatment to be undertaken. (See "Congenital 
Asthenia.") 

f The note is uniform in quality and pitch so long as the stomach is percussed, though 
intensity depends upon the distance of the stroke from the stethoscope. 
53 



Swallowing 

sounds. 



A valuable test 
for esophageal 
stenosis. 



834 



MEDICAL DIAGNOSIS 



Modern 
technic. 



The bismuth 
meal. 



Great 
importance. 



Concurrent 
palpation. 



Variable. 



ROENTGENOGRAPHY AND ROENTGENOSCOPY LN THE DIAGNOSIS 
OF GASTRIC AND DUODENAL DISEASE 

Dr. Frank S. Bissell 

Minneapolis, Minn. 

Historical Note. — Professor Roentgen announced his discovery of the X- 
rays in 1895 and stated that not only metals but the salts of metals, either 
solid or in suspension, would obstruct the passage of these rays. This sug- 
gested the procedure of filling certain hollow organs invisible to the ray, 
with solutions or suspensions of these metallic salts, thus to render these 
organs roentgenizable. Dr. W. B. Cannon of Boston was probably the first 
to employ a bismuth salt mixed with food in a roentgenologic study of the 
gastrointestinal tract and the method has grow r n with time and experience 
until today it occupies the most important place among physical methods of 
gastrointestinal diagnosis. 

TECHNIC. — The patient takes a morning meal prepared as follows: 

Meal No. 1. — Fifty grams of bismuth subcarbonate is w r ell mixed with a 
small quantity of raspberry syrup and water. This mixture is added to 150 
grams of breakfast gruel and thoroughly mixed therewith. Six hours later, 
the patient steps behind the fluoroscopic screen in a properly darkened room. 
The examiner notes w T hether the stomach is empty or contains a residue, 
and what progress the meal has made in its journey through the intestine. 

Meal No. 2. — A suspension of 50 grams of bismuth (subcarbonate or 
oxychlorid) in fermillac 500 c.c. is then given and observed as it passes 
through the esophagus into the stomach to fill that organ. 

The stomach is studied to discover any accessory pocket, niche, incis- 
ura, or permanent contraction, any evidence of spasm, or abnormality of 
peristalsis, any ''filling defects," deformities, or pyloric obstruction. 

The first part of the duodenum, known as the cap, is examined from all 
possible angles to determine w T hether it is deformed or regular in outline. 

Necessary Procedure. — To this end one must observe from various angles 
each portion of the gastric wall, through a reduced diaphragm. As the food 
enters the stomach it is observed to pass along the lesser curvature, filling 
the stomach by distending it gradually in all directions. The normal stomach 
contracts upon the ingesta so that the organ constantly appears filled except 
for a variable quantity of gas which is always present at its upper pole. 

The stomach is palpated under direct observation to determine the mobil- 
ity and patency of the pylorus. 

The duodenum is also palpated and the degree to which this stimulation 
increases gastric peristalsis is noted. Following the examination the patient 
is observed fluoroscopically at intervals as these two bismuth meals progress 
through the intestinal canal. Roentgenograms may be made from time to 
time, as a permanent record of any pathological condition noted, or, possibly, 
to reveal something overlooked on the screen. 

Appearance of the Normal Stomach. — The normal stomach varies rather 
widely with the sex and habit of the individual. The most common type is 



EXAMINATION OF THE STOM H n 






the perpendicular, hook-shaped 0f£a*f, with equidistant borders, the lower pole -h 
reaching a point about 2) £ inches below the pylorus. ! Bh * ped " ,y '"'- 

Another type is the semihorizontal, steerhoru-sha ped stomach which lies high "Stttrtem* 1 
/;/ the abdomen with the pylorus at its lowest extremity. 







Fig. 434. — Congenital atresia of the esophagus. Note distention of stomach and 
intestine with air. This was explained at autopsy by a union of the distal end of the 
esophagus and the main bronchus. (Dr. Frank S. Bissell.) 

This is the type usually observed in the male of "stout" habitus. It is 
rarely seen in the female. Various types, depending upon the muscu- 



8 3 6 



MEDICAL DIAGNOSIS 



Normal reten- 
tion periods. 



Significance 
of delay. 



lar tone of the stomach, as well as the length of its mesentery are described 
as: (i) Hypertonic. (2) Orthotonic. (3) Hypotonic. (4) Atonic. 

Motility. — An unobstructed stomach will, with rare exceptions, clear itself 
of bismuth meal No. 1, within six hours after ingestion. The time of complete 
evacuation varies from two to six hours, depending upon muscular tone, and the 
degree of acidity of the gastric contents. A delay of more than six hours dis- 




Fig. 435. — Carcinoma of the pylorus. Note area of gross filling defect, i.e., absence of 
bismuth shadow. (Dr. Frank S. Bissell.) 

tinctly suggests a lesion of the stomach or duodenum, less frequently of the 
gallbladder. 

Peristalsis. — In the normal stomach we can observe, usually, but one or 
two superficial peristaltic waves at the same time. They begin near the 
cardia increasing progressively in depth until they attain the antrum, and 
are usually seen distinctly only upon the greater curvature. 

Interruption of peristaltic waves occurs at the site of any gastric tumor or 
induration. Spontaneous peristalsis may be wholly absent during an exami- 
nation, even when no organic disease exists and this is especially true in the 
presence of extreme fatigue, nervous depression and certain cases of gastro- 



EXAMINATION OF THE STOMACH 837 



ptosis and atony, though in the latter they are sometimes apparently strong 
and vigorous. 

Bulbus Duodeni. — The first or horizontal portion of the duodenum resem- 
bles stomach more than intestine in roentgenologic appearance as well as in 
many other respects (acid contents, motor phenomena, embryology). As 
a rule, it is the only portion of the duodenum which can be clearly visualized 




Fig. 436. — Early carcinoma of the pylorus. Xote slignt pre-pvloric rilling defect. 

{Dr. Frank S. Bissell.) 

with the X-ray. It has been called the "cap'' because of its appearance, The "cap." 
resting upon the pylorus, or separated from the pyloric end of the stomach 
by the sphincter pylori. While the size and shape of the cap may vary 
considerably in different individuals, it is always regular in outline unless 
deformed by ulcer or adhesions. It is often necessary, however, to continue 
observations over a long period or to make a large number of roentgenograms 
before its normal regular contour can be demonstrated. 



8 3 8 



MEDICAL DIAGNOSIS 



Important 
points. 



Tonus. 



Motility. 



Effect of 
posture. 



Aid of abdo- 
minal muscles. 



Atony. 



Gastroptosis. — This concomitant of congenital asthenia may exist in any 
degree, with or without marked atony and is detected at once by the use of 
the bismuth meal. 

Even in extreme grades of ptosis, the pylorus is usually found fixed in 
its normal position at the level of the second lumbar vertebra. The import- 
ant points for the roentgenologist to determine are (i) the tonus of the 
gastric muscle, (2) the motility of the stomach under variable conditions, 
(3) the effect of various positions upon gastric motility, and (4) the ability 
of the abdominal muscle to aid in gastric motility. 

1. The tonus is determined by the degree to which the content is equally 
distributed from fundus to pylorus. Sometimes the tone will appear excel- 
lent at first, but the stomach muscles seem to tire quickly, allowing the 
contents to fall to the lower pole. 

2. A stomach which is abnormally slow in emptying itself when the 
patient is nervously or physically tired may function in a normal manner 
after rest. Likewise it may readily be determined whether a stomach 
functions better upon a full meal or upon a partial one. 

3. It has been frequently observed that a hypotonic stomach will empty 
very slowly while the patient retains an upright position, but when in the 
prone, supine, or right lateral decubitus, the apparent obstruction is lifted. 
It is important to learn which position suits a given case best. 

4. Another point which may be of importance is the ability of the patient, 
by voluntary action of his abdominal muscles to raise the intragastric food 
column, or even the lower pole of the stomach itself, thus aiding materially 
in the emptying process. 

A knowledge of these various factors may prove of much value to the 
clinician in his management of the case. Gastroptosis is usually accom- 
panied by a ptosis of one or both flexures of the colon, and the X-ray examina- 
tion is not complete until the meal has been followed through the intestinal 
tract. 

Dilatation. — When the stomach becomes dilated in any degree, its 
borders no longer appear equidistant. 

The lower pole tends to bulge like a distended bag. If atony is asso- 
ciated with the dilatation the ingesta tends to fall to the bottom of the stomach, 
leaving a very large gas filled space above. 

CARCINOMA VENTRICULL— Probably the most important province 
of the X-ray in gastric diagnosis is that of the early detection or exclusion 
of cancer of the stomach. A negative diagnosis, if made by an experienced 
examiner, is practically conclusive. A positive diagnosis too is rarely in 
error although there are certain pitfalls which must be avoided and certain 
non-malignant conditions which may closely simulate cancer. In such 
cases, however, a careful consideration of the clinical evidence will usually 
save one from a false diagnosis. 

Roentgenological Signs. — Cancer developing within the gastric wall 
soon encroaches upon the lumen producing thereby a defect in the normal 
outline. This distinction between cancer and ulcer should be constantly 



EX \MIV\1 I< >\ i H nil STOM \< H 






borne in mind: that while in ulcer the barium column encroaches upon its 
surroundings, in cancer the column itself is encroached upon. Before an 
actual filling defect is demonstrable, the gastric wall within the involved 
area becomes so infiltrated that normal peristalsis is interrupted at that point. 




Fig. 43; 



-Carcinoma of stomach. Xote filling defect on greater curvature. 
Dr. Frank S. Bissell.) 



When the peristaltic waves are not present within a certain limited part of 
the greater curvature, therefore, carcinoma should be strongly suspected. 

Before a diagnosis based upon a filling defect is made, one must be certain 
that it is not 

1. Artificial — produced by pressure of stomach against spine. 



840 



MEDICAL DIAGNOSIS 



Differentiation. 



2. Syphilitic — produced by gumma or specific infiltration. Here one 
notes a relative well-being and freedom from symptoms on the part of the 
patient, and a positive Wassermann aids somewhat in the differentiation. 

3. Extrinsic — produced by a tumor, organ, or mass without the stomach, 
or by skeletal deformities. 

4. Spastic — due to persistent contraction of gastric musculature. Not 
difficult to differentiate with careful observation. 




Ftg. 438. — Perforating gastric ulcer with hour-glass constriction, 
vious to the examination. Death from haemorrhage one week later. 



No haemorrhages pre- 
(Dr.FrankS.Bissell.) 



Pyloric Patency or Obstruction. — The pyloric ring may become so in- 
filtrated that it fails to close, the meal passing through into the duodenum 
with great rapidity. On the other hand, the infiltrating mass may so 
encroach upon the pylorus that an obstruction of variable degree is caused. 
Hence a six-hour retention may result. 

The differentiation between carcinoma of the pylorus and adhesions of 
the gallbladder is not always easy. Usually, however, carcinoma produces 
a characteristic deformity of the pylorus. When an obstruction is due 
to carcinoma, the stomach is more likely to appear inert, showing little or 



EXAMINATION OF THE STOMACH 84] 



no visible peristalsis, or perhaps an occasional peristaltic wave. Obstruc- 
tions due to adhesions or chronic duodenal ulcer arc more prom- to cause 
active or hyper-peristalsis. 

2. Scirrhus Carcinoma. — In this form of carcinoma, filling defects and 
obstructive phenomena are less marked, and a shrinkage of the gastric wall 
occurs, thus developing the "leather bottle" form of stomach. The area 
of invasion may have a worm-eaten appearance with overhanging edges. 
The growth may be annular, small and freely movable, merely constricting 
the pylorus to form the apex of a cone. 

The early roentgenologic diagnosis of carcinoma must depend, not upon 
gross filling defects which are late manifestations, but upon minute defects, the 
finer functional and motor disturbances, perverted, irregular or interrupted 
peristalsis and the occurrence of unexplained residues. 

GASTRIC ULCER. (Ulcus ventriculi). — A large percentage of active, 
i.e., symptom-producing gastric ulcers will manifest one or more roentgen- 
ologic symptoms. These are: (1) Delayed evacuation. (2) Presence of an 
incisura in gastric outline. (3) Presence of an accessory pecket. (4) The 
niche. (5) Hour-glass contraction. 

1. Delayed evacuation, resulting in a residue in the stomach after a six- 
hour period, frequently occurs in cases of gastric ulcer, even though the ulcer 
is situated at a distance from the pylorus. Hyperchlorhydria is not neces- 
sarily a concomitant symptom and this residue may be due solely to pylorospasm. 

Other causes of delayed evacuation are: carcinoma of the pylorus, duod- 
enal ulcer, or pylorospasm incident to gall-bladder disease. Practically 
all cases having a six-hour residue are found to have some surgical lesion. 

2. An incisura on the greater curvature, which persists despite palpation and 
the previous administration of belladonna, is a cardinal symptom of gastric 
ulcer. 

It is probably due to spasm of circular muscle fibers and hence occurs at a 
point directly opposite an ulcer on the lesser curvature. 

3. Accessory Pocket. — As the bismuth suspension enters the stomach, it 
may be seen to run into a pocket or miniature stomach outside of the gastric 
wall. This always indicates a gastric ulcer, perforating most frequently 
into the liver or pancreas. 

4. The niche is a pathognomonic sign of penetrating gastric ulcer. It is 
observed as a small fleck-like bismuth shadow on the lesser curvature. Its 
presence is usually confirmed by an incisura on the greater curvature. 

5. "The hour-glass constriction" of gastric ulcer must be found present 
upon repeated examinations to avoid the possibility of error. 

When it is observed, the patient must be re-examined after the adminis- 
tration of belladonna. Twenty drops of the tincture will usually serve to 
determine the tolerance of the patient and if no reaction follows the same 
dose may be given every two hours until the physiologic limit is reached. If 
the "hour glass " persists upon re-examination it is positive evidence of a lesion. 

Such a contraction may disappear under anesthesia so that only the 
ulcer is found at operation. 



842 



MEDICAL DIAGNOSIS 



DUODENAL ULCER.— The most important roentgen signs of duodenal 
ulcer are: (i) cap deformity; (2) diverticulum, or accessory pocket. 

1. Deformity of the bulbus duodeni, pilleus ventriculi or cap as it is 

variously styled, is constantly observed when duodenal ulcer is present. The 
defect in outline may be difficult to demonstrate since it sometimes occurs 




Fig. 439. — (See Fig. 440.) Chronic duodinal ulcer. 

on an inaccessible part of the cap. When, however, a normal cap is clearly 
seen either on screen or roentgenogram, a negative diagnosis is justified. 

Failure to visualize the cap should not be accepted as evidence of ulcer. 
Here one must rely upon secondary gastric signs such as (1) hyper peristalsis 



KXAMINATION OF THE DUODENUM 






and (2) delayed emptying lime, to make a probable diagnosis. The differ- 
entiation usually lies between duodenal ulcer and gallbladder disci 

Gallbladder disease may cause cap deformity, either by direct pressure 
of an enlarged gallbladder or by adhesions. Such deformities have not. 




Fig. 372. 
Fig. 43Q and 440. — Chronic duodenal ulcer. Note irregularity of birfbus duodeni, con- 
stant in a series of roentgenograms. (Dr. Frank S. Bissell.) 



as a rule, the usual characteristics of ulcer deformities, 
assume one of the following forms : 

(a) Incisura — single or multiple. 

(b) Excavation — basal or on posterior wall. 

(c) Niche or accessory pocket. 



The latter usually 



8 4 4 



MEDICAL DIAGNOSIS 



2. A diverticulum, when observed, is distinctive evidence of perforating 
duodenal ulcer. 

Minor or confirmatory signs of duodenal ulcer are: (i) Hypermotility 
with speedy clearance of the stomach. (2) Lagging of bismuth in the duodenum 
even after the stomach is empty. This is especially significant if it is associated 
with a (3) tender pressure point. (4) Intestinal hypermotility, which may occur 
with duodenal irritation despite normal or increased acidity of gastric contents. 
(5) Gastric hypertonus. (6"> Hyperperistalsis. (7) Spasmodic hour-glass con- 




Fig. 441. — (See Fig. 442.) Old duodenal ulcer. 

tractions of the stomach which are occasionally produced by intense duodenal 
irritability. (8) Delayed gastric evacuation resulting in a six-hour residue fre- 
quently occurs in duodenal ulcer. 

It should be noted that hyperrnotility or rapid clearance may occur in 
duodenal ulcer without obstruction, whereas delay occurs when spasm or 
adhesions interfere with evacuation. 

The writer's experience has convinced him that it is not safe to make a 



EXAMINATION OF THE Dl'ODKNI M 



S 45 



diagnosis of duodenal ulcer upon any of these minor symptoms but that the 
presence of either one of the major signs is conclusive. 

The gastric hyperperistalsis observed in duodenal ulcer is probably 
a reflex from duodenal irritation. It varies in intensity from a slight 
exaggeration in wave depth to most energetic, cramp-like contractions. 
The lesser curvature participates in these contractions so that the waves appear 
in symmetrical pairs. Three or even four of these may be observed at once 
whereas normally only one or two relatively superficial ones are seen. 




Fig. 441 and 442.- 



Fig. 4+2. 
Adhesions from old duodenal ulcer. 
(Dr. Frank S. Bissell.) 



Deformity of bulbus duodeni. 



True hyperperistalsis rarely, if ever, occurs except in conjunction with 
delayed gastric motility, but partial pyloric obstruction due to a lesion on 
the gastric side is not accompanied by this symptom. Hence it is apparent 
that it is a manifestation in some way dependent upon duodenal irritation. 
Since it occurs only intermittently, it may be readily overlooked in a given 



846 



MEDICAL DIAGNOSIS 



case. When a six-hour retention has been demonstrated, however, persist- 
ent observation will usually be rewarded. The concomitant occurrence of 
true hyperperistalsis and a six-hour retention is conclusive evidence of 
obstructive duodenal ulcer. 




Fig. 443. — Chronic ulcer of the duodenum, after gastro-enterostomy. Note that the 
bulbus diwdeni contains barium-laden ingesta, showing also constant irregularity, despite 
a properly functionating gastro-enterostomv. Hyperperistalsis is evident. {Dr. Frank S. 
Bissell.) 

A gastric residue after six hours occurs in about 40 per cent, of the recognized 
cases of duodenal ulcer. Hence it is a very important sign. Other conditions 
in which it occurs are actual pyloric stenosis, gastric ulcer and, less frequently, 
in gallbladder disease. 



THE STOMACH TUBE 



Of the minor roentgenological signs of duodenal ulcer, the writer h 
the most important one is intestinal hypermotility. 

It is especially significant in the presence of hyperacidity of gastric con- 
tents which when due to other causes tends to retard intestinal motility. 
The degrees of intestinal motility are determined by the position of the head 
of the bismuth column at a given time following ingestion. 

Normal Intestinal Motility. — Under normal conditions the first part of 
the bismuth meal should reach the cecum in four hours. To attain the first 
portion of the transverse colon eight to ten hours are required and in 
from twenty to twenty-four hours it should be in the rectum or appear in 
the stool. 

A portion of the bismuth may remain in the colon for forty-eight hours. 

Constipation of all grades may be recognized roentgenological!}' and often- 
times the information furnished is of great value, a statement especially 
applicable to the misleading spastic cases characterized by a striking state 
of colonic spasticity and marked bismuth delay in the cecal region. 

The Colon. — While various obstructive phenomena may be observed as 
the meal passes through the colon, the bismuth or barium clyster offers the 
best means for the roentgen study of the colon. The suspension employed 
should be warmed to body temperature and observed on the screen as it finds 
its way from ampulla, via sigmoid, descending colon, splenic flexure, hepatic 
flexure and ascending colon to cecum. 

Filling defects due to carcinomatous infiltration are carefully searched 
for and when observed are very characteristic. 

Palpation during process of filling may elicit evidence of adhesions. 
Small pockets or diverticuli may be seen to fill and may remain filled for days 
after the evacuation of the colon. 

The position of the flexures is carefully noted as evidence for or against 
a diagnosis of splanchnoptosis. The position of the transverse colon 
is less important since it may appear in various positions at as many 
examinations. 

The appendix may frequently be visualized upon screen or plate twelve 
to twenty-four hours after ingestion of a fermillac -barium meal. When it 
fills and empties as the cecum empties, and is apparently non-adherent, a 
negative roentgen diagnosis should be made. The tip of the filled appendix 
may be fixed (adherent,) or it may remain filled for many hours or days 
after the contents of the cecum have passed on. Here a positive diagnosis is 
indicated. A retrocecal appendix is usually pathological. 

Indirect evidence of chronic appendicitis may be of considerable import- 
ance. It consists of 'a ileal stasis (delay in the terminal ileum for 18 hours 
or more); (b) cecal stasis (retention of a barium residue in the cecum after 
the rest of the column has passed on through the colon; (c) pressure, tender- 
point discovered while manipulating the appendix under the screen. 

ILEOCECAL TUBERCULOSIS.— La wrason Brown has recently pointed 
out that the most characteristic roentgen sign of this disease is a failure of 
the cecum to fill and remain filled in a normal manner with an opaque 



848 



MEDICAL DIAGNOSIS 



enema. Whether this sign is due to spasm, to a hypermotility, or to a diffuse 
infiltration producing a rigidity of the part of the bowel affected, is unde- 
termined. The speed with- which this phenomenon manifests itself from 
time to time seems to indicate that it is due to spasm. 




Fig. 444. — Gall bladder disease. Note thickened gallbladder producing deep concave 
impression upon bulbus duodeni. {Dr. Frank S. BisseU.) 

Tuberculosis elsewhere in the intestine manifests itself in no typical 
manner but is indicated by obstructions or localized narrowing of the bowel 
lumen. 

CHRONIC ULCERATIVE COLITIS is characterized by an absence of 
haustral markings and at times by a marked narrowing of the affected 
colon. 



THE STOMACH TUBE 



849 



GALL-BLADDER. — The degree of precision with which chronic chole- 
cystitis can be diagnosed roentgenological^ seems to vary directly with the 
effort and persistence devoted to the problem. The modern trend seems 
to be toward an attempt to demonstrate thickened and hence pathological 
gallbladders rather than gallstones which may be contained therein. If 
one accepts the statistical reports of an increasing number of men of large 
experience, one reaches the conclusion that it is possible to demonstrate from 
85 to 95 per cent, of all chronically diseased gallbladders. 

The only direct sign, of course, is a diffuse shadow extending below iht 
liver margin somewhat simulating gallbladder in outline. If within this 
shadow gallstones can be outlined, the diagnosis is much more conclusive. 

More indirect signs are (1) pressure deformities of the cap, (2) displace- 
ments of the duodenum upward and to the right, (3) persistent filling of 
the second and third parts of duodenum during barium meal examination, 
(4) unexplained pylorospasm or gastrospasm, and (5) six-hour gastric 
residues unexplained by other lesions. 

THE STOMACH TUBE AND ITS USES 

The Tube. — One should use a soft rubber tube carrying ample fenestra- 
tions at its extremity and a large terminal perforation. It should be sur- 
mounted by a glass funnel, below which some physicians introduce a glass 
tube as an indicator. For diagnostic purposes, the simpler the stomach tube 
the better are the results, and the very elaborate and complicated special tubes 
are unnecessary. 

Contraindications. — Under certain conditions the introduction of the tube 
is unjustifiable and dangerous, and it is always necessary to balance the value 0] 
the result to be obtained and the possible danger experienced* 

The following conditions usually forbid the use of the tube in those not habitu- 
ated to its use: (a) Extreme anemia; weakness and exhaustion from whatever 
cause, (b) Advanced myocardial weakness, (c) Recent hematemesis or tarry 
stools, (d) Advanced arteriosclerosis or past cerebral hemorrhage, (e) Ad- 
vanced pregnancy. (/) Aortic aneurysm, (g) Terminal pulmonary tubercu- 
losis, especially if hemoptysis has occurred, (h) High grades of emphysema 
and severe bronchitis, (i) Cases showing excessive arterial tension. 

Furthermore, in elderly persons of apoplectic build and tendency, the first 
passage of the tube usually involves an amount of straining and congestion 
that is extremely dangerous. False teeth should be removed before attempt- 
ing to introduce the tube. 

In the case of patients who have become habituated to the use of the tube pre- 
viously these restrictions need apply only to recent hemorrhagic cases and 
aneurysm. 

Technic of Introduction. — By word, manner and method the operator 
should minimize the procedure in the mind of the apprehensive victim. The 

* That this is not imaginary was shown not long since in a case observed by the author 
in which a large soft tube passed directly through the base of a carcinomatous ulcer. 
54 



Simple 
requirements. 



Important 
suggestions. 



MEDICAL DIAGNOSIS 



Keep 

fingers out of 
patient's 
mouth. 



Expression of 
contents. 



Aspiration. 



Tube blocking. 



patient should be reassured and told to obey orders absolutely, swallow 
when told to do so and breathe deeply throughout. He should not be instructed 
primarily to breathe through the nose, for any such conscious effort in that 
direction tends to increase his initial sensibility. 

If, however, his breathing is checked as the tube enters the esophagus, 
he should be told to close his lips upon the tube and breathe through the nose. 
Sharp commands are often successful and effective in shutting off nervous 
gagging or retching or attempts to pull out the tube, which should be warmed 
by placing it in hot water, held like a pen and introduced promptly and firmly 
without haste and without regard to temporary obstruction. 

The patient receives the tube with the head inclined somewhat forward, 
the mouth comfortably open, not stretched to the limit, and the tongue unpro- 
truded. He may be asked to swallow as it reaches the pharynx and there 
need be little fear that it will enter the larynx; if it does, the fact is at once 
evident, the tube is removed and no harm done. No considerable force is 
at any time necessary nor should it be employed. 

The depth to which it should normally be passed is from 16 to 22 inches 
from the teeth and the normal distance is usually marked upon the tube, 
but is of slight use.* In gastroptosis and ectasia it will need to be deeply 
introduced before results can be obtained and that fact is diagnostically 
suggestive. 

In all individuals showing the stigmata of congenital asthenia it may be 
taken for granted primarily that the point of the tube must descend well 
below the level of the navel. 

On the other hand, one should not fail to try the effects of aspiration at 
different lev els and in different positions of the body before accepting the 
fact that the stomach is emptied. 

The tube may fail to reach the surface of any residual content or may coil 
or tilt upward in such a way as to maintain its point above that level. 

In the introduction of a stomach tube there is not the slightest reason 
for introducing the finger into the patient's mouth, a procedure which increases 
"gagging" and distress and often involves well-deserved injury to the physician's 
finger. 

To obtain the contents, the patient is asked to lean sharply forward 
with the knees pressed together, take a deep breath and strain as at stool. 
Either the physician or the patient may assist this movement by firm 
pressure over the region of the navel or at a lower level if visceroptosis 
exists. 

In some cases it may be necessary to attach a syringe bulb or Politzer's 
bag to the tube and make suction, f From time to time a tube may be 
blocked and the bulb may be used to force in jets of air, or the obstruction 

* Most of the stomachs investigated are of the vertical, low-lying (ptotic) type. 
f Such a bulb can readily be fitted with a glass tube that accurately fills the caliber of the 
stomach tube and the device is better than the use of a compression bulb on the tube itself. 
The fortunate ones who can milk a tube as if it were a cow's udder require neither excessive 
straining on the part of the patient nor the use of a suction bulb. 



THE STOMACH TUBE 



851 



may disappear if the tube be slightly withdrawn and reintroduced; this latter 
procedure being often necessary in any event. 

The first attempt to introduce a stomach tube is usually associated with 
more or less violent retching and straining and is greatly dreaded by the pa- 
tient, but he may be assured that after three or four introductions the dis- 
comfort will be slight. 

If the patient's head is thrown back, the tube may enter the glottis and 
stridor at once follows. As stated previously, no harm is done except from 
the fright the patient may suffer. 

The use of the X-ray and "exploratory incision" has displaced the 
systematic examination of the gastric contents to an unjustifiable 
degree. 

The stomach tube should still hold first place, not only because it is 
readily available to the use of all practitioners, rather than the fortunate 
few, but also because the X-ray, valuable and often indispensable as it is, 
cannot and does not fill its place. 

Roentgenography and roentgenoscopy sliow certain pathologic condi- 
tions with a promptness and certitude which is most gratifying, but on the 
other hand the stomach tube alone shows many of these quite as definitely 
and many more which the X-ray does not reveal. The one supplements 
the other and often aids in confirming findings. Both are fallible. 

The exploratory incision is at once the most valuable and most abused 
and overdone of diagnostic procedures. If it were made an invariable rule 
that, save in actual emergency, none should be undertaken until all other 
modern diagnostic procedures had been exhausted, it is probable that the 
present number of operative short cuts to diagnosis would be reduced by 
80 per cent. 

In relation to the stomach itself the tube properly used is one of the 
most valuable of our aids to diagnosis and therapy alike. 

THE DIGESTIVE FERMENTS.— It should be clearly understood 
that the gastric digestion is but part of a complex process in the completion 
of which the following non-gastric ferments are concerned to a considerable 
degree. 

(a) Ptyalin. — This constituent of the saliva is an important enzyme serv- 
ing to convert starch to maltose, doubtless acting for an hour or more upon 
such portions of a full meal as are contained in the fundus of the stomach 
and for a considerable time protected from the action of the HC1 which in- 
hibits its activity. 

(b) Amylopsin. — *This enzyme is contained in the pancreatic secretion 
and converts starch to maltose and achroodextrin. 

(c) Maltose. — A constituent of the saliva, of the secretion of the small 
intestine, and of that of the pancreas. This converts maltose to dextrose. 

(d) Invertase. — An enzyme of the small intestine which converts cane 
sugar into dextrose and levulose. 

(e) Lactose. — This occurs in the secretions of the small intestine and 
converts maltose into dextrose and galactose. 



Habituation 
rapid. 



Prolonged 
action in 
stomach. 



852 



MEDICAL DIAGNOSIS 



Prepare food 
for absorption. 



Genuine 
importance. 



Both gastric 
and duodenal. 



Ease of 
introduction. 



Shows reten- 
tion period. 



(e) Trypsin. — This derivative of the pancreatic juice acts upon proteins. 

(/) Erepsin. — Derived from the small intestine, this prepares peptones 
for absorption. 

(g) Steapsin. — This substance splits neutral fats into fatty acids and 
glycerin. 

Gastric Digestion not Indispensable. — It will be seen readily that gastric 
secretions are not absolutely indispensable to digestion as is well demonstrated 
by cases of functional achylia and other conditions in which the gastric secretory 
functions are wholly lacking. 

The ferments acting in the small intestine upon ingested food are peculiarly 
efficient in that they carry the processes to the point where actual absorption may 
take place. 

Indirect Gastric Aids to Digestion. — The stomach permits a certain 
amount of absorption of water, dextrins, salts and peptones and by its acid 
content stimulates the production of secretin in the duodenum, which sub- 
stance in turn increases the secretory activity of the pancreas, hastens the 
neutralization of the acid chyme and promotes the activity of the 
ferments. 

Bile. — The bile assists in the conversion of the neutral fats and is believed 
to exert some inhibitory influence upon intestinal putrefaction. 

Extent of Digestive Processes. — Enzyme activity extends from the 
buccal cavity to the ileocecal valve and absorption is especially active 
in the duodenum and jejunum, though the colon is also an important 
channel for the completion of absorption of the residuum of prepared 
substances. 

The remainder of the ferments will be considered in connection with the 
examination of the gastric contents. 

EXAMINATION OF DUODENAL CONTENTS.— Much information 
of genuine importance is obtainable by this procedure and although some 
of the finer reactions sought are somewhat time-consuming, others are 
extremely simple. 

Present Field of the Duodenal Tests. — This is both gastric and 
duodenal for the tube lends itself admirably to fractional * analysis of 
the stomach contents if swallowed immediately after the test breakfast is 
taken. 

Furthermore it is comparatively innocuous from the patient's point of 
view, especially if his attention is directed to the fact that it is no larger than 
the bulky drug capsule, or large food fragments, swallowed without diffi- 
culty. It is evident that in many instances the gastric "emptying time" will 
be defined very sharply and it should also prove useful in determining the 
presence of persistent hypersecretion. 

Not the least of the advantages claimed for the duodenal tube, is the fact 
that it may be left in situ for as long a time as is desired. 

* Fractional analysis demands that specimens of stomach contents be taken every 
10 or 15 minutes throughout the entire period of digestion of the test meal; the tube 
remaining in situ until the stomach is empty. 



THE DUODENAL TUBE 



853 



With respect to both the stomach and the duodenum it may be of con- 
siderable value in determining the presence of blood. 

Occult blood, however, might be due to the procedure. 

In the duodenum itself, its chief specific value is derived from the facility 
and promptness with which one may obtain the pure or relatively uncon- 
taminated duodenal content. 

The clinically essential tests for pancreatic ferments and bile pigment and 
bile acids are extremely simple, and quickly performed. Cultures may be 
readily made if desired and have proven useful in cases of recovered typhoid 
with persisting cholecystic infection. 

It is conceivable that the same procedure might prove useful in the puz- 
zling first stages of typhoid fever with dominant primary cholecystic and duct 
symptoms. 

The Duodenal Tube. — Many modifications of the original "Einhorn 
tube" are now available, one of the best of which is that of Rehfuss, which 
instead of a perforated bulb has one which is elongated and carries longitudinal 
slits, each of which in length is equal to the diameter of the tube and suffi- 
ciently roomy to prevent plugging in most instances. 

Duodenal tubes are so marked as to indicate certain distances from the 
mouth of the patient to the terminal bulb, these corresponding, in the ordinary 
position of the stomach, to the distance of the cardia, the pylorus, and the 
duodenal portion itself, from the teeth of the patient. 

In duodenal feeding one may need to introduce the tube 100 or even 125 
cm. Tests for duodenal content begin ordinarily when the tube has entered 
for a distance of from 75-80 cm. 

Method of Introduction. — This is simplicity itself in most instances. 

The bulb is placed at the back of the tongue; the patient takes a few 
swallows of water and with tightly closed lips continues to swallow until the 
tube is fed in well beyond the 40 cm. mark indicating its passage through the 
cardiac orifice and entrance into the stomach. 

This consumes but two or three minutes if the patient is ordinarily docile 
and sensible. 

He may sip water at will during the process, but the ingestion of any con- 
siderable quantity is undesirable. Little gagging or straining is likely to be 
encountered, but if this should appear, it is a simple matter to anesthetize 
the pharynx by a local application. 

If considered desirable for any purpose to leave the tube in situ for 
several hours or days it may be made fast to the patient's clothing or to his 
cheek by a strip of adhesive plaster, and he may read, write, or sleep without 
discomfort. 

About one-half hour is required usually for the passage of the tube through 
the stomach and into the duodenum. Its passage through the pylorus is 
readily determined by touching a piece of red litmus paper to the liquid which 
presents at the orifice of the tube (if the "capillary-size" tube is used) or is 
secured by aspiration. 

The reaction will be alkaline if the duodenal secretion has been attained. 



Detects blood. 



Yields pure 
content. 



Most of tests 
simple. 



Cultures. 



Passes rapidly 
to stomach. 



Anchoring the 
tube. 



The average 
passage time. 



Alkaline 
secretion. 



854 



MEDICAL DIAGNOSIS 



Empty stomach 

necessary. 



Stomach contents may be acid or neutral, but never alkaline unless some 
such substance as magnesia or soda has been ingested. 

It is customary to introduce the tube while the patient is sitting and, 
when 75-80 cm. have been swallowed, to place him in recumbency on the 
right side with the hips elevated. 

More elaborate postural procedure is recommended by Holzknecht and 
other authorities but is seldom necessary. In some cases the passage of the 
tube from stomach to duodenum requires several hours or even a whole night. 
The patient must have eaten no food during the twelve hours preceding 
the test. 

Sufficient stimulation of duodenal secretion is secured by the introduction 
of the bulb and the older Volhard-Boldireff method (oil breakfast) is no 
longer desirable. 

The capillary (very small) tubes are to be preferred for diagnostic 
purposes. 

The work of Eppinger, Bondi and J. P. Schneider has demonstrated the 
extent to which the hemolytic process is reflected in the duodenal secretion 
in cases of plastic pernicious anemia and hemolytic jaundice and Schneider 
has devised a relatively simple method of demonstrating the great increase of 
urobilinogen peculiar to these conditions. 

The qualitative tests for the various gastric ferments, for blood and for 
bile, have been given already elsewhere and the method of Dr. Schneider 
is here quoted from his interesting paper>* together with such portions of 
his "summary" as directly affect this procedure. 

Color. — This is of prime importance and presents four distinct shades. 
The chocolate-yellow secretion is characteristic of pleochromie and it always 
yields a -\ — 1 — \- value bilirubin. The normal yellow secretion may vary in 
opacity according as it is rich in bile acids admixed with hydrochloric acid. 
This opacity is by many erroneously regarded as mucus. The lighter shade 
of yellow is significant of a duodenal secretion poor in biliary pigment, just as 
the colorless secretion is proof of absence of pigment. 

Bilirubin. — To 10 c.c. of duodenal contents are added 10 c.c. of an alka- 
line solution of calcium chlorid. After vigorous shaking this is filtered. The 
precipitate is dissolved under gentle heat in 10 c.c. of acid alcohol, and the 
resulting green solution concentrated to a given volume. By colorimetric 
comparison with a standard green solutionf the quantity is indicated as +, 

++, or + + +• 

Urobilin and Urobilinogen. — To 10 c.c. of duodenal contents are added 
10 c.c. of Schlesinger's solution, the whole thoroughly shaken and allowed to 
filter. The filtrate should be slightly alkaline; if not, a drop or two of dilute 
ammonia solution may be added. The filtrate will in the presence of uro- 
bilin show a more or less pronounced green opalescence. To 10 c.c. of this 
filtrate are added 1 c.c. of Ehrlich's benzaldehyd solution (paradimethyl- 

* Archives of Internal Medicine, Vol. XVII, pp. 32-41, January, 1916. 
t Ten grams of zinc acetate in 100 c.c. of absolute alcohol. A turbid solution which must 
be shaken. 



THE DUODENAL TUBE 



8.S5 



aminobenzaldehyd, 2 gm.; acid hydrochloric, 15 c.c; aq. dest., 15 c.c). 
In the presence of urobilinogen a red color will develop. This solution is 
allowed to stand in a dark place for fifteen minutes, when it is subjected to a 
spectroscope* study for the values of both urobilin and urobilinogen. The 
acid character of Ehrlich's solution enhances the absorption bands of both 
these pigments many fold, the urobilinogen band being a very dense, narrow 
one in the yellow and the urobilin a wide one covering all of the blue into the 
green, the acid shifting the latter to the blue side. 

The above solution is read in a graduate, and dilutions made with 95 per 
cent, alcohol, until a point is reached for each pigment where the absorption 
band will have disappeared at a fixed median position of the aperture, to 
again reappear with two revolutions of the aperture toward closure. The 
number of dilutions required for each element multiplied by twenty (5 c.c. 
of the original duodenal contents) will be the dilution value per 100 c.c. 
Following the basis used by Wilbur and Addis, the value has been reduced 
to the scale of 1000 c.c. 

In developing this method as applied to the duodenal contents it would 
appear that bilirubin being so concentrated would present a practical diffi- 
culty in that it gives a diffuse absorption of the spectrum. Wilbur and Addis, 
working with the products of gall-bladder fistulae, etc., made use of fullers' 
earth to remove bilirubin. The writer found that it did so but that it also 
removed especially urobilin. If the original 10 c.c. are well shaken with 
Schlesingers solution before filtering, practically all of the bilirubin is re- 
moved, the retained quantity causing no error or inconvenience owing to the 
fact that the end-stages are read in a highly diluted medium where any slight 
diffuse absorption of the spectrum no longer operates. 

That the above simple method is quite as accurate as one first removing 
bilirubin, was established by comparing the values thus secured with those 
prior to adding Schlesinger's solution. 

A report of nineteen cases showing the enormous increase in urobilinogen 
in the five cases of plastic pernicious anemia included is followed by the sum- 
mary given, in part, below. 

Summary. — 1. The early icteric feature of certain types of pernicious 
anemia is an expression of the primary fundamental hemolytic process of 
which the fully developed disease is a late bone-marrow exhaustion. 

2. The excessive hemolysis of pernicious anemia is attended by both a 
pleochromie and urobilinocholie. 

3. Pleochromie is an expression of the immediate hemolysis; urobilino- 
cholie of the heaped-up pigment in the portal system. 

4. Urobilinocholie varies directly as the portal system is surcharged or 
becomes relatively empty of the plus of pigment. It is highest in crises 
regardless of whether or not gross liver changes can be demonstrated. 

5. Normally the duodenal secretion contains a certain level of bilirubin, 
occasionally urobilin, but never urobilinogen in considerable amounts. 

6. The most constant blood finding in genuine pernicious anemia is the 
* Kirchhoff and Bunsen, large model. 



8;6 



MEDICAL DIAGNOSIS 



Indicates 

pancreatic 

disease. 



Digestion test. 



Important 

clinical 

bearing. 



Duodenal 
feeding. 



high index. This is an expression of the overplus of hemoglobin-building 
material heaped up in the liver. 

Significance of Duodenal Findings. — Impaired trypsin activity is evidence 
of pancreatic disease and, in its persistent absence during several days of 
tests, the other ferments of importance need not be sought and the existence 
of pancreatic disease is established. 

A very rough estimate of its activity, when it is present is furnished by the 
relative slowness or imperfection of its digestion of' a disc of lightly boiled 
egg, as compared with the normal, exactly as in the test for pepsin.* 

More accurate testing demands the use of a more elaborate procedure. 

F. W. White finds that normal trypsin content is indicated by the diges- 
tion of 10 c.c. of a " Jf o P er cent, alkaline casein solution"! in one hour in a 
water bath at 37°C. by the trypsin contained in i c.c. of duodenal content in 
dilutions of from i : 1,000 to i : 10,000. 

Bile. — The presence of bile in the duodenal content does not prove an 
unobstructed common duct for it may be present in marked degrees of con- 
striction and also in cases of impacted stone or catarrhal jaundice despite its 
apparent or even actual absence from the feces. 

Its entire absence from the duodenal content strongly indicates occlusion 
of the duct by malignant growth; more rarely, complete block from other 
causes. 

Therapeutic Value. — The value of the duodenal tube in gastric intolerance 
or subnutrition with absolute anorexia or repulsion is very great. 

Many authorities state that as compared to rectal feeding, both being in 
skilful hands the actual increase of potency gained is as three to one. 

It may be retained in situ for two weeks if necessary and is well borne 
by the stomach in most instances even though food and even liquids are 
promptly ejected. 

When so used the food must be only warm, not hot, and is introduced, 
strained and in liquid form, every two hours, by means of a funnel or other 
attachable appliance, at a rate of flow of about 60 drops per minute, until 
250 c.c. have been given. 

To prevent overcooling during the half hour required for feeding by this 
drop method, a hot water bag may be laid upon the tube CF. W. White). % 

EXAMINATION OF GASTRIC CONTENTS.— Aside from the methods 
described under "Examination of the Abdomen," our knowledge of gastric 

* Any pepsin present will be inactive in the alkaline medium and produce no confusion. 
Undigested casein is shown by a clouding of the solution upon the addition of acetic 
acid, at the end of the test period (one hour). 

t Griibers pure casein 1 gram; dissolve in 1000 c.c. of a 1 per cent, solution of 
sodium carbonate; boil. No single test suffices by reason of the known variability of 
the trypsin content. 

% Milk, cream, cane sugar or lactose and eggs, simply stirred into milk are the food sub- 
stances most employed. Of these milk and cream are the most dependable and reenforce- 
ment by sugar and eggs must be cautiously carried out. 

One cannot with propriety discuss the therapeutic aspect of this procedure in a work on 
diagnosis but this brief reference will serve to suggest the possibilities of the duodenal tube. 



THE GASTRIC CONTENTS 



857 



Pancreatic 

ferment 

activity. 



ailments still depends largely upon a consideration of the case history in con- 
nection with a chemical examination of the stomach contents taken after a 
test meal. 

It should be clearly understood that the old belief in the sacrosanct in- 
violability of the stomach, upon which many tests have been based, can no 
longer be maintained. Quite apart from our recognition of the considerable 
part played by the salivary diastase in the stomach itself, stands the fact that, 
normally, the pancreatic secretion enters the stomach through regurgitation 
and initiates the digestion of the fats within the stomach itself. 

We know also that in connection with malignant growths of this viscus 
special peptolytic and proteolytic agents become active and that similiar 
substance may be present in other gastric ailments. Nor does the chief 
ferment of the stomach itself confine its activity to the parent viscus. It 
is known to be active in the small intestine and even within the lymph 
stream itself. We are chiefly concerned nevertheless with the simpler phe- 
nomena of gastric digestion. 

The test meal serves the purpose of stimulating the stomach to a degree 
which should produce the physiologic phenomena of digestion in full measure, 
if the stomach is normal, and reveal its weakness if it is abnormal. 

Period of Rising Acidity. — After the ingestion of food there follows a period 
of rising acidity. The secreted hydrochloric acid combines promptly with the 
proteins and alkaline bases leaving no free acids to inhibit fermentation by 
bacteria, hence from fifteen to forty minutes after a meal one would find hydro- 
chloric acid abundant in combination, but absent as a free acid, while starch 
transformation would progress unhindered and lactic acid would appear because 
of fermentation or introduction with the food. 

Second Period. — A second period follows during which the affinities of the 
proteins are satisfied, free hydrochloric acid appears and fermentation ceases. 
After certain test meals, this period should be attained an hour after the meal is 
ingested and one thus has a definite normal by which abnormal variations may be i 
measured. This second period is followed after two how*s or more by a third Third period. 
characterized by a fall in the acidity. An excess of proteins requires much acid 
for combination and means in all cases a delay in the appearance of free hydro- 
chloric acid. An excess of carbohydrates acts in the opposite way, their acid 
affinities being promptly satisfied. 

Points to be Deterrnined. — Primarily one seeks for free and combined 
hydrochloric acid. The latter represents a loose chemical combination with 
alkali-albumin and undergoes a progressive transformation by means of the 
acid and the action of the digestive ferments which results in the production 
of: (1) acid-albumin; (2) proto- or hetero-albumoses ; (3) deutero-albumoses; 
and finally; (4) peptones. 

Certain standard test meals are here given, but it should be remembered 
that any meal will give good clinical results if its constitution is known and 
that finical exactitude is not essential. The chief purposes of the test meal 
are to stimulate secretion and determine motility, one or both, and the type 
of meal is more important than the exact amount of food introduced. 



Basic 
purpose. 



MEDICAL DIAGNOSIS 



Best test 
breakfast. 



A simple 
retention test. 



An excellent 

test breakfast. 



The Test Dinner of Von Leube and Riegel. — Four-hundred c.c. (12 to 14 

ounces) of soup, 50 grams (2 ounces, or two ordinary slices) of wheat bread, 
100 to 200 grams (3 to 6 ounces) finely divided beefsteak and 200 c.c. (6 
ounces) of water constitute the meal. It is removed four hours later. 

Ewald's Test Breakfast. — This consists of two slices of stale white bread 
or toast, or one or two baker's rolls, and from 300 to 400 c.c. (8 to 12 ounces) 
of water.* 

Improved Meal. — Two shredded wheat biscuits make a still better test break- 
fast, being wholly free from lactic acid and yeast cells. 

These meals represent 35 to 70 grams (1 to 2 ounces) of solid, but the 
exact amount is not material. They should be taken in the morning and be 
removed one hour after the commencement of the meal. 

Boas' Test Breakfast. — One tablespoonful of oatmeal is added to 1 quart 
of water and boiled down to 1 pint. It should be taken plain save for a little 
salt and removed in one hour. 

This breakfast and the shredded wheat meal are especially valuable in cases 
of suspected cancer of the stomach, as they introduce no lactic acid, the determina- 
tion of which is so important in this disease. In such cases the stomach should 
be washed out the night before or in the morning an hour before the meal 
is taken. 

Ewald's breakfast seldom causes any confusion, lactic acid not being in- 
troduced in sufficient quantity to produce the ordinary clinical reaction 
suggesting carcinoma. 

Effective Propulsion and Free and Timely Discharge. — An extremely 
simple test of freedom of discharge or patency of the pylorus consists in allow- 
ing a patient to eat a few cooked cranberries, raisins, prunes, black berries 
or other thick-skinned or stony fruits at night after the stomach has been 
completely emptied and thoroughly washed. The contents are removed in 
the morning one hour after a "shredded wheat" or "oatmeal" breakfast 
when the residue will show seeds, or skins, if actual decided stenosis is 
present, and also permit a chemical examination of the ingested morning 
meal. 

Yet another readily available and informative method for general pur- 
poses requires the removal of the stomach contents on the morning following the 
ingestion of a full test dinner or ordinary meal which includes some of the sub- 
stances mentioned above. 

Bourget and Kemp's Retention Meal. — This extremely convenient test 
meal is composed of 200 c.c. of soup, 100 grams of chopped or shredded 
beefsteak, 50 grams of bread, and 6 stewed plums (prunes or raisins). 

This meal should be passed out of the stomach wholly and completely in 
three hours. By the amount and character of residue the degree of retention 
is roughly measurable. 

* Tea is often recommended but should not be used. It to some degree modifies the 
activity of ptyalin and the production of hydrochloric acid, two points which, as Fuld puts 
it, overweigh both the lack of savor and the suggestion of prison fare embodied in the plain 
test breakfast. 



THE GASTRIC CONTENTS 



859 



Repeated observations at varying periods after the ingestion of the test 
meal will further establish the grade of retention present. 

The grosser meals advocated have little or no advantage and some decided 
disadvantages as compared with a light mixed one of this type. Many can- 
not be retained by patients of the very type in which such test procedure 
proves most helpful. 

Much ingenuity has been wasted, vast amounts of time consumed and 
many diagnostic errors incurred through the highly creditable but wholly 
futile attempts made in the past to measure the propulsive power of the 
stomach and certify the adequacy and normal reactivity of the pyloric out- 
let by means of special and specific chemical tests. 

So far as the author can determine each and every one of these has proven 
vitally defective and should be retained no longer in the text-book or in 
practice. 

The death blow of the best of them was delivered by Pawlow in his dis- 
covery of the fact that regurgitation of pancreatic secretion into the stomach is 
not uncommon even under normal conditions and the effective check inter- 
posed by the roentgen-ray has done the rest. 

Aside from the agency last named, one must place his reliance upon prop- 
erly controlled and, usually, repeated test meals associated with such other 
data as are yielded by the history of the case and the physical signs 
elicited. 

The X-ray has proven invaluable in relation to the determination of 
effective motility and is by far the most reliable method. 

All procedures in which the determination of muscular and pyloric potency 
is dependent upon the amount of residuum recoverable by the tube is fallible even 
though very valuable, in that quite frequently complete removal of the stomach 
contents cannot be achieved. 

It constitutes nevertheless the best method available to the generality 
of practitioners, but is better fitted to establish than to disprove gastric 
disability. 

On all such occasions the patient should thoroughly masticate the meal, 
brush the teeth and cleanse the mouth after taking the retention 
meal in order that no coarse lumps may delay the passage through the 
pylorus and no indigestible particles remain in the buccal cavity, become 
detached at some later period and lead to spurious findings and false 
conclusions. 

Two hours after the shredded wheat or Ewald test breakfast or six hours 
after the Riegel dinner, a stomach should be either entirely or approximately 
empty. 

In actual extreme stenosis with pronounced secondary ectasia solid food rem- 
nants representing the residue of several previous meals may be present. 

In mere atony such prolonged retention of undigestible remnants seldom or 
never occurs. 

It is obvious that the contents must not only be expressed but further sought 
for through a thorough stomach washing. 



Point of 
importance. 



86o 



MEDICAL DIAGNOSIS 



Simple tests 
for acidity. 



The Macroscopic Appearance of the Normal Stomach Contents. — The 

normal fasting stomach should show only a few cubic centimeters of fluid 
of variable reaction and color, containing mucus and oftentimes a bile- 
stained mixture of gastric and duodenal secretions. 

One hour after an Ewald test breakfast the appearance should be that of 
thin porridge, the bread in particles rather than distinct fragments, and little 
or no mucus present. The filtrate should be clear or faintly yellow, yielding 
a slight odor, and from 20 to 70 c.c. in amount. 

A residue of less than 20 c.c. suggests too rapid emptying of the stomach; 
an amount exceeding 30 c.c. suggests retention, if rich in food remnants; 
otherwise hypersecretion. 

The first inference is rendered uncertain by the difficulty often encoun- 
tered in completely emptying the stomach. If, however, the stomach be 
washed before the tube is withdrawn a somewhat more accurate inference is 
obtainable through the appearance of the washings. 

Abnormal. — Anacidity or marked hypoacidity is indicated by unchanged 
or slightly modified bread fragments, slow filtration usually, and a musty 
odor. 

Hyperacidity is suggested by greater fluidity, foamy surface, stale, acid 
odor, rapid deposit of sediment and a larger liquid residue (70 to 100 c.c). 

In catarrhal gastritis the thick slimy content with evidence of subacidity 
is characteristic and in hyperchlorhydria with excessive motility or in achy- 
lia gastrica in which gastric digestion is nil owing to the entire absence of 
HC1 and ferments, the stomach may be entirely empty. 

Suggestive Odors. — Normal gastric contents yield no odor, a slight 
"bready" aroma, or an acid' smell. 

In cases of stasis one may recognize the alcoholic odor like that of ferment- 
ing wine, if yeasts are present in quantity; of rancid butter, if the fatty acids 
dominate; of sulphureted hydrogen, if albuminous putrefaction prevails. 

Elaborate Chemical Tests and Instrumental Procedure. — Many elaborate 
and complicated procedures have been devised by enthusiastic specialists, 
and necessarily and properly by research workers, but fortunately for the 
student and practising physician every necessary and reliable test whether 
chemical or instrumental may be satisfactorily and oftentimes even more 
reliably performed by extremely simple methods. 

Hence, throughout this section, the author will pay scant or no attention 
to methods or instruments whose chief merit is delicacy or super-refinement. 

GASTRIC CONTENTS— CHEMICAL TESTS 

QUALITATIVE TESTS.— Free HC1— The following procedure is simple 
and convenient: (a) Test filtrate with congo-red paper or solution (congo-red 
1, distilled water 100), or add to a portion of the filtrate 1 or 2 drops of an 
alcoholic solution of di-amido-azo-benzol (0.5 per cent.). 

Free hydrochloric acid is indicated by a decided blue discoloration with the 
former, or red with the latter reagent. 



THE GASTRIC CONTEXTS 86 1 



Theoretically, both tests show only that a free acid is present, but 
practically, a decided color change proves the presence of free hydro- 
chloric acid. 

Organic acids can only produce it when present in quantities never en- 
countered in the stomach. Saturated and dried filter paper may be used in 
the di-amido-azo-benzol test if desired. 

Tropeolin Test. — Tropeolin test paper is made by soaking strips in a 
saturated alcoholic solution of tropeolin oo. Dipped into the gastric con- 
tents and dried over a flame, it strikes a lilac blue color if free hydrochloric 
acid is present. 

Gunzberg's Test for Free HC1. — A few drops of resorcin solution (resorcin 
5, cane-sugar 3, alcohol 100), or phloroglucin solution (phloroglucin 2, vanillin 
1, alcohol 100) may be mixed with an equal amount of filtered gastric con- 
tents in a porcelain capsule or on any white non-absorbent surface and 
evaporated slowly to dryness, a beautiful marginal rose color indicating 
free HCI. 

The Boas Test for Free HC1. — This test is applied in exactly the same 
manner as is that of Giinzberg. The test solution is more stable, the color 
reaction less vivid. 

Reagent. — Resublimed resorcinal 5 grams 

Cane-sugar 3 grams 

Alcohol 100 c.c. 

Lactic Acid. — In the absence of HCI, lactic acid should be sought by placing 
in the test-tube 2 drops of carbolic acid and 6 drops of neutral tincture of ferric 
chloride, adding water until a deep but clear amethyst color appears. The 
gastric filtrate after being treated as directed below is then added drop by drop 
and if lactic acid be present, a clear yellow reaction appears. 

The reaction is intensified by shaking up 5 c.c. of the filtrate with 
ten times its volume of ether, evaporating, adding 5 c.c. of water and 
applying the test. The use of unprepared filtrate makes the reaction very 
uncertain . 

Xo attention is paid to doubtful reactions. Lactic acid should disappear 
as free HCI appears in the process of digestion and is always abnormal if 
found one hour or more after a test breakfast. 

Simon's Modification of Kelling's Test. — This should replace the classical Best test for 
lactic acid test of Ueffelmann, because of its comparative immunity to the 
disturbing influence of glucose, the albumoses and the phosphates. 

Test. — Fill a test-tube with distilled water and add a sufficient number 
of drops of a saturated aqueous solution of ferric chloride to give the solution 
a faint yellow tint. Divide into two equal portions, add to one a small 
amount of the gastric filtrate and compare with the control. A distinct yel- 
low indicates lactic acid. 

Quantitative Test for Lactic Acid. — The least complicated quantitative 
test is the simplified Boas procedure which gives results slightly lower than 
the true figures, but is sufficiently accurate. 



lactic acid. 



862 



MEDICAL DIAGNOSIS 



Other fermen- 
tation acids. 



Fermentation 

present. 



HC1 absent. 



Simple tests. 



Relation to 
HC1. 



Test. — To io c.c. of filtered stomach contents add a few drops of dilute 
sulphuric acid. Filter to remove albumin. Evaporate to syrupy consist- 
ence on water bath. Add water to regain original volume. Again evaporate 
to small volume to remove fatty acids. Shake up thoroughly with 200 c.c. of 
ether which takes up the lactic acid. Evaporate. Raise to original volume 
with distilled water. Titrate with a decinormal solution of sodium hydrate 
using phenolphthalein as an indicator. One uses the same notation as in the 
test for HO, i.e., multiply the number of cubic centimeters used by 10. 
In clinical work the game is not worth the candle.* 

Acetic and butyric acids are revealed by the odor of vinegar and rancid 
butter produced upon heating. Butyric acid appears as small oily drops of 
characteristic odor if a bit of calcium chloride be added to an ethereal 
residue. 

A more exact test for acetic acid demands treatment with ether, evapora- 
tion, neutralization of the ethereal residue with dilute sodium hydrate and 
the addition of a drop or two of dilute ferric perchlorid, but the clinical 
results are not worth the labor. 

These volatile fatty acids redden litmus-paper, held over the tube during 
boiling and indicate fermentation. Lactic acid is the only fermentation acid 
of marked clinical importance. It proves the absence or extreme attenuation 
of HC1 and the presence of a stasis and fermentation strongly suggesting 
carcinoma. 

Pepsin and Pepsinogen. — With normal or increased hydrochloric acid no 
test is necessary as the presence of this acid proves also that of the ferment 
and in any event pepsinogen may be disregarded. 

The entire absence of pepsin in the gastric contents clinically is essentially 
characteristic of so-called " functional achylia gastrica" true gastric atrophy 
or carcinoma. 

Test. — Prepare three tubes. (1) Water 10 c.c. + pepsin 5 grains + HC1 
dil. 3 drops. (2) Filtrate of gastric contents 10 c.c. (3) Filtrate 10 c.c. + HC1 
dil. 3 drops, add to each a disc of egg albumen about 1.5 mm. thick, and 10 
mm. in diameter. 

These should be constantly on hand and are readily prepared from slowly 
and lightly boiled egg, preserved in glycerine and washed before using. 
Cooking over a water bath is an excellent method. 

Tube No. 1 serves as a standard of comparison. Digestion in No. 2 
indicates both pepsin and HC1; in No. 3, No. 2 failing, it shows the presence 
of pepsin or pepsinogen alone. Digestion should be complete in about three 
hours at blood heat, but considerable variation is allowed.! 

As a rule, pepsin activity and acidity run parallel, but this rule may be 

* Each c.c. of the decinormal solution used represents 0.009 °f lactic acid. Hence, 
multiplying by 10 gives the actual amount present; by 100, the percentage. 

t The quantitative methods of Thomas and Weber depending upon the digestion of a 
solution of casein in 0.2 per cent, solution of hydrochloric acid, and the still more compli- 
cated one of Mett, are too cumbersome for the general practitioner. The still newer ricin 
method of Jakoby-Solms and the edestin method of Fuld are described in the later litera- 
ture but are open to the same objection. 



THE GASTRIC CONTENTS 



86 3 



departed from in extreme hyperacidity and certain functional cases of sub- 
acidity. If motor sufficiency is present or increased even a total absence of 
acid and ferments may cause few symptoms as is shown in many cases of 
"achylia gastrica" over long periods. 

Rennin Test. — Add to 10 c.c. of milk 3 to 5 drops of gastric nitrate keeping 
mixture at blood heat. The appearance of coagulation within fifteen minutes 
indicates rennin. It may be entirely absent in carcinoma, achylia gastrica Most resistant. 
and atrophic gastritis, but is the most resistant of the ferments. 

A positive test for rennin is almost absolute proof of the presence of pepsin 
and of free hydrochloric acid. 

Lipase. — The elaborate test reaction for lipase is of interest only to la bora- slight value. 
tory workers as its only clinical importance lies in the diminution or entire 
absence of this ferment in achylia gastrica or atrophic gastritis, and this 
may be assumed if both HC1 and the ferments are absent. In any event it 
is but slightly active. 

Albumin. — This should be absent one hour after a test breakfast. 

Starch. — The digestive transformation of starch into amidulin by the Transforma- 
action of ptyalin begins in the mouth. This later becomes erythrodextrin 
which strikes a violet or mahogany brown color with Lugol's solution. This Tests. 
in turn becomes achroodextrin (unaffected by iodin) and maltose (readily 
detected by Fehling's solution). 

It is evident that if the gastric secretion be normal the hydrochloric acid 
will prevent more than a partial conversion of the starch, despite the rapid 
action of the ptyalin, the extent of which depends primarily upon the thor- 
oughness of mastication and secondarily upon the character of the food in 
relation to the penetration of the acid encountered and the time certain 
portions of an ingested meal are held in the fundus and protected in great 
measure from the acid. It is checked when the appearance of the free acid 
proclaims the satisfaction of proteid affinities and this is able to reach the 
food then being acted upon by the ptyalin. This ferment is doubtless 
more of a factor in gastric digestion than we had supposed until Cannon 
set us right. 

Clinical Inference.— ^4 marked starch reaction in the stomach contents sug- 
gests hyperacidity; a marked achroodextrin reaction, diminished hydrochloric 
acid, and a marked Fehling's reaction, decided subacidity or absent HCl. 

Trypsin. — The pancreatic ferments are of interest chiefly in the examina- 
tion of the duodenal secretion but may be found in the gastric contents even 
under normal conditions and especially after the injection of oil. They do 
not reveal their presence save in an alkalinized fluid. (See "Duodenal 
Content.") 

Test. — A 1 per cent, solution of sodium carbonate may be used for 
this purpose and to the alkaline gastric juice contained in a test-tube, 
one adds a few flakes of fibrin which have been previously stained with 
Magdala red. 

The fluid is then incubated and the digestive action of the trypsin pro- 
gressively liberates the dye which in turn colors the solution. 



86 4 



MEDICAL DIAGNOSIS 



Iodide tests. 



Solution No. i. 



Total acidity. 



Combined 
HC1 Solution 
No. 2. 



Free HC1 
Solution No. 3. 



Color of 
mixtures. 



Red-total 
acidity. 



Steapsin. — A few drops of neutral olive oil and gastric contents are mixed 
upon a watch glass and the mixture colored by the addition of alcoholic 
rosalic acid. It is then hermetically sealed by covering it with another glass 
and placed in a water bath for an hour when the disappearance of the original 
pink color will indicate the presence of steapsin. 

Amylopsin. — Tests for amylopsin are of slight value in relation to the 
gastric contents because of the presence of the ptyalin of the saliva the action 
of which has been inhibited by the HC1 ordinarily present. 

The test is merely that of adding i or 2 c.c. of the filtrate to four times the 
amount of dilute starch paste and keeping the solution warm. In a short 
time Fehling's solution will show the conversion of starch to sugar. 

The absorptive power of the stomach may be tested by the administration 
of 10 grains of potassium iodide, in capsules, which should produce in the 
sputum the characteristic iodin reaction with starch paper within ten or 
fifteen minutes. Obviously the test is of very limited value. 

QUANTITATIVE TEST FOR HYDROCHLORIC ACID.— Take three 
portions {10 c.c. each) of the unfiltered gastric contents. Add to one 3 or 4 drops 
of phenolphthalein solution (1 per cent, alcoholic solution). 

This substance, being the indicator for organic acids, acid salts and both 
free and combined HC1, upon titration with an alkaline solution of known 
composition will measure the total acidity. 

To the second portion add 3 or 4 drops of alizarin solution (1 per cent, 
aqueous sol. alizarin monosulphonate of sodium). This, being the indicator 
for free acids and acid salts, measures the degree of acidity less the combined 
HC1, i.e., the physiologically active acid loosely combined with the proteids; 
hence by subtracting the reading thus obtained from the total acidity 
{which does include the combined acids) one gets the amount of the com- 
bined acids. 

To the third portion add 3 or 4. drops of dimethyl-amido-azo-benzol (0.5 
per cent, alcoholic sol.), this being the indicator for free hydrochloric acid. 

Solution 1 is cloudy, white or grayish. Solution 2 is bright yellow. Solution 
3 is cherry -red if free acid be present. 

The three solutions representing the gastric contents and the respective, indi- 
cators are now each to be titrated with decinormal sodium hydrate solution* 
1 c.c. of which will neutralize 0.00365 grams of HCl.f 

This neutralization is indicated by a maximum depth of the color ob- 
tained; therefore the titration is continued in each case as long as color deepens, 
but no longer. 

END REACTIONS. — These are: In solution 1 {for total acidity) a distinct 
and persistent red which does not deepen on further titration. 

* A decinormal solution = Ho of the molecular weight of the substance, in grams, in 
1000 c.c. of distilled water, hence in the case of NaOH the molecular weight being 40 the 
solution contains 4 parts in 1000 of distilled water. (A normal solution = the molecular 
weight of the substance in 1000 parts of distilled water.) 

t The fact that the three right-hand figures correspond to the number of days in the 
ordinary year is an allowable crutch for a limping memory. 



PLATE III. 







Important color reactions in connection with the examination of the gastric contents. 
(Drawn from actual specimens.) 



THE GASTRIC CONTENTS 



86 



DESCRIPTION OF PLATE III 

A. Lactic acid reaction. 

B. Test fluid before adding stomach contents in Uffelmann's lactic acid test. 

C. Di-amido-azo-benzol reaction for free HCl (qualitative test). 

D. True terminal reaction for total acidity (phenolphthalein). 

G. Antecedent color change in same test, not the terminal reaction. 

E. Color of stomach contents after adding test solution for free HCL 

H. Terminal color reaction same test. (Color also nearly represents that assumed by 
stomach contents after adding test fluid (alizarin sol.) for combined HCl.) 

F. Terminal color reaction combined HCl. 

I. ] Antecedent color, not true end reaction same test. Test really represents all acids 
in stomach contents except combined HCl (see text), the result obtained being 
subtracted from the previously determined total acidity. 



55 



866 



MEDICAL DIAGNOSIS 



Violet-eom- 
bined HC1. 
Tellow-free 



Total acids. 



Combined acid 



Free HC1. 



Normals. 



In solution 2 (for free acids and acid salts) a pure violet.* In solution 3 
(for free HC1) a fixed yellow. 

One must carefully note at the commencement of each titration the exact 
reading indicating the height of the solution in the burette and again take 
it repeatedly on and after the first suggestion of the end reaction. 

The number of cubic centimeters used in exact titration multiplied by 
10, represents the degrees of acidity of the specimen in each case, for the 
amount of the decinormal sodium hydrate solution actually used represents 
the number of cubic centimeters found necessary to neutralize the acidity of 
10 c.c. of the given stomach contents and multiplying by 10 expresses the 
amount which would be required to neutralize 100 c.c. This simple and con- 
venient notation is the one in common use. 

Example. — If the burette reading shows the use of 3.5 c.c. of the NaOH 
solution, we say that the acidity is 35 or 35 degrees; if 5 were used, 50, etc.f 

Example. — 0.00365 X 50 (degrees of acidity) = 0.182. 

RECAPITULATION.— Sol. No. 1 (phenolphthalein) reacts to free acid, acid 
salts, and the loosely combined acids, is grayish-white and cloudy and gives a 
red terminal reaction. 

Sol. No. 2 {alizarin) measures the same acid contents as No. 1 less the loosely 
combined acid, thus necessitating for an estimate of the combined acid the sub- 
traction of the result obtained, from the figures representing the total acidity. 
The original color of No. 2 is yellow, the end reaction violet. 

Sol. No. 3 (dimethyl-amido-azo-benzol) reacts only to free acid, is originally 
cherry-red, and its end reaction is a brilliant yellow. 

Finally, the normal total acidity is 40-60 (0.146 to 0.22); the combined 
acidity 25 (0.09); the normal free HCl 20-40 (0.073 t° 0.146) after a test 
breakfast. 

After a Riegel dinner the total acidity is no; free HCl, 44. 

Sources of Error. — Topfer's method as here given is by far the most 
accurate and convenient for clinical work, but is slightly inaccurate when 
free hydrochloric acid is absent, especially in the presence of an excessive 
amount of the organic acids. { 

These errors are not sufficiently great to disqualify this simple and con- 
venient test for practical clinical use. 

Hydrochloric Acid Deficit. — If free HCl is absent 10 c.c. of the unfiltered 
gastric contents may be titrated with a decinormal solution of this acid using 

* A red-violet first appears and as suggested by Todd, the true color is best appreciated 
by comparison with a separate control solution composed of 5 c.c. of a 1 per cent, sodium 
solution to which 2 or 3 drops of the indicator have been added. 

t The figures may be readily converted into terms of hydrochloric acid; for each degree 
represents the amount required to neutralize 0.00365 grams of hydrochloric acid. 

Multiplying 0.00365 by the acidity expressed in degrees or by its exact equivalent the 
reading in cubic centimeters multiplied by 10 expresses the result in terms of HCl per- 
centage. 

% The methods of Sahli, Reissner, Martius, Hayem and Winter, Leo and Luttke, may 
be found in works devoted solely to clinical diagnosis, but are too complicated for he uset of 
the practising physician. im 



THE GASTRIC CONTENTS 



867 



di-methyl-amido-azo-benzol as an indicator and continuing the titration until 
the red color indicates the presence of free acid. The result is expressed in 
exactly the same terms as are used in the preceding tests and represents the 
amount of HC1 shortage, i.e., the amount required to saturate the alkaline 
bases and proteins present. In cases where HC1 is wholly absent this may 
replace the test for combined acids. 

Effects of Diet. — Variations in the hydrochloric acid content, particularly 
in that of free acid will, of course, depend somewhat upon diet, and an 
excessive amount of saliva may neutralize the gastric contents; in the latter 
case the addition of a few drops of dilute HC1 and 2 or 3 drops of ferric 
chloride solution to the stomach contents causes a red color reaction. 

A s the weak a<id annuities of starch foods are readily satisfied and tlie demands 
of proteid substance is much :he highest acid values are found in meat 

eaters and the lowest in vegetarians. 

Within normal limits, the more liberal the diet and the better the 
nourishment, the greater is the acidity. It is evident also that the real 
value of our figures is represented by the '" combined"' and '"'free''' acid 
percentages. 

The Diagnostic Bearing of the Foregoing Methods. — For hasty work the 
mere determination of free HC1 is most readily achieved by the use of congo- 
red paper easily procured of any chemist, though it tells us nothing save the 
bare fact that free HC1 is present. This being the case, lactic acid need not 
be considered or sought in the presence of a sharp reaction and the presence 
of normal ferments is usually a fair presumption. Too much dependence 
must not be placed upon the first test meal, for by reason of the 
emotional disturbance, the result may be misleading. The same rule may 
be applied to several successive tests, if, as seldom happens, the nervous 
disturbance continues to be excessive. Ordinarily we have to consider four 
conditions: 

1. NORMAL ACIDITY Euchlarhydria). (HC1 20 to 40 —This excludes 
achylia gastrica. chronic gastritis and usually carcinoma of the stomach. It 
does not exclude gastric atony and dilatation, nervous dyspepsia or the rare 
cases in which carcinoma develops upon an old ulcer base. 

2. HYPERCHLORHYDRIA Free HC1 40-. i.e.. 0.146 per cent, or 
higher). — We distinguish between the secretion of excessively acid gastric 
juice during digestion hypercMorhydria proper^) and the same condition ap- 
pearing in the fasting stomach and representing more or less continuous 
hypersecretion. 

As regards hyperchlorhydria proper, its chief clinical importance depends uicer. 
upon its frequent but far from constant association with ulcer of the stomach 
and the possibility that it is a factor in the production of that lesion. 

Simple hyperchlorhydria. moreover, is common in gastric neuroses without 
ulcer symptoms, in the gastric crises of tabes dorsalis. disease of the gall- 
bladder, and as a temporary condition due to exhaustion, emotional disturb- 
ance, constipation, dietetic errors, overuse of alcohol and tobacco or even to 
special articles of food. 



Rough 
deductions. 



Get more than 
n i :35: meil. 



Various 
associations. 



86S 



MEDICAL DIAGNOSIS 



Suggestive 
signs. 



Dietetic and 
drug test. 



Pain. 



Appetite. 



Hunger pain. 



A word of 
caution. 



Symptoms. — Its symptoms are probably due chiefly to an associated hyper- 
esthesia of the mucosa often attributable to distant sources and especially to 
ulcer or chronic appendicitis. 

The most characteristic feature is the combination of slight or decided diges- 
tive disturbance (epigastric oppression, pyrosis, regurgitation, nausea, perhaps 
vomiting, relative or actual intolerance of starches, and occasionally diffuse pain 
and headache) with a good appetite and a clean tongue. 

The attacks appear from one to three hours after a meal, evidently 
marking the height of digestion and the maximum of free hydrochloric acid. 
They are relieved if vomiting occurs, or often (temporarily) by taking nitrog- 
enous food and are in all cases ameliorated by the administration of an alkali. 
The attacks may also recur at the end of the digestive period and when the 
patient has been for many hours or even a day without food. In such cases 
starches may be almost wholly eliminated from the diet by the patient him- 
self. Slight diffuse tenderness may be present and constipation is the rule 
though diarrhea is sometimes a troublesome symptom. 

The stomach content is usually clear, acrid in odor and of low specific 
gravity. It will of course show high acid values and unconverted starches.* 
The urine at the height of an attack is usually neutral and deposits phos- 
phates. In acute attacks the pain may be severe and strongly suggests ulcer 
save that it is more diffuse. As in many cases of ulcer it is relieved rather 
than increased by taking nitrogenous food, but the condition itself in most 
cases is corrected readily by attention to diet, constipation, and proper rest 
and recreations. Anemia and other evidence of marked malnutrition are fre- 
quently absent, but may result from limitation of ingesta. The appetite is fre- 
quently unimpaired, more often variable Hypermotility is common and 
pylorospasm occasionally occurs. 

There is a broad zone between normal acidity and actual hyperacidity 
which is symptomless or symptomful according to the irritability or non- 
irritability of the individual stomach and the line cannot be strictly drawn. 

Asthenic Cases. — In general, the nutrition of the patient suffers but little, 
but one meets the condition frequently in the visceroptotic congenital asthen- 
ics and such are likely to show more or less decided weight loss or even a 
striking emaciation, such as is often present also in ulcer. 

Pain Variants. — The pain is extraordinarily diverse in type and especially 
in severity, varying from mere discomfort to the severe attacks described 
above. "Hunger pain" is not only common but itself varies greatly in 
character in different cases and is sometimes constantly associated with 
nausea. 

Epigastric Tenderness. — This is usually wholly absent or if present is 
diffuse and slight. 

Secondary or Complicating Hyperchlorhydrias. — The frequency of this 
condition as an accompaniment of some organic disease must be remembered. 

* After a test breakfast the free acid which is the determining factor in the diagnosis will 
exceed 40, the total acidity 70. The stomach is frequently entirely empty one hour after 
the meal because of coincident increased motor activity. 



DISORDERS OF GASTRIC SECRETION 



869 



Establishing the fact that hyperchlorhydria is present is but a single step 
in the diagnosis in many instances. 

The condition of the gallbladder, hernial openings, female pelvic 
organs, appendix, the deep reflexes and duodenum deserve primary con- 
sideration. 

The existence of the stigmata of congenital asthenia, evidences of 
psychasthenia, the excessive use of stimulants and narcotics as well as the 
question of overwork must receive attention. 

One does not know how to strike a balance between the errors of commissivn 
on the part of the surgeon as represented by many futile and unnecessary opera- 
tions and those of omission on the part of those physicians who treat the condition 
as a primary clinical entity. 

Many cases, so regarded and treated, carry gastric or duodenal ulcers 
or a diseased gall-bladder. 

Many others who might be cured by mere rest and bettered nutrition 
or proper treatment for an existing chlorotic anemia go to the operating 
table. 

The history of the case must be carefully studied, due weight, but 
not blind faith, given to the absence of sharply localized tenderness, 
the absence of occult blood in the stool, to the X-ray findings especially, 
and to any and every means available for application to the differential 
diagnosis. 

Fortunately these cases are for the most part distinctly unlike the urgent 
operative cases of the conditions they simulate and usually, therefore, can be 
given the benefit of careful observation and more or less extended medical 
treatment without incurring serious danger. (See" Gastric and Duodenal 
Ulcer.") 

Under proper conditions the great majority make a prompt recovery. The 
congenitally asthenic individuals with visceroptosis and an atonic musculature 
should be shielded especially from hasty operative interference, for they are poor 
subjects for the knife. 

CHRONIC HYPERSECRETION.— This includes two chief syndromes of 
hypersecretion usually marked by decided hyperacidity. 

In Teichmann's disease hyperacidity in the fasting stomach is continuous. 
Though closely following the etiology of simple hyperacidity, it is often asso- 
ciated with ulcer, may occur in pyloric stenosis, simple dilatation or chronic 
gastritis, with impaired motility, and is a mere syndrome. 

Rossbach's disease {nervous gasttoxynsis), also frequently associated with 
gastric ulcer, may be merely a chronic periodic or irregularly intermittent 
form of what was primarily simple hypersecretion. The symptoms are 
those of the ordinary "bilious attack" with nausea, bilious vomiting, 
epigastric distress and diffuse pain and tenderness. It is recurrent, lasting 
from one to several days at a time, frequently accompanies the gastric crises 
of tabes, but hardly deserves a place among actual diseases. 

Between the simple hyperchlorhydria and chronic hypersecretion stands 
the so-called "alimentary hypersecretion" which occurs only at the normal 



Continuous. 



A mere 
syndrome. 



Recurrent. 



MEDICAL DIAGNOSIS 



digestion periods, the contents showing often an excess of 50 to 200 c.c. over 
the amount of ingesta.* 

Comment. — Admitting that for the present the foregoing classification of 
hyperchlorhydria and hypersecretion must be preserved, the utmost caution 
is necessary in accepting it in the individual case, because of the frequency 
of unrecognized gastric or duodenal ulcer and the tenuousness of the differ- 
ential lines drawn. It is true that in typical active ulcer the pain and tenderness 
are more distinctly localized; yet often both these symptoms and hemorrhage 
are entirely absent, the ulcer going quietly on to spontaneous recovery or 
perforation. The crises of locomotor ataxia, moreover, may be associated 
with either hyper- or hypochlorhydria with or without hypersecretion. 

In every case of periodic recurrent hypersecretion the first thought should be 
of pyloric ulcer with spasm, the second of locomotor ataxia. 

3, HYPOCHLORHYDRIA (HC1 under 20).— Low HC1 values point to 
subacute or chronic gastritis, but are frequently met with in asthenic dys- 
pepsias, early carcinoma, certain late forms of gastric ulcer, duodenal ulcer, 
dilatations with or without stenosis, the early stage of achylia gastrica, and also 
in chronic disease of the gallbladder, pancreas and vermiform appendix. Its 
value as a positive symptom is. therefore, slight. 

4. ANACHLORHYDRIA (HC1 absent).— As a symptom this is of posi- 
tive and decided value, though met with in certain cases of asthenic dyspepsia, 
advanced chronic gastritis, as well as nearly all gastric carcinomas, pernicious 
anemia, achylia gastrica and true atrophic gastritis. 

Unfortunately, according to the author's experience, many cases of 
dyspepsia apparently purely nervous, and especially those of congenital 
asthenia accompanied by marked malnutrition due usually in part at least 
to the common cause (viz., chronic starvation induced by foolishly restricted 
and monotonous diet), show this condition, the acid reappearing after a 
short period of treatment. 

The sign is, therefore, chiefly valuable in connection with the associated 
symptoms (see "Acute and Chronic Gastritis," " Cancer of the Stomach," 
and "Achylia Gastrica") ancl the general discussion of the stomach contents. 

Heterochylia (HC1 variable). — This is merely a convenient term covering 
the cases of decided intermittent variations in secretion from day to day. 

It may occur in health or in any form of gastric disturbance, functional or 
organic and emphasizes the inadequacy of single examinations. 

CERTAIN PROMINENT GASTROINTESTINAL SYMPTOMS 

Aside from the functional or secondary hypersecretion previously dis- 
cussed, we may encounter so-called neuroses relating to pain, tenderness, 
peristaltic action, eructations, vomiting, motor spasm or relaxation, appetite 

and various paresthesias (see '''Combined Gastric Xeuroses"). 

* One of the most marked of the cases of continuous hypersecretion ever seen by the 
author was caused and maintained by the hourly or two hourly introduction of the stomach 
tube by the patient himself during the entire day and at intervals during the night. 



GASTRIC DISORDERS 



8 7 i 



APPETITE. — Anorexia. — Loss of appetite, though related to many con- 
ditions, may be described under this head. 

It is present in the active stage of all fevers, in many chronic exhausting 
diseases and under the stress of violent emotion (grief, worry, anxiety). It 
may be purely hysterical or psychasthenic and take the form of mere loss of 
the hunger sense, actual repulsion, a sense of repletion, actual perversion, 
or nausea upon taking a slight amount of food. 

Chlorosis, chronic alcoholism, hysteria, nervous and emotional overstrain, 
influenza and septic processes, including advanced tuberculosis are some of 
the best known examples, but again the author would emphasize the fre- 
quency of chronic anorexia as the result of the malnutrition of congenital 
asthenia, of dietetic fads and fancies and a narrowed monotonous regimen. 

Again and again the most obstinate cases of dyspepsia with complete an- 
orexia and excessive emaciation are promptly relieved under the rest cure and the 
gradual introduction of a varied and generous dietary. 

Bulimia. — An insatiable and inordinate craving for food is one of the 
marked symptoms in certain cases of true diabetes and occurs normally in 
convalescence from fever such as typhoid and the exanthemata. It is met 
with as a nervous or hysterical manifestation as well as in cerebral disease, 
epilepsy, exophthalmic goiter, etc. 

In the hysteric and psychasthenic cases it may be associated with an 
absence of the sense of satiety (acoria) or there may be a craving for unusual 
articles or such as are seemingly or actually injurious. Occasionally it as- 
sumes the form of a morbid desire for disgusting substances, as is sometimes 
observed in insanity, hysteria, pregnancy and chlorosis. To a less degree 
it appears in childhood, where it no doubt oftentimes represents in normal 
children a genuine structural need, in so far as it relates to special starches 
or proteids, too often combated by parents. 

"Heartburn" (pyrosis or "water brash''') covers a regurgitation of stom- 
ach contents common to many forms of gastric disturbance, and u merycis- 
mus" (rumination), usually observed only in psychasthenia, hysteria, idiocy 
or epilepsy, covers voluntary regurgitation and remastication of the food. 

Peristaltic Unrest (Supermotility; Hyper kinesis). — This troublesome ex- 
cessive motility is accompanied by noisy gurgling and rapid emptying of 
the stomach, but may occur in the empty organ. It is a common transient 
phenomenon, but may be persistent in hysteria and neurasthenia. 

Eructation (Pneumatosis, Belching, Flatulence). — This common phenome- 
non needs no explanation. Ordinarily negligible, it is a persistent, trouble- 
some and characteristic symptom in certain " asthenic dyspepsias" associated 
with marked psychasthenia or hysteria. 

The disturbing sense of distention and frequent " audible eructations" 
may humiliate a perfectly innocent patient and disgust and annoy those 
about him. 

The term "pneumatosis" is properly applied to an extreme distention of 
the stomach by air, swallowed persistently by certain dyspeptics or by malin- 
gerers. The cause may be detected by placing a large cork between the teeth 



The 
aerophagi. 



r- 



:.:?: : i : :, :-::: ?:s 



::" it :n 



i:z-5» : .*? • 



ii ii : i ii ::::: _ - : : : 

"Cocking up" i 
iei ;::i::;: i i 

Tie mi i:il: 
21 1211 il 7'-:: .-:■:•:::: 
same form in ffe psyckastkeni* 

NAUSEA AKD VOMUIN 
in origin, its center being dosel] 

Li riiii: me ie i:: : 
lei.rii 7 ireiy :ii;: Liz 
trated by hysterical Tomitin 
or mental shock. - Its rdatk 
1:11 reiiiie :: in 1 
ri-enlei 

^ :ien < : 11111 — .if 



iinr i: ie:e ~ ji-t it :::le! is ie: : lit: ::- 
1; i.ei reril: :::n ie iint ::: 1 :_:e ::: liii : 1- 
ny 1: in :y ie :2.:ien 

illy ::in it iiiim ::' it :i2~eieE5ieii ::' 
:::: :: n :i:r«:'.v: ns ::rm:::i. 
7 ie: : -_ I-;: ' : 7 :rvt:: ie i - : niiy ene—ii 
••:::; :; -; n:-.' in'; ; . ; - ,....._•- ;-. _- : ^-._-y. 



. . - - .1 . 

:: :e:i2i 
:: =1:1 ir: 

Tirrr ill : 

Refei 



**fls <?/ Ife asthenic type. 

■-::;:•:; -::; :: n ;•;•;;-:" :' I'l^-i-i 
:: ie :e :ii: :ry :ri:t: z ::r neiili 
iv ::!:: in :ni: niiii :iieiv 
ire iiiile :: iriiiir i: 25 ii illus- 
.1: 2ii:oii:ei nil ;::::_- i en::ii 
i-eilil nil ;5 hi :y lie iiv.l- 
1:5 iiiriiii :ii: 



eii 






1 leois:: : 

".in : r 11 em. 
ii urii = 
: leieinl iisi 



"lie: :y Eei-siiieii i 
lie 5:0=12 11 ii :: :: i ; t 
ie:e t : : : ; il inlini: 
secretion. Under smrik 

leii: : i: irriii nil 

renin it: niii 

reriiii lie :eiii 



1 15 i: ::y 21 
liige 11 : riiii i 
:eii ill' ii: 



ei:= ::' :tii:ti :: 



I111: 
:iizt ny 
ondary cons 

Aiie :': 
11 niieiie 
enmlei i 
: : :eei in 



in iii zereiii. nreiii :: ien:r- 

1 \ : in : ii iiriiii tfni :: :::i 
ii:e:i .1 ii" ii: :: 1 i. iieise 

r :: Iiliii iiioiie lit 112.7 zr2.cz is 

1 '. - 111 1 : : 1! 

iierlie iliilienei: 1: 1111 



THE VOMITUS 



873 



Obscure Hernias. — According to the author's observation vomiting of an 
irregular, urgent, paroxysmal type, or a recurring causeless and equally 
erratic nausea result frequently from incipient inguinal hernias or tiny um- 
bilical-ruptures. Pain is often present but widely diffused.* 

Points to be Especially Noted. — These are (a) frequency ; (b) the time 0} day 
or night; (c) pain and its persistence or intractability; (d) the presence or absence 
of any associated nausea; (e) its relation to meals both as to the character of the 
food and the time elapsing after ingestion; (/) the character of the vomitus, viz.: 
the amount, color, taste, odor, consistence, stage of food conversion, the presence 
of remnants of remote meals, and blood whether bright red, dark or of the "coffee- 
grounds" variety. 

EXAMINATION OF THE VOMITUS.— The vomitus affords informa- 
tion of great importance and vomiting sometimes occurs in such a manner 
and at such regular periods as to render the use of the stomach tube unneces- 
sary in the very type of cases in which its use is contraindicated. 

On the other hand, its usefulness with respect to the exact determination 
of secretion is decidedly limited, for one can draw few inferences from a quan- 
titative or qualitative analysis of the vomited material in cases characterized 
by an acute suspension of digestion. 

In some instances the regulation test meals of various types can be used 
with advantage, but only when the time interval between food ingestion and 
vomiting is approximately of the proper duration. 

The general appearance of vomited materials is too well known to need 
description and it is the significant variations that demand our attention. 

The amount, scant or excessive, suggests hyperacidity and excessive 
motility on the one hand, hypersecretion, dilatation or atony upon the other. 
Vomitus from a fasting stomach, if considerable in quantity, clear and 
of a sharply acid taste and odor, suggests hypersecretion; if the mucous con- 
tent be large and the tongue coated, gastric catarrh. 

Distinctly bilious vomiting is a common indication of acute indigestion, 
but if persistent may also point to pyloric incompetence and excessive re- 
gurgitation or to duodenal stenosis, simple, or associated with ulcerative or 
malignant infiltration. Such vomiting occurs in incipient or developed 
hernias, peritonitis and intestinal obstruction. If the two latter conditions 
persist, the vomitus soon presents an unmistakable fecal odor. 

Mucus may be present in all degrees, according to the nature of the lesion, 
but is rarely absent entirely even if HC1 be present, and may take the form of 
snail-like masses. 

Mucus which comes from the stomach itself is incorporated with the food, 
does not rise to the surface, and usually markedly slows filtration, if present in 
excess. 

In hyperacidity it is scant and soon dissolved and so usually points to sub- 
or anacidity if present in considerable quantities at the height of digestion. 
That which floats on the surface is of no clinical significance, being derived 

* As stated elsewhere, a mere relaxation of the ring may be sufficient to cause such dis- 
tress. 



Test meal 
sometimes 
unnecessary. 



Acute 
indigestion. 



Test meals 
may be used. 



Bile. 



Gastric 
mucus- 






MEDICAL DI 



?i- = 5.:e5, 



?f:._=_: ~z:i. 




m the pharynx and buccal cavity. This fad is important because of the false 
conclusions so often based upon the excessively large quantities so often present, 
especially in vomitus. 

Pus may be visible in rare instances of gastric abscess or because of 
fistulous communication with abscesses of other organs. 

In cases : : poisoning the characteristic odor of the toxic substance may 
be evident and even in cases of gastric catarrh or the ejection of a meal rich 
in butter fat, the rancid-butter odor of fatty acids may be detected. 

In advan : e i ac riveiv ulcerating carcinoma or in the presence of foul puru- 
lent material from whatever source, the odor may be peculiarly and offens- 
ively putrefactive. 

In benign pyloric stenosis with pronounced gastric stasis the familiar odor 
I sulphurated hydrogen is often peculiarly characteristic. 

Various parasites may be evident in rare instances to the naked eye. 
Such are round worms, thread worms and segments of tape worm. 

The color aside from food admixture and discoloration is light yellow in 
anacidity, green, if bile contamination is present or the development of 
certain yeasts has taken place; but is ordinarily dirty gray or greenish brown 
and, rarely, rose color from bile decomposition with high acidity, or, in the 
crises of tabes dorsalis (Lorenz) with hypersecretion. 

Bile may be present in small quantity even in a normal stomach and in 
health and occur in any vomitus if the efforts are prolonged. If present in 
:ua-:::y a: ±e :u:.se: :: iz_ re;ei:ei sli^l- ~ 5.::-:>r :: s zrs :s is s:i:e: 
pyloric insufficiency or duodenal infiltration. 

If 7 in the case of vomiting several hours after a mealy the gastric content, 
when set aside in a high glass jar, shows a lower chyme stratum equal to or 
exceeding one-half the total height of the mixture, it suggests stenosis or acute 

HEMATEMESIS. — If the blood be recently effused, it is bright red and 
fluid; if partially digested, it resembles coffee grounds; if in an intermediate 
stage and in sufficient quantity, it may be clotted. The appearance of blood 
is simulated by jellies and jams, cocoa, coffee, beef juice, such drugs as iron 
and bismuth, the dark red wines, grape juice, and fruits, such as currants, 
cranberries and cherries 

The amount of blood may be large or small and the small amounts may 
be derived from any source ; indeed a mere streaking of mucus may accompany 
excessive and persistent vomiting and of itself indicates no serious lesion. 
On the other hand, hemorrhages of all degrees occur in ulcer and carcinoma, 
splenomegaly, certain cachectic conditions of the hemorrhagic type (such as 
advanced leukemia, hemophilia, scurvy, and purpura), in esophageal lesions, 
in virulent infections chiefly associated with tropical fevers, such as yellow 
fever and pernicious malaria, and as the result of the action of irritant and 
corrosive poisons. Blows and wounds the varices of portal obstruction, 
chronic heart disease and vicarious menstruation, also must be considered. 

Source of Error. — In nosebleed, hemoptysis, ruptured tonsillar abscess, 
and similar conditions the blood may be swallowed and its source may be 



HEMATEME5I? 






^nized only through the presence of the causative factors named. In 
hemoptysis as opposed to hematemesis. the bright red finely frothy blood of 
alkaline reaction is raised by coughing and such bloody sputa ordinarily 
persist for several hours. There are usually significant or even localizing 
physical signs and oftentimes distinctly or characteristic subjective sensa- 
tions referred to the thorax.* 

Chemic and Microscopic Tests for Blood. — The following test will 
apply equally to blood in the stools and in the stomach contents and it must 
be remembered that an examination of the stools is of the utmost importance 
in all cases of supposed carcinoma or gastric ulcer, vomiting being frequently 
absent and slight hemorrhages unrecognized. 

Furthermore, any effused blood is usually promptly removed from the stools or 
stomach and, in general, the feces usually prove a more satisfactory medium contents. 
for its detection than the gastric contents. 

The Weber -Miiller Guaiacum Test. — If solid, a small portion of the sus- Extremely 
pected material should be thoroughly subdivided and shaken up with a little 
distilled water. 

Transfer : c.c. of the suspected mixture to test-tube; add a few drops of 
acetic acid and 4 c.c. of ether. Shake up thoroughly and carefully decant the 
supernatant ether into a clean test-tube. Add a pinch of guaiac resin and 
shake thoroughly but briefly. Allow an amount of ozonized turpentine 
equal in volume to that of the remaining ethereal mixture to run down the 
side of the test-tube and underlay. If blood is present a blue ring forms at 
the junction of the ether and turpentine layers and becomes diffused upward. 

Teichmann's Test. — This requires the careful evaporation of the sus- valuable t«t. 
pected material on a glass slide, after which a crystal of sodium iodide or 
sodium chloride is added, followed by a drop of glacial acetic acid. Too 
rapid evaporation is prevented by the use of a cover-glass and it is then gently 
heated to the exact boiling point, fresh acid being added as evaporation goes 
on. When a brown color appears, indicating the formation of hemin, 
complete evaporation is allowed and a drop of water run under the cover- 
slip. The microscope will then show the characteristic black or brown 
rhomboidal crystals of hemin. 

Benzidin Blood Test. — Mix fresh each time the following solution: 
Benzidin, an amount that will stay on the point of a pen knife; glacial 
acetic acid. 2 c.c: hydrogen peroxide 1 c.c. If solid material is to be tested, 
mix it thoroughly with a small amount of water. Put a drop of the mixture 
on a slide and place the cover-slip over it. Then allow a few drops of ben- 
zidin solution to flow around the edge. A blue or grc-. : :-:\-:1op 
at the line of contact in the presence of blood. 

For liquids, if opaque, proceed as above; if translucent, place a few 
cubic centimeters in a conical glass and allow the benzidin solution to flow 
slowly down inner edge. A blue ring uill develop in presence of blood. 

* Though in hemoptysis the blood is raised by coughing, vomiting is a frequent accom- 
paniment and may predominate, the cough being slight. Hence too much stress should 
not be laid upon this as a differential factor. 



876 



MEDICAL DIAGNOSIS 



Weakness of Benzidin Test.— Potatoes, milk and farina or similar sub- 
stances may yield the benzidin color reaction but the Ewald meal does not 




Fig. 445— (See Fig. 447.) Boas-Oppler Vacilli. 




Fig. 446. — (See Fig. 447.) Boas-Oppler Vacilli. 

produce it. Unfortunately, the ingestion of cooked meat even if taken 
forty-eight or seventy-two hours previously may cause a false reaction. The 
Weber-Miiller test should be given preference. 



MICROSCOPIC GASTRIC FINDINGS 



377 



GENERAL MICROSCOPIC FINDINGS.— The food detritus depends 
upon the character of the meal previously taken and the time elapsing since starch and 
its ingestion, but, in general, consists of muscle fibers and starch granules, more u ers ' 

or less changed by cooking and digestion, the former being recognized bv 
their markings, the latter by their peculiar form and structure or their blue 
reaction with Lugol's solution. Skins of fruit, seeds of berries or even the indigestible 
more digestible substances, if remaining from a remote meal, point to im- 
paired motility or actual stenosis. 

Saliva is indicated by pavement epithelium and the so-called salivarv 
corpuscles, and the various vegetable cells are usually so peculiar and bizarre 
as to at once suggest their nature. 




Photomicrographs of feces from three cases of advanced pyloric carcinoma showing 
Boas-Oppler bacilli in the stools. In all of these the organisms were most abundant in 
the gastric contents. The Boas-Oppler bacilli are seen as large segmented organisms 
slightly different in form in the three specimens. 

In Fig. 445 they are shown with many of the other forms of fecal organism, among which 
their size easily distinguishes them, and in Fig. 446 they are the predominant bacilli. 

Fig. 447 shows many short, thick-rodded bacilli that may be mistaken for the Boas- 
Oppler, but the difference in size between these (bac. areogenous capsulatus) and the 
Boas-Oppler will be noted by comparing the first with the second forms, about half a dozen 
of the Boas-Oppler being shown in the same field. X 1000. (Bassler's ''Diseases of the 
Stomach and Alimentary Tract," copyright, F. A. Davis Company, 1916.) 

Fat may appear in the form of crystals or of the highly refractile droplets 
soluble in ether, staining orange-red with Sudan III, and black with osmic 
acid (1 per cent.). The presence of a few red blood corpuscles after vomiting 
or the passage of a stomach tube is not necessarily pathologic. 

Vegetable Parasites. — The Boas-Oppler bacillus, the sarcina lentriculi 
and the tubercle bacillus are the most important of the organisms found in the 
stomach though it seems possible that in the near future the streptococcus 



878 



MEDICAL DIAGNOSIS 



Boas-Oppler 
V9. Leptothrix. 



may be found to play an active part in the production of some of the more 
important organic lesions both gastric and duodenal. 

The Boas-Oppler bacillus is apparently a pleomorphic microorganism 
but if present, is commonly seen in the form of large long rods frequently ar- 
ranged in chains or zigzags and staining brown with Gram's solution, whereas 
the leptothrix which resembles it stains blue. 

High degree of stagnation with impaired motility, absence oj free hydro- 
chloric acid and the presence of lactic acid represent the conditions most favorable 
to this microorganism. 

It is obvious that gastric carcinoma of the stenotic type is the ailment which 
oftenest and to the highest degree produces the conditions which satisfy these re- 
quirements. Moderate degrees of stenosis, malignant or not, are not sufficient 
to permit the development of these bacilli. 

They are always present in large numbers if found at all and usually abound 
in the large clots sometimes met with in cancer. 

They invariably co-exist with lactic acid and with rare exceptions the acid 
is present in large quantities. * 

They never co-exist with hydrochloric acid and the finding of the one proves 
the absence of the other. 

In advanced stenotic gastric cancer they are almost invariably present. It 
is doubtful if they are ever present in the benign stenosis or in primary atony 
in any considerable number or otherwise than as an accidental or fortuitous 
finding. 

The Sarcinae. — These indicate stasis and fermentation processes, require the 
presence of hydrochloric acid and though present in large numbers in many benign 
cases of that type, are seldom or never found in cancer of the stomach showing an ab- 
sence of HCl. Both the large and small varieties usually assume the form of bales. 

Yeast fungi are present in large numbers in marked degrees of atony or 
ectasia with absence of HCl, and in hyperchlorhydria unchanged starch gran- 
ules will be plentiful in cases showing decided subacidity and muscle fibers 
will be correspondingly numerous in their definite and unchanged form. 

Cancer Cells. — Rarely one finds detached particles of new growths, but 
more often such fragments are absent or unrecognizable. 

DISORDERS CHARACTERIZED BY SENSORY, MOTOR AND 
SECRETORY DISTURBANCES 

GASTRIC SPASM. — Spasm may occur either at the cardia or pylorus, 
and both may be purely nervous phenomena, the former almost invariably 
so, the latter being most frequently associated with hyperacidity or actual 
ulcer; in either, there may be a subjective localized sensation of obstruction. 
Both may be painful and the latter may produce visible or even reversed 
peristalsis, and, if long continued, lead to actual dilatation. If the two con- 
ditions are simultaneous (invariably neurotic), the marked overdistention 
may be evident. (See "Roentgenography.") 

* Fuld states that in rare instances the bacilli may be found when only the finer tests 
reveal lactic acid. 



SENSORY MOTOR AND SECRETORY DISORDERS 



879 



Gastric Hyperesthesia. — Marked gastric intolerance with a sense of 
weight, fullness or burning and without an organic basis may be encountered 
in hysteria, asthenia, exhausting and debilitating disease, mental and physical 
overstrain, profound anemia, shock and forced or voluntary fasting over long 
periods. It may be associated with marked diffuse tenderness corresponding 
to the stomach outline and is probably a chief cause of symptoms in simple 
hyperchlorhydria, and in many cases of hypersecretion. 

Gastralgia has been previously referred to as a misused term representing 
in most instances appendicitis, gall-stones, gastric ulcer or cancer, the gas- 
tric crises of locomotor ataxia, splanchnic arteriosclerosis or angina pectoris.* 
A true neuralgia of the stomach is exceedingly rare, and whether such a con- 
dition exists save as a secondary ailment is questionable. 

ANOREXIA NERVOSA. — This curious condition, rare but by no means a 
clinical curiosity, is characterized by absolute loss of appetite and frequently 
by abhorrence, and prompt ejection and rejection of all foods. It may 
follow prolonged fasting (starvation "cures"), shock, grief and the like, or, 
as is usually the case, be associated with hysteria or profound psychasthenia. 

In hysterical cases, especially, the patient may be profoundly or but 
slightly anemic, will promptly vomit all food administered, complain of vague 
and often shifting abdominal pain and tenderness, and frequently pretend 
to vomit blood, or, if posted, imitate the painful crises of ulcer. 

Emaciation may be extreme and a fatal issue is possible, if proper treatment 
is not available. 

Absolute rest, isolation, suggestion and forced feeding is necessary and 
firm control by a competent nurse and physician will usually clear up the 
diagnosis and cure the patient. 

One of the most characteristic features is the almost instant vomiting of 
the ingested food, though, usually, water will be retained and very frequently 
the act is obviously little more than mere regurgitation. 

All cases so far encountered by the author have proven amenable to the 
effect of firm insistence combined with complete change of environment and 
absolute exclusion of the sympathetic oversolicitous family and friends. 

In some cases the simulation of gastric ulcer has been absolute until the 
opportunities for deception with respect to hematemesis were removed and 
ocular demonstration demanded in place of the hearsay evidence previously 
imposed upon family and physician alike. 

ACHYLIA GASTRICA. (Apepsia Gastrica).— Definition.— As the name 
indicates, the achylias represent a total lack of digestive ferments and of hydro- 
chloric acid free or combined in the gastric juice. 

This interesting condition as at present represented in medical literature 
is one of the most blurred of all clinical pictures, but, in practice, it resolves 
itself into a reasonably clear and definite grouping. 

1. Those achylias which yield no evidence of being distinctly secondary to 
or associated with any other organic disease. 

* With epigastric maximal pain localization. 



Often 
misleading. 



A rare 
condition 



Two main 
groups. 



Primary. 



88o 



MEDICAL DIAGNOSIS 



Secondary. 



Subdivisions. 



2. Such achylias as are clearly secondary to or associated with a dominant 
chronic organic ailment. 

Group I. — SIMPLE ACHYLIA. — This contains cases of achylia of special 
interest and primary importance from the standpoint of their apparent 
clinical independence. 

In these we find two chief divisions based upon the physical type of the 
patient; (a) the depressive or asthenic type; (b) the active type. 

In the former may be placed the most interesting examples of this peculiar 
condition and it probably embraces the greater part at least of the congenital 
cases which may be far more numerous relatively than we can assume justly 
at the present time. 

The " Active Type." — This needs no special description, but is remarkable 
in that it presents absolutely no clinical, and but little, if any, pathologic, 
anatomic, or physiologic, basis for the presence of the achylia itself. 

The signs in cases of this type, aside from the gastric findings, are usually 
negative, in the clinical sense, to an extraordinary degree. The patients 
often show no striking subjective symptoms, in many instances suffer little 
if any weight loss over long periods, and wholly lack the general anatomic 
physiologic and psychic stigmata of the "passive" type of achy Ha. 

Actual but transient simple achylia may occur during profound emotional 
crises, on the first day of menstruation, or in association with severe diarrheas. 
Many of the psychasthenic victims of asthenic dyspepsia seem to pass from 
hypochlorydria to achylia and back again under their own exaggerated play of 
emotions. 

We are concerned here only with the persistent types, yet must not for- 
get the liability to erroneous conclusions in the heterochylic cases and the 
proof it offers of the absolute indispensability of repeated examinations. 

The Passive Type of Achylia. — This is the form occurring in those carry- 
ing the stigmata of " congenital asthenia," elsewhere fully described. - 

In these individuals achylia may exist for years without symptoms if 
their general nutritional balance and reserve are well maintained, but the 
congenital tendency to instability and inadequacy of function as reflected 
in anatomic structure and in the labile psychomotor sphere usually make 
them ultimately more or less typical "nervous dyspeptics." 

In nearly all of them visceroptosis and muscular relaxation of varying 
degree are easily demonstrable and not a few show distinct evidences of gastric 
atony. 

General . Symptoms. — There are no subjective symptoms peculiar to 
achylia, but in its advanced stages the various and variable manifestations 
of so-called "dyspepsia" may individually or collectively appear and dis- 
appear or become relatively fixed and permanent. Flatulence, however, is 
rarely troublesome unless motility is impaired. 

As time passes, periods of more or less severe diarrhea supervene, due ap- 
parently to a progressive inability of the intestinal digestive ferments to 
carry the overload represented by an entire absence of gastric digestion, 
together with the premature and excessive expulsion of the gastric con- 



ACHYLIA GASTRICA 88 1 



tents replacing the proper rhythmic fractional release of the gastric content 
which, in health, is maintained by the "acid reflex." 

Doubtless the stimulus to pancreatic secretion is also measurably im- 
paired by the achlorhydria and a secondary state of achylia pancreatica may 
possibly occur in rare instances. 

The decided value of small, frequently repeated feedings is in accord with 
the facts outlined above. 

As time passes, the intestinal inadequacy and irritability often increase, 
the patient's nutrition suffers, and decided emaciation and cachexia may 
develop. 

Such periods may come early, very late, or never. They may at times 
be held in check for many years by proper treatment or by it be rendered of 
only rare occurrence. 

Cases showing repeated, more or less frequent diarrheal attacks, of somewhat 
prolonged duration, should be suspected of, and examined for, achylia, and also, 
its chemical opposite, hyperacidity. Such seizures occur in both conditions 
and show a predilection for an early morning maximum and an afternoon 
recession. 

The author has yet to see an actual death chargeable to simple achylia 
though he has watched certain cases for many years, but such patients 
may and do become weak and anemic and many fall readily under the 
attack of some intercurrent ailment.* 

Stomach Findings. — The diagnosis of achylia rests wholly upon repeated 
examinations of the stomach contents, both following test meals and when wholly 
empty. 

The differentiation of simple from secondary achylia is attained only through 
the careful elimination of primary dominating organic disease not alone through 
the examination of stomach contents, but by complete and thorough general 
investigation. 

Examinations of the stomach contents should not be made during severe 
diarrheal seizures, or, in the case of women, on the first or second day of a men- 
strual epoch. 

During such periods the wholly normal individual may present a typical 
achylia. 

The characteristic findings are the following: 

First. — The recovered stomach content one hour after the test breakfast 
shows macroscopically no digestive change, the bread fragments appearing 
as if just taken into the stomach. 

Second. — The gastric content is small in amount and, in fact, is often 
wholly absent, after the interval usually observed, owing to the absence of 
the normal "acid reflex" which adjusts pyloric activity and consequent pre- 
mature discharge of the contents into the duodenum. 

It is frequently found necessary to express or aspirate the meal within 
three-quarters or even half an hour of its ingestion and the combination of 

* Two cases of achylia simplex at present under the observation of the author are not 
only well nourished but plump and have absolutely no gastric or intestinal discomfort. 
56 



882 MEDICAL DIAGNOSIS 



evident reduction of content and unchanged food is in itself almost pathog- 
nomonic of achylia. 

Third. — The fasting stomach after a " retention test meal" shows no 
residue indicative of obstruction or stasis. 

Fourth. — Under chemical tests a faint acidity may be demonstrated which 
is due to traces of organic acids, but hydrochloric acid whether free or com- 
bined is wholly lacking. 

Fifth.— -The usual tests for pepsin and for labferment are wholly negative 
or yield only such slight traces as are clinically negligible. 

Sixth. — The amount of mucus present is extremely slight or only mod- 
erate in amount, in striking contrast to the achylias of certain rare types of 
true chronic gastritis. 

Heterochylia. — In certain cases of that form of achylia associated with 
chronic congenital asthenia and its associated nutritional instability and 
psychomotor lability, no less than in achylias of the "active type," associated 
with convalescence from acute illness, overwork, worry or emotional strain, 
such findings as have been given may alternate with, be interrupted by, or, 
in the latter group, actually replaced by periods of hydrochloric acid secretion 
and ferment secretion. 

This constitutes the so-called "heterochylia" referred to elsewhere which, 
as stated, leads to many errors both of commission and omission if diagnosis 
is based upon the result of a single test meal. 

Such contradictory findings also may precede for long periods the full develop- 
ment of a persistent achylia. 

Motility. — The motor activity of the stomach may be wholly normal, 
increased, or distinctly diminished in some of the asthenic cases with atony 
and gastroptosis, but such impairment seldom or never is excessive. 

Hence, "achylia" with true stasis and food stagnation, even though these 
three conditions may stand alone, demands surgical exploration. 

Anatomic Changes in the Stomach. — In many cases the stomach itself 
has been found to be wholly normal, but in others an extremely low-grade 
granular gastritis may exist which is not believed to be primary or to merit 
the name of an actual disease. 

Friability and Vulnerability of the Mucous Membrane. — In many cases of 
achylia the stomach is extraordinarily susceptible to bruising and abrasion, 
and this is doubtless especially true of those cases which present the degen- 
erative changes described in the foregoing paragrapn. 

Fragments of the friable mucosa often may be recovered readily by the 
stomach tube in such instances, and submitted to microscopic examination. 

Hemorrhage. — Erosions are not uncommon and may be quite symptom- 
less or sufficiently severe and extensive to cause occult blood to appear in 
the feces or produce an actual hematemesis. Pain sufficient to suggest round 
ulcer of the stomach is occasionally encountered, but the gastric findings 
and case history are usually sufficient for differential purposes. 

The Stools. — The stools of such patients as show diarrhea are usually 
highly suggestive if meat is taken over a period of several days. They con- 



LSTRICA 



tain, as a rule, undigested muscle fiber and a considerable excess of unchanged 
connective tissue. 

In severe cases the evacuations are liquid and highly offensive. Mucus 
mav be present in quantity if the small intestine has become inflamed and, 
in this event, will be mixed intimately with the food remnar. 

Frequency and Age Incidence. — Achylia is probably far more frequent 
than clinical statistics would indicate and is found in about equal percentage 
in each decade beginning with the third and ending with the fifth. In the 
second it is about one-half as frequent; in young children, supposedly 
extremely rare, perhaps because of lack oi tes - 

77 must be said that all s:>. U to show true incidence when applied 

to an ailment so silently lor.. generally overlook::. 

Pernicious Anemia and Achylia. — Atrophic gastritis has been described 
as a separate ailment associated with a blood picture of anemia. 

It would seem more rational to say that in pernicious anemia practically 
all cases show a decidedly low hydrochloric acid content, and many an entire 
absence of both hydrochloric acid and ferments, i.e., a secondary achylia. 

In rather more than half of these raises an actual atrophy of the stomach 

rmonstrable post-mortem. 

This apparent atrophy is regarded by many as a post-mortem phenome- 
non, but the observations upon the fragments of mucosa obtained from the 
stomach of living cases of pernicious anemia would indicate that the change 
actually exists intra vitam to a considerable extent. 

It is certain,, nevertheless, that many cases of that ailment run their course 
lacking both achylia and atrophy and equally so that achylia often goes to 
the final exivas without gas:::: atrophy. 

Hig:: grades of secondary or chlorotic anemia may accompany true sim- 
ple achylia and few achylic patients carry wholly normal blood findings. 

Differential Diagnosis. — The differential diagnosis of simple achylia de- 
pends primarily upon an analysis of the stomach contents and the absence 
of high grades of stasis and stagnation of either the malignant or benign 
type. 

.■'.:•'■'.■;:: . ::>.*.: ':■-: : :ne to :>:■; primary 

mi nation of such patients, but also the course of the ailment after discover . , 
for t inoma {the only operative stage) may present for a time a strikingly 

parallel picture. 

Chronic gastritis, save for the rare, terminal atrophic type, is at once ruled 
out by the absence of mucus in excess or iri quantity in the recovered test 
meal. 

Terminal chronic nephritis or diabetes and advanced pulmonary tuber;:/.:::: 
may be associated with achylia but are easily recognized. 

ents apparently nothing more than the usual secretory 
and circulatory deficiencies of old age carried to an unusual degree. Senile 
kypocklorhydria and achlorhydrias are a common event. 

Disease of the gallbladder and chronic appendicitis must also be borne 
in mind always as possible causes. 



884 MEDICAL DIAGNOSIS 



The achylic of malignant disease of the stomach is associated with the signs 
and symptoms of that ailment as fully described under its proper heading, 
but, as just stated, great difficulty may be encountered in relatively early 
stages of the malignant growth at which period stasis and stagnation of high 
grade may be absent. 

The old observation of Fenwick, that achylia may result from the presence 
of progressive carcinomatous growths in regions other than the stomach has 
been in some measure confirmed by modern workers and should at least 
be held in mind in estimating the importance of the achylia in the individual 
case and as a stimulus to thorough and complete examinations. 

GASTROPTOSIS.— The general topics of "visceroptosis" and ''con- 
genital asthenia'' cover this condition. 

Gastroptosis may and usually does exist without dilatation or even 
demonstrable peristolic atony. It may be symptomless or associated with 
psychasthenic and asthenic dyspepsia or decided motor insufficiency, though 
the latter is rare save in the severer forms or in the presence of the other 
recognized factors. 

The tendency to both persistent and recurring tonus-inadequacy is never- 
theless marked by reason of the basic constitutional defects. (See Congen- 
ital Asthenia, ''Drop" Heart, etc.) 

Among the commoner symptoms of active cases are: subjective distention; 
troublesome borborygmi, especially if tight clothing or bands are worn; 
tenderness over the solar plexus; subjective aortic pulsation, and, in the pres- 
ence of sacro-iliac relaxation, a dragging sensation or dull pain referred to the 
region of the sacro-iliac joint or lower lumbar region. 

Such symptoms are not due to gastroptosis which in the greater propor- 
tion of cases is relatively or wholly symptomless, but is chiefly a reflection 
of states of depressed nutrition and impaired circulation. 

As stated elsewhere, ptosis of the stomach is but one manifestation of the 
general visceroptosis of congenital asthenia. According to the author's ob- 
servations, finding a gastroptosis one may predict the presence of the "drop" 
heart (or vice versa) and, less constantly, some demonstrable degree of abnor- 
mal renal displaceability. (See Fig. 386.) 

Floating kidney, a typical "drop" heart and gastroptosis of the 3d degree 
(pelvic) go very generally together. 

Thence one ascends through the 2d and 1st degrees of definite gastroptosis 
to the common fish-hook type, lying above or at the navel in the standing 
posture, and finds the ideal stomach in the transverse "steer-horn" type 
whose pylorus constitutes its lowest portion. 

Grades of "drop" heart, closely following, in the degree of their departure 
from the normal size and outline, the grades of descent in gastroptosis, are 
quite clearly demonstrable. 

Exceptions of course may occur especially in men for reasons stated else- 
where, and the modification of the "drop" heart outline due to actual disease 
of the heart or kidneys, together with an unfortunate adherence to the term 
"small heart" as descriptive of a hitherto nondescript type, have served to 



GASTRIC ATONY 



88 5 



confuse the picture hitherto and prevent the recognition of a clinically in- 
teresting and important grouping. 

Succussion is often present and low in site. The displacement is detected 
by the low position of the lesser curvature readily determined by inflation,* 
as is any coincident dilatation, or stilJ more definitely by the X-ray. 

DISORDERED MOTILITY.— Hypermotility has already been touched 
upon and is marked in many cases of gastric or duodenal ulcer, some of 
cholecystitis, hyperacidity, achylias, tapeworm and the ingestion of certain 
drugs, such as pilocarpin and strychnin. 

Motor insufficiency of varying degrees may result from simple atony and 
the term is less properly applied to the stasis produced mechanically by 
pyloric stenosis, as in these cases there may be actual hypertrophy of the mus- 
cular layers and, for a time at least, partial compensation. Dilatation may 
result from the stasis of either myasthenia or stenosis. 

With respect to the retention time, motility may be affected by many 
conditions other than mere muscular sufficiency or insufficiency: such are 
the presence of gastric or duodenal ulcer, occasionally in cholecystitis, the 
character and consistency of the food ingested, the position of the stomach 
itself, the activity or non-activity of the abdominal muscles, the amount of 
material in the great and small intestines, the attitude and activity of the 
individual, etc. 

GASTRIC ATONY AND CHRONIC DILATATION.— The modern 
roentgenologist divides the stomach into the corpus ventricidi which sustains 
the food column, preparing it for passage into the intestine, and the antrum 
pyloricum which is chiefly concerned in projecting it into the duodenum. 

Each of the first-named divisions may share the work of its fellow but its 
chief function is as above stated. 

The corpus ventriculi may also be subdivided into a fundus occupied by 
gas and a pars media. The actual movement of food is concentric rather bubble." 
than a mere grinding or mixing process. 

As in the case of the ptotic heart it may be evident as a mere narrowing of 
reserve and hence of the symptomless performance of function. The author has 
repeatedly encountered gastroptotic patients in whom no gross roentgenoscopic 
signs of atony were demonstrable, but who experienced a most striking relief from 
or amelioration of symptoms when they were instructed to lie upon the right side 
for an hour or more after each meal. 

Impaired tonus or "atony" actually means in large degree, though by no 
means wholly, impaired power of the concentric contraction, i.e., perisystole. 

Peristalsis is the term applied to the vermicular waves of annular con- 
traction which run in series from left to right. The two types of contraction 
are normally correlated, but so far structurally independent as to permit the 
one to be impaired without a parallel degree of involvement of the other. 

The third important variety is that by virtue of which the pylorus relaxes 
and contracts under the operation of the hydrochloric acid reflex in such a 

* Best employed when the patient is standing erect, inasmuch as posture greatly 
influences the degree of descent. 



886 MEDICAL DIAGNOSIS 



manner as to propel its contents into the duodenum in such fractional por- 
tions and at such intervals as best conserves the maximal effective digestive 
activity of the latter. Under normal conditions the duodenum inhibits the 
relaxation of the pyloric sphincter until the acid chyme previously received 
is completely neutralized. 

The fruoroscope has demonstrated the fact that the structurally and 
physiologically normal stomach, when receiving a bismuth meal, so grasps it 
through the power of concentric contraction (tonus) inherent chiefly in its 
fundus and central portion as to hold and compress it and more or less roughly 
presents the profile of a horn of plenty. 

This is filled to about two-thirds or more of its capacity, the upper sur- 
face of the fundus content being capped by air. 

If tonus be impaired decidedly, the column is illy maintained, the meal 
carries down the weakened inferior portion and finds its level far below the 
normal. Atony may be marked without any demonstrable serious involvement 
of peristalsis, and, moreover, with no serious interference with the efficient 
regulation of the pyloric sphincter so long as hydrochloric acid is present in 
adequate amount. 

In extreme cases, of the asthenic type especially, peristalsis gradually may 
become involved and delayed emptying results, but true stasis and high grades 
of food stagnation such as characterize pyloric stenosis, do not occur in cases 
of simple atony. Even in high degrees the stomach is empty of all food the 
morning after an evening's "retention meal." 

Any attempt to sharply classify the various conditions associated with muscular 
insufficiency or actual dilatation of the stomach leads to much confusion and it is 
better to consider the stomach and its musculature exactly as one would the heart. 

Weak musculature resulting in impaired motor activity with either 
decrease or increase of demonstrable peristalsis, and relaxation of the mus- 
cular walls constitutes true atony of the stomach and, as in the case of a 
chronically weak heart, leads to lessened effective functional activity. 

In certain instances a misleadingly active peristalsis occurs from a height- 
ened irritability which results probably from sub-nutrition and overstrain 
due to impaired muscle tonus. 

If an actual obstruction exists at the outlet, the stomach and the heart 
act alike in that they try to overcome the mechanical obstacle and the initial 
or gradually induced dilatation by increased action and hypertrophy of the 
muscle, or, if this is not possible, to undergo passive dilatation with conse- 
quent stasis. 

The parallel is sufficiently exact and helps to clarify this complex subject 
which is involved in a maze of contradictory opinions even at the present 
time. 

Disregarding a suppositious megalogastria we have first to deal with 
gastric atony or myasthenia, i.e., decreased concentric contractility due to 
selective muscular insufficiency. 

This may exist without marked or permanent dilatation in any degree 
so long as peristalsis remains unaffected, but persistence of atony plus im- 



GASTRIC ATONY 



887 



paired peristalsis to an extent involving prolonged retention of the stomach 
contents tends to produce a secondary dilatation (ectasia) varying greatly, 
but seldom attaining the extreme form encountered in cases of actual 
mechanical obstruction. 

Hence, as stated in the opening paragraphs, we find that in atony con- 
siderable degrees of dilatation are possible without the extreme manifesta- stasis 
tions of gastric stasis and fermentation encountered in pyloric stenosis. In 
this last condition, as in stenosis of the aortic orific of the heart, unless myas- 
thenia or atony preexist, there is primarily an hypertrophy of the muscular 
coats which may for a long time prevent extreme dilatation or marked stasis. 
Ultimately, however, either because the stenosis becomes more extreme or Ectasia 
the muscular weakness predominates over hypertrophy, marked dilatation 
occurs with an increased degree of myasthenia and resulting stagnation. 




Fig. 448. — The normal and the ptotic stomach. A, the "steerhorn" type; B, the 
"fishhook" type; C and D, two of the several grades of gastroptosis. According to the 
author's observation a grade of descent (sagging) lying between C and D is extremely 
common. {After Holzknecht.) 

Gastroptosis. — Any case of dilatation, if marked, may be associated with 
varying degrees of displacement (ectasia with gastroptosis), but marked ptosis 
may and usually does exist without dilatation (gastroptosis proper), is one of 
the commonest of clinical conditions and usually is wholly symptomless save 
during periods of depressed general nutrition and diminished myocardial 
tonus. Having the preceding factors in mind, one may proceed to discuss 
the conditions under three chief heads. 



MEDICAL DIAGNOSIS 



Chronic or 

acute. 



Fatal cases. 



Gross Atony. — {Myasthenia, "Relative" "Motor or Facultative Instiffi- 
ciency"). — This covers the non-obstructive form and may be primary, sec- 
ondary, acute, or chronic and associated with mere temporary dilatation, 
abnormal distensibility, or a true ectasia. (See Section on Roentgenography.) 




Fig. 449. — Decided gastroptosis with impaired tonus. Patient decidedly asthenic and 
complaining of decided gastric discomfort of the asthenic-dyspeptic type. Lower pole of 
stomach just above white strip at right. 

In rare instances acute, fatal dilatation occurs, a condition of special impor- 
tance in connection with heart disease, arteriosclerosis, the acute infections and 
major operations, particularly of the abdominal type. 

Chronic dilatation of an extreme form may be seen in the employees of 
breweries or others who are gross eaters and heavy beer drinkers. In its 
lesser degrees it is not uncommon, especially in association with the vis- 
ceroptosis of congenital asthenia. 



GASTRIC ATONY 



889 



Etiology. — No disease is richer in asserted etiologic factors, chief among 
which are hereditary structural defect and functional inadequacy or instability 
and chronic or recurrent nutritional depression, often resulting from uncon- 
scious voluntary chronic starvation, from nervous shock, grief, worry, mental 
or physical overstrain, or exhausting diseases, chronic cryptogenetic sepsis and 




Fig. 450. — Same patient (Fig. 380) showing the effect of his improved condition. 
Position of lower pole indicated by upper level of white strip. Tonus manifestly greatly 
impro^^ ed. Peristalsis active in both cases. Emptying time somewhat shortened, sus- 
pected duodenal ulcer. Diagnosis not confirmed by surgeon. 

certain acute prostrating infections, and obscure toxemias. A host of other 
causes are given usually, but probably are, for the most part, of slight 
importance. 

The more one studies the manifestation of congenital asthenia and its viscer- 
optoses in both the complete and the still more interesting imperfect forms, the 
better he realizes the dominant part played by it in simple atony. 

The Symptoms. — Subjectively the gastric symptoms are those described 



Inefficient 
musculature. 



8oo 



MEDICAL DIAGNOSIS 



Effect of rest. 



under " nervous dyspepsia." In the early stages at least, appetite is often 
well maintained, though in others and especially in cases of long standing, 
the slightest quantities of food may give the sensation of repletion and dis- 
tention. Vomiting is relatively infrequent, irregular or wholly absent in 
marked contrast to stenotic atony and ectasia and there is usually more or 
less obstinate constipation. 

It is commonly stated that these patients are intolerant of food and that 
its ingestion immediately excites distress, pyrosis, eructation, heartburn and 
the like. 




Fig. 451. — Atony of the demonstrable type. Note failure to grasp the bismuth meal 
in a normal manner. The great elongation of the stomach represents usually the con- 
genital deficiency of tonus which is largely symptomless so long as a certain nutritional 
level is maintained. Ectasia is manifest in this case. 

This is certainly not to be taken as wholly expressive of the behavior of 
cases or applying to food in all forms and quantities. 

Liquid food is often badly borne, whereas light solids and semisolids, es- 
pecially if taken six rather than three times a day in less quantities may give 
great relief and bring about the desired improvement in nutrition. 

The prompt effect of rest and isolation is often demonstrated in cases of 
this type, and large daily quantities of food given at even shorter intervals 
together with rest for the heart are well borne and rapidly overcome the basic 
subnutrition. 

Objectively, one notes usually only the filling abnormality (not "defect" in 
the roentgenologic sense) heretofore described as determinable by the X-ray 
to which may be superadded oftentimes gastric enlargement. (Fig. 451.) 



GASTRIC ATONY AND ECTASIA 



Gastroptosis of some degree is an almost invariable rinding according to 
the author's personal experience. 

The milder cases may show merely excessive distensibility , as revealed by 




Fig. 452. — Decided congenital defect with no demonstrable atony of the concentric 
muscle fibres. Such a patient may be free from symptoms or profoundly dyspeptic, the 
question being largely one of a sustained adequate level of nutrition. 





Fig. 453. — Dilated and displaced 
stomach (inflated) (crescentic form). 
Outline — personal observation. {Figure 
after Riegel.) 



Fig. 454. — Simple gastroptosis. Per 
sonal observation. Stomach tensely 
inflated. {Figure after Riegel.) 



inflation. The test of low level of dulness resulting from the ingestion of a pint 
of water sometimes advocated proves only a gastroptosis, not a severe atony. 

Contrary to the findings in many stenotic cases excessive or reversed peristalsis 
is usually lacking. 



892 



MEDICAL DIAGNOSIS 



Succussion is sometimes apparent even six or seven hours after a meal and is 
abnormally low in position from associated gastroptosis. 

Residual food may or may not be found seven hours or more after the 
Riegel dinner, but not if the meal has been retained overnight. 




Fig. 455. 

A = Heart of robust athletic male (ideal normal). 

A' = The high transverse stomach (ideal normal) "steer-horn" type. 

B = Feminine type of heart. Commonest of types. Frequent in males. 

B' = Feminine type of stomach; normal for both sexes. The "fish-hook" stomach. 

C = Slight cardioptosis; extremely common, more so in women. 

C = Moderate or slight gastroptosis. Extremely common. 

D = Centrally placed " drop " heart. In the author's opinion possibly expressing very 
slight enlargement of the "drop" heart. 

E = Laterally placed "drop" heart. Right border indeterminate. Both D and E very 
common, especially in women. 

D' and E' = Corresponding grades of gastroptosis. 

The curious parallelism or concurrence of cardioptosis ("drop" heart) and gastroptosis 
(dropped-stomach). So generally does the author find this concurrence in his routine radi- 
ography as to make him feel that the presence of the one is almost proof positive of the 
presence of the other stigma of chronic congenital asthenia. Within variable limits the 
grade of the gastroptosis and that of cardioptosis correspond. Apparently both are 
affected by transient or prolonged states of toxemia or subnutrition as regards outline, 
though gastric atony is also readily induced. The absence of proper support from below 
as a factor in the intensification of "drop" heart peculiarities is strongly suggested. Atony, 
actual or relative, is common to both, but obviously must be symptomatically expressed 
more frequently and decidedly by the heart. The fluoroscopic appearance of a heart of 
the D and E types is that of a pulsating bag. A, B, C, D and E are drawn direct 
from x-ray negatives. A', B', C, D' and E' represent the concurrent types of stomach 
determined by the radiogram. Heart A measured 13 cm. total transverse diameter; 
heart B, 11. 5 cm.; heart C, 10 cm.; heart D, 8.3 cm.; and heart E, 7.5 cm., allowing half the 
width of the sternum as representing the concealed right border. All heart radiographs 
were taken in the inspiratory phase, as this best determines variations in form and tonus 
according to the author's experience. Even the expiratory phase of quiet breathing 
markedly obscures the characteristics of the plastic heart and especially of its modifica- 
tions. The difference is comparable to that observable in gastroptosis as between the erect 
posture and recumbency. In the latter posture the ptosis may be almost or quite inap- 
preciable. 

In forced expiration the heart outline is so greatly modified as to increase its trans- 
verse diameter by two or more cm. and wholly conceal defects of conformation and tonus. 



ASTHENIC DYSPEPSIA 



893 



Hydrochloric acid values are normal in about 50 per cent, of the cases, 
the remainder being about equally divided between hyper- and hypochlor- 
hydria. 

These figures do not include those of primary or secondary achylias with 
or without stenosis. 




Fig. 456. — Cardioptosis. — Slightly modified "drop" heart, centrally placed. Minor 
symptoms of cardiac inadequacy present. Total transverse diameter 8.5 cm. The 
ptotic but non-atonic stomach is shown in Fig. 388. 

The stomach contents may show a relatively slight degree of stasis or none 
at all as indicated by fermentation, though the stomach findings vary greatly 
and are not in themselves distinctive. 

ASTHENIC DYSPEPSIA.— "Nervous Dyspepsia" {Combined Gastric 
Neuroses"). — These terms cover certain forms of gastric disturbance prolific in 
subjective symptoms and barren in objective signs other than those related to an 



894 



MEDICAL DIAGNOSIS 



associated visceroptosis which is manifest in varying degrees in a large majority 
of the cases. 

It is commonly associated with congenital or acquired asthenia, a history 
of nervous overstrain, or cardiac shock, grief or worry, or it maybe due to 
reflex causes such as chronic appendicitis and pelvic disease. Frank psych- 
asthenia or hysteria may be present. 




457. — Stomach of the patient whose heart is shown in Fig. 387. 
gastroptosis without marked atony. 



Decided 



In actual practice it represents in a considerable number of instances the 
digestive or pseudo-dyspeptic manifestations of minor cardiac insufficiencies, 
the earlier toxemic expressions of chronic interstitial nephritis or one of the 
many obscure effects of chronic focal infection of the cryptogenetic type. 

There are but few organic diseases that lack dyspeptic subjective symp- 
toms and up to the present time nervous dyspepsia has been nothing more 
than a more or less kaleidoscopic grouping of symptom fragments. 



CHRONIC CONGENITAL ASTHENIA 



895 



77 is essentially a mere syndrome and %n itself proves no serious derange- Fundamental 

. • . . ,. , , . points. 

mcnt of gastric junction or actual disease of the stomach. 

Chronic Congenital Asthenia. — By far the most common underlying con- 
dition is that described by Bert hold Stiller under this name. 

Such patients are delicately built, have a narrow, attenuated, relatively 




Fig. 458. Heart corresponding to sub-type between "B" and "C" of Figure. 384. 
Total transverse measurement 11.3 cm. 

This man's heart is distinctly of the feminine type and possesses certaiD character- 
istics of the true ptotic or "drop" heart, yet it is perfectly competent and represents a 
normal in the same sense that we apply that term to the high-lying fishhook stomach. 

It is certainly the commoner type of adult heart as seen in healthy, but slenderly- 
built males and in seventy to eighty per cent, of females. 

In this instance gastric atony and ptosis were present because of a sharp nutritional 
deficit, but the only evidence of heart participation lay in the primary complaint of ex- 
cessive fatigue following accustomed exercise, this being followed by the development 
of decided gastrointestinal discomfort. 

On the mother's side both male and female members are of the visceroptotic type. 
The hilus and lung shadows are interesting and suggestive. 



MEDICAL DIAGNOSIS 



or actually atonic, readily displaceable, low-lying heart and an unstable func- 
tional and nutritional balance. They tend more or less constantly toward 
subnutrition; as a group, bear acute ailments badly, recover from them 
slowl}% and are possessed of a highly irritable and labile nervous system. 

Their visceroptoses are manifest chiefly in the low position, and often 
the atonicity of the the stomach, and the instability of muscle tonus and 
functional potency on the part of both heart and stomach, during periods of 




Fig. 459. — Stomach of patient (Fig. 458)' showing marked ptosis and atony. All 
symptoms have disappeared under a gain of weight of fifteen pounds. No medicinal 
treatment required. 

nutritional depression. As might be expected, a large proportion reacts 
positively to a tuberculin test even though for the greater part wholly free 
from active lesions. 

The stomach in such cases may show descent in any one of three grades 
below the "ideal" and the heart and stomach for the most part run measur- 
ably parallel in their degree of departure from the normal in outline. 

The Tongue. — In asthenic or nervous dyspepsia the tongue is usually 
clean or lightly furred and may show some flabby enlargement and lateral 
indentations from the teeth in the long standing inveterate cases. 



ACUTE GASTRIC DILATATION 



897 



Suggestive 
symptoms. 



Globus 
hystericus. 



Hunger Pain. — When the stomach is empty the patient may complain 
of faintness, a "gone" sensation in the epigastrium, actual epigastric pain, 
headache, or a sense of cerebral pressure or dulness. Food usually brings 
marked relief though some patients experience marked subjective weakness 
and palpitation after taking it. 

Protean Symptomatology. — In the kaleidoscopic symptomatic pictures 
encountered m this disease everything and anything in the way of subjec- 
tive dyspeptic symptoms may be encountered. There may be troublesome 
distention, persistent eructation and, oftentimes, peristaltic unrest associated 
with pyrosis and irritating borborygmi. Dizziness, epigastric pulsation and 
very rarely the so-called " globus hystericus" may be encountered. The sub- 
jective sensation last named is, too often, actually a misinterpreted sub- 
sternal expression of an " insufficient " heart. 

The gastric contents are usually normal but may show hyperacidity, 
hypoacidity or a temporary or persistent anacidity. Heterochylia is very j Heterochyiu 
common in these cases and malnutrition may or may not be marked. 

Motility may be excessive or diminished but is usually but slightly im- 
paired though, as stated, gastroptosis of varying degree is almost invariably 
encountered and may be present in a most extreme form. 

Persistence of symptoms is due usually to chronic fatigue and a state 
of relative starvation chargeable to unduly restricted or monotonous diet, 
lack of needed rest (mental and physical), and proper recreation and 
diversion. A pernicious and persistent form of introspection is commonly 
encountered. 

- Many of these cases require absolute rest, isolation, a gradually increased 
and ultimately generous diet, absolute control by a specially trained nurse, 
the oversight of a competent physician, a modicum of common sense, and re- 
newed will power as a leaven. 

ACUTE ATONIC DILATATION.— Terrifying epigastric oppression, vio- 
lent dry retching, or more rarely, slightly productive vomiting, actual pain, 
and belching followed by persistent gas distention, cold extremities and a weak 
and rapid pulse, mark an ailment less often recognized than it should be as 
a cause of sudden death, yet overfrequently assumed to be responsible for 
an abrupt exitus due to unsuspected cardiovascular disease. 

The mysterious sudden death at home, on the street or in hotels, and on rail- 
ways, which is so often attributed to acute atonic dilatation, is doubtless in 
nearly every instance due to previously unrecognized disease of the heart, arteries 
or kidneys * 

The stomach may so dilate as to entirely fill the abdominal cavity and 
the duodenum may or may not participate. 

Etiology. — The chief cause probably is sepsis, and by far the greater number 
follow abdominal operations. 

* Few years pass without such a death in some patient of the author's, whose condition 
is unknown to those about him at the time of his abrupt exitus. The primary diagnosis on 
such occasions is almost invariably acute indigestion or acute dilatation, supported by the 
statement that the patient had shortly before complained of epigastric distress, vertigo, etc. 

57 



Introspection. 



A cause of 
sudden death. 



Various 
causes. 



MEDICAL DIAGNOSIS 



Usually frank. 



Stasis signs. 



Distention. 



It is doubtless true that any acute infection with profound toxemia may 
cause it in rare instances, and this is especially true of pneumonia. 

The assumption that intestinal kinks or mesenteric constriction cause it, 
seems to be unsupported by adequate evidence. 

Mechanical pressure, such as is exercised by a tight plaster cast which 
produces dorsal counter-pressure as well as anterior pressure, is said to have 
produced it in a few instances. 

Toxemic paralytic dilatation plus abdominal traumatism, and such direct 
mechanical dilatation as is seen in certain foolish individuals who are eager 
to back by physical performance, bets on their gastric capacity and tolerance 
would seem to cover the etiologic factors. 

As a cause of death in ambulant patients, or apart from the causes given, it 
is probably very rare. 

Symptoms of Acute Dilatation. — The chief and only symptoms of impor- 
tance are: (a) decided enlargement of the stomach; (b) the repeated and persistently 
recurring vomiting of bile-stained fluid; (c) the large quantities of such fluid 
recoverable by the introduction of the stomach tube, and the relief afforded by this 
measure reinforced by gastric lavage and maintained drainage. 

It is often evident that the vomiting represents little more than overflow 
and indeed the vomitus may come into the mouth without any visible effort in 
some instances. Decided "straining" is the exception rather than the rule. 
Some patients do not vomit at all and cessation of vomiting may be ominous 
rather than encouraging, unless the stomach tube no longer siphons fluid 
and the patient is manifestly improved in other respects. 

The mortality was formerly over 70 per cent., but is much less 
under modern tube drainage and postural procedure. 

POST-STENOTIC MOTOR INSUFFICIENCY.— In this condition 
actual obstruction, not mere loss of muscle tone, is the primary factor; indeed, 
actual muscle hypertrophy may occur in a dilated stomach, as in the case of 
the heart with an obstructed outlet. 

Etiology. — Whatever produces obstruction of the pylorus or duodenum 
may cause ultimate gastric dilatation and insufficiency. It may be due to 
adhesions following operation, pyloric tumors, tubercular or luetic infiltra- 
tion, congenital stenosis,* or the scars of healed ulcers. 

The chief and most frequent causes are malignant growths, pyloric 
spasm and obstructive scars or deformities. Even excessively tight corsets 
or plaster jackets may produce chronic obstruction and dilatation through 
pressure effects. 

SYMPTOMS. — The symptoms of simple nervous dyspepsia or myas- 
thenia predominate, but pain may be present and be severe, paroxysmal and 
attended by violent visible peristalsis or palpable contractions or, on the other 
hand, be wholly absent or replaced by, or associated with, constant or re- 
mittent extreme epigastric oppression with or without tenderness. 

* Congenital stenosis is far commoner than has been supposed, three cases (Drs. J. U. 
Goodrich, P. A. Hoff and W. Ramsey) having been brought to the author's attention within 
a period of ninety days, all confirmed by autopsy. 



POST-STENOTIC ECTASIA 



8 99 



Objective Symptoms are Readily Elicited. — The stomach is often visibly 
distended or, if inflated, appears in characteristic but enlarged outline with or 
without displacement (gastro ptosis) and is then readily palpated. Increased 
resistance may be noted as well as " rhythmically intermittent rigidity" 
("magensteifung"). Peristalsis may or may not be visible but is marked 
during painful crises, if such are present, or shortly after a meal. 

As in the case of heart, long persistence of stenosis may cause loss of mus- 
cle tonus and diminution of the palpable contractions or visible peristalsis. 
The degree of dilatation may be determined roughly by inflation combined 
with auscultatory percussion and palpation of the stomach tube in situ, 




Fig. 460. — Post-stenotic ectasia due to scar of old gastric ulcer. {After von Bergman.) 

fluoroscopy, the gyromele, etc. Changes of note corresponding to changes of 
posture may be evident as in pulmonary cavities if large quantities of fluid are 
present. Succussion is of course constant in marked ectasia. 

Residual contents in marked quantity, varying with the degree of stenosis 
and ectasia, are found in the fasting stomach even though the " retention" 
dinner be taken the preceding evening after lavage, and the contents are 
foul-smelling. The odor may be that of fermenting cabbage or garlic, or 
that of hydrogen sulphide, perhaps aromatic like fermenting wine, or inex- 
pressibly vile, according to the nature and cause of the stasis and its accom- 
panying stagnation and fermentation. (See "Retention Meals" and 
"Vomitus.") 

Vomiting is one of the most constant signs of obstructive ectasia in contra- 
distinction to mere atony. 

The vomitus is, as above described, frothy, of excessive quantity and contains 
remnants of several previous meals, especially seeds and the like. 

It frequently separates into three layers on standing, and is bitter and 
foul to the taste. 



900 



MEDICAL DIAGNOSIS 



The total acidity is increased by fermentation acids and the microscope 
shows in benign cases the yeasts and sarcinae; in cancer (90 per cent, of ob- 
structive cases) the Boas-Oppler bacilli. The fatty acids may be present 
by chemical and microscopic tests, the urine is scant, concentrated if vomiting 
be profuse, and if gastric acidity be high is often alkaline in reaction. 

The persistent presence of bile in large quantity invariably points to duo- 
denal stenosis. 

In stenotic cases the symptoms may come and go over long periods be- 
cause of the changes in calibration due to temporary local congestion of the 
mucous membrane. 

Such remissions or intermissions are more frequently seen in benign than 
in malignant cases, but may occur in either. 

Complications. — Acute auto-intoxication occasionally occurs and even 
coma may result. Extreme distention may not only produce dyspepsia, 





Fig. 461. — Dilated stomach. Post- 
stenotic ectasia. Slightly modified to con- 
form to personal observations. (After 
Riegel.) 



Fig. 462. — Dilated stomach (in- 
flated). Combined displacement and 
dilatation of lesser degree. (After 
Riegel.) 



bradycardia, or palpitation, but may seriously endanger a weak heart. 
Gastro-succorrhea is common and, finally, that rare and interesting condition 
known as gastric tetany may supervene, during the passage of a stomach 
tube, vomiting, or even percussion. 

Differentiation. — The clinical distinction between these various forms 
rests primarily upon the evidence of delayed emptying of the stomach and 
the presence and degree of stasis, as indicated by persistent retention of 
food residue and fermentative changes. 

Furthermore, in actual mechanical obstruction, the recurrent vomiting 
of strikingly excessive amounts of food and liquid showing persisting and 
often ancient food residue, marked visible or palpable peristalsis and usually 
the presence of a pyloric tumor assist the diagnosis. 

In stenotic insufficiency, moreover, we are ordinarily dealing with carcin- 
oma, more rarely with pyloric ulcer or its scars, and the gastric contents will 
vary somewhat characteristically with the causative factors. 



HOUR-GLASS STOMACH 9OT 

As between the benign and malignant cases great difficulties may arise 
in diagnosis, but in general it may be said that, while marked stasis charac- 
terizes both, the presence of large numbers of the Boas-Oppler bacilli, the 
cachexia, profound anemia and the entire absence of hydrochloric acid, free 
and combined, so nearly constant in cancer, are absent or present in less 
degree in benign stenosis, in which, moreover, the sarcinae are usually present 
in large numbers. (See "Roentgenography.") 

HOUR-GLASS CONTRACTION {Bilocular Stomach).— This deformity, 
if organic and not congenital, results usually from a penetrating ulcer, the 
healing of a large annular ulcer, more rarely from adhesions or scirrhus. The 
stomach is divided into two lateral segments and the communicating opening 
may be relatively large or very small. The symptoms vary with the cause 
and may closely simulate pyloric stenosis if the opening be greatly contracted. 

Diagnosis. — Inflation alone will rarely make the diagnosis, which is 
easily established by fluoroscopy. The following signs are of some value: 

1 . The return of only the major portion of a liter of water introduced by the 
tube. 

2. In distention by air and liquid, if the opening is narrow, (a) the bulging 
or the dull percussion note may at first be only in the cardial pouch and later be 
apparent in the pyloric portion, (b) The water or gas may be heard or felt to 
pass through the narrow orifice, especially if pressure be applied, (d) If all 
recoverable water be withdrawn succussion sometimes may be efficient and only 
over the pyloric loculus. (See " Roentgenography.") 

Occasionally adhesions may produce a false hour-glass stomach when 
the patient is erect which disappears in recumbency. 

DISEASES OF THE ESOPHAGUS 

THE CHIEF ORGANIC ESOPHAGEAL LESIONS.— Varices.— Some 

very serious, dramatic and even lethal hemorrhages may arise from the rup- 
ture of varices of the esophageal veins, usually due to an obligatory collateral 
circulation associated with portal or inferior vena caval obstruction. 

The usual point of rupture is at the inferior segment of the esophagus and 
hepatic cirrhosis of the Laennec, Band, or luetic type is the most common 
basic factor. 

Acute Esophagitis. — This occasionally occurs as a result of the irrita- 
tion of foreign bodies, the action of corrosive poisons or hot liquids, or in 
connection with diphtheria or other acute infections. It may also be second- 
ary to malignant disease or an extension of a catarrhal process in the throat. 
Its symptoms are chiefly dull substernal pain and dysphagia with or without 
spasm and are described further on. 

ESOPHAGEAL STRICTURES.— The chief points of normal esophageal 
narrowing are: First. — The segment opposite the cricoid cartilage, normally 
about 14-15 cm. from the incisor teeth. 

Second. — The point opposite the bifurcation of the trachea and at the 
level of the crossing of the aorta, normally 24 to 26 cm. from the incisor teeth. 



g02 MEDICAL DIAGNOSIS 



Third. — At the "hiatus" where the esophagus passes through the dia- 
phragm, about 40 cm. from the incisor teeth. 

These are the points at which pathologic constrictions most frequently occur, 
whether due to the contracting scar tissue following corrosive acid burns, ulcera- 
tions, or malignant disease. 

Furthermore they represent the points of election for the lodgment of 
foreign bodies, for instrumental injury and, in the case of the median con- 
striction point, for compression by aortic aneurysms involving the transverse 
portion of the arch. These occasionally constitute a genuine source of danger 
in the use of dilating esophageal bougies, though if the condition is kept in 
mind as a possibility, error should seldom occur. 

In the absence of paralysis, inability to swallow solid or liquid food de- 
mands immediate recourse to the esophagoscope or esophageal bougie. True 
stricture is usually due to cicatricial contraction following the ingestion of 
corrosive poisons, syphilis, or malignant growth and is rarely congenital. 
Obstruction from the pressure of aneurysm or other tumors, or even, it is 
said, of massive pericardial effusion may occur. 

A bougie should never be passed without a careful preliminary examination 
for possible aneurysm or necrotic processes and it should be remembered that nine 
out of ten strictures in adults are due to malignant growths. 

Strictures may be single or multiple, sharply defined or involving the 
whole tube, but are usually either near the cardia or just below the pharynx. 
No definite information is obtainable without the use of the esophagoscope, 
X-ray, or bougie, but as a matter of interest the esophageal bruit may be 
auscultated at the left of the spine. It should be heard at the left of the 
seventh dorsal vertebra within seven seconds of the time that a mouthful of 
water is swallowed, and a delay suggests obstruction. The most convenient 
bougies are those with detachable heads of varying size and an elastic steel 
or whalebone stem. As in the passage of a urethral sound and for the same 
reasons, the larger sizes should be first tried and forcible maneuvers avoided. 
The patient should be asked to breathe deeply with the head thrown far 
back and the spine straight, and, without introducing the finger, the bougie is 
passed gently, firmly and steadily along down the pharyngeal wall disregard- 
ing the slight obstruction encountered at the cricoid level. Perforation dur- 
ing the procedure is a rare but deplorable accident. 

Symptoms. — Food regurgitation and dysphagia, the latter usually of a 
gradually but persistently progressive type and preceded by a period of hyper- 
esthesia or recurring spasm are the basic and dominant symptoms, whether 
the lesion be due to past traumatism, or to malignant growth (70-80 per 
cent.), syphilis (only in the rarest instances), diverticula, or, the pressure of 
aneurysm, enlarged bronchial glands or the cold abscess of " Pott's disease." 

The use of the fractional repeated ingestion of bismuth subcarbonate or the 
oxychloride suspended in gum acacia is proving of great assistance in the diag- 
nosis of esophageal cases and the esophagoscope is invaluable. 

ESOPHAGEAL DILATATIONS.— These may be due to the effect of re- 
current spastic constriction upon the segment just above it, or, to extreme 



DISEASES OF THE ESOPHAGUS 903 



atony of the esophagus. A form of diffuse dilatation of the lower segment, 
wholly due to recurrent spasm, is occasionally encountered and may reach 
enormous proportions. 

It is obvious that aside from diverticula more or less symmetrical dilata- 
tion may occur above any points of pathologic constriction. 

DIVERTICULUM.— This is a pouch-like dilatation on the order of sac- 
cular aneurysm, involving one or more of the coats of the esophageal wall. 

Etiology. — Aside from the congenital diverticula, this ailment is rare in 
children, unusual in women and most frequent in men. a triad of facts relating 
to occurrence that usually strongly suggests a luetic origin. As a matter of 
fact, esophageal syphilis is an extreme rarity, according to statistics at 
present available. 

Two distinct forms are encountered, viz., pressure diverticula and those 
due to traction. 

The former are caused apparently by a congenital muscular weakness of 
the posterior wall of the superior esophageal segment or a yielding of the 
fibers of the anterior or lateral wall of the inferior segment. 

''Traction diverticula'* result from cicatricial contraction or the pull of 
adhesions formed between the esophagus and contiguous structures. 

They are located usually on the anterior wall at or near the junction of 
the upper and mid-divisions. 

For the greater part diverticula are unrecognized during life, though if 
large enough to retain food and produce stagnation or pressure a diagnosis 
may be made. 

Symptoms. — The leading symptoms in the severer forms are: Substernal 
burning and pain, foul breath, sense of persistent esophageal irritation or dis- 
tention, vomiting if the sac be large and, in extreme cases, pressure symptoms 
similar to those of aneurysm. 

Obviously, evidences of abscess may exist in some instances not alone as 
a result of a purulent esophagitis, but, in the traction forms, from fistulous 
communication with the primary source of abscess formation. 

Such pouches readily escape the sound, but may be detected both • by 
the esophagoscope and the roentgen technic. 

Bassler directs attention to the ease with which perforation may result, 
even from the passage of a stomach tube. 

ACUTE ESOPHAGITIS.— Participation of the esophagus in the exan- 
thems of acute infectious disease (scarlet fever, variola and even measles), 
the pharyngeal inflammation of diphtheria, or the acute toxemic states 
(typhoid and sepsis) are among the etiologic possibilities. 

Extension of any existing inflammation in junctional or neighboring tis- 
sues and (most commonly; direct irritation from hot drinks or (less often) 
corrosive acids or alkalis (lye , ! and foreign bodies are adequate causes. 

Symptoms. — In severe cases, pain persistent or only on swallowing, thirst 
and oftentimes the sensation of a foreign body in the tube, are present. 

In milder cases the signs may be merely those of slight substernal distress 
and pain or decided discomfort on swallowing. 



904 MEDICAL DIAGNOSIS 



The latter group of symptoms also serve as the sole manifestations of 
simple chronic esophagitis, aside from any apparent or genuine neurosis such 
as may appear in any esophageal case and often precedes the full develop- 
ment of a serious organic lesion. 

SYPHILIS. — This disease is so rare as to render its occasional occurrences 
clinical curiosities. 

It is possible that a routine resort to the luetin and Wassermann tests 
might affect accepted etiology much as it has that of gastric syphilis, which 
is known now to be much more common, or, less rare, than previously was 
believed. 

ESOPHAGEAL NEUROSES.— Hyperesthesia, paresthesia, esophago- 
spasm and cardio-spasm are extremely common occurrences, but doubtless 
their frequency as supposedly idiopathic manifestations will diminish as 
esophagoscopy becomes more generally employed. 

Lerche states that "a local neurosis is present in every case of anatomic lesion 
of the gullet at some time." 

ESOPHAGEAL SPASM.— This condition is usually associated with 
functional nervous disease, such as hysteria, hypochondria, neurasthenia or, 
more rarely, epilepsy and chorea. It is also a symptom of hydrophobia and 
the diagnosis rests upon the recognition of the causative factors named and 
the passage of an esophageal bougie of full caliber which meets with only 
temporary obstruction. 

CARCINOMA OF THE ESOPHAGUS.— This, the commonest cause of 
organic obstruction of the esophageal tube, differs in no essential respect from 
carcinoma elsewhere in its nature, mode of onset, constitutional symptoms, 
course, or termination. 

Primary carcinoma is rare, most cases of obstruction being due to malig- 
nant disease extending upward from the cardia. The symptoms are those of 
obstruction associated with rapid and extreme emaciation and cachexia. 
Perforation into the mediastinum, aorta, pericardium or pulmonary and 
pleural structures may occur or the spine may be involved. In some of 
these cases the X-ray gives evidence of positive value. 

It should always be kept in mind when dealing with organic stenoses or 
even motor or sensory disturbances apparently functional. 

Symptoms. — Those symptoms specially appertaining to esophageal malig- 
nant involvement are the following: 

(a) Persistent, steadily but slowly increasing dysphagia and demonstrable 
stenosis, the latter tending to become absolute. 

(b) Regurgitation of food. 

(c) Evidences of malignant ulceration as the disease advances. 

(d) Substernal pressure or actual pain, seldom wholly absent. In late 
cases a lancinating type of pain may supervene and present nocturnal ex- 
acerbation. 

(e) Significant enlargement of the supra- and infraclavicular glands may 
be demonstrable. 

(f) Thirst is often a prominent symptom in advanced cases. 



GASTRITIS 905 



(g) Pressure symptoms from crowding of the many important medias- 
tinal structures. 

(h) Hemorrhage, often one of the earlier symptoms in the form of oozing., 

ORGANIC DISEASES OF THE STOMACH 

ACUTE GASTRITIS (Gastritis Glandularis, Acute Gastric Catarrh 
Phlegmonous Gastritis) . 

Definition. — An acute (simple toxic, or phlegmonous) inflammation of the 
gastric mucosa. 

Etiology. — Indiscretion in diet, nervous shock, toxic irritants such as 
ptomaines, arsenic, alcohol, mercuric chloride and potassium cyanide, or, 
if phlegmonous, pyemia, septicemia, the exanthemata, and rarely direct 
infection. 

It is most frequent at the extremes of life and in those debilitated and 
dyspeptic. Excessively hot or cold drinks, overeating and imperfect mas- 
tication are important factors. 

Morbid Anatomy. — The lesions vary from a simple catarrhal inflammation 
to necrosis and single or multiple abscesses. 

Symptoms. — Mere subjective weight or fullness, anorexia, and a coated 
tongue with or without nausea, slight pain and general dyspeptic manifes- 
tations may be the only symptoms. 

In the severe forms one finds headache, epigastric pain; nausea, vomiting 
and constipation or diarrhea, complete anorexia, excessive thirst, and a burn- 
ing sensation which may amount to agonizing pain in the traumatic cases. 
In the toxic forms, prostration is extreme, the pulse feeble, the surface cold, 
the case tending to coma and death. Such cases may occur in myasthenic 
stenotic ectasia. 

Stomach Contents. — Mucus is present in the vomitus, associated 
with blood and shreds of mucous membrane in the toxic forms and 
perhaps pus in the phlegmonous forms. Free hydrochloric acid is usually 
absent. 

Prognosis. — Recovery is prompt save in exceptional severe toxic or 
phlegmonous cases. 

CHRONIC GASTRIC CATARRH (Chronic Gastritis) .—A chronic catar- 
rhal inflammation of the gastric mucosa. 

Etiology. — The disease may follow an acute gastritis, but is more fre- 
quently associated with a monotonous or improper dietary, chronic disease 
of the heart, liver, kidneys and lungs, gout, diabetes and the anemias, ex- 
cessive smoking and drinking, the habitual use of highly spiced dishes, rapid 
and excessive eating and imperfect mastication. 

It follows certain infectious fevers, as typhoid, cholera, yellow fever, 
and the exanthemata, ulcer, cancer or dilatation of the stomach itself or 
may be superimposed upon long-standing asthenic dyspepsia. It follows 
that certain cases complicating other conditions are hardly distinguishable. 

Symptoms. — Among the commoner symptoms, are: flatulence, belching, 



Varying 
severity. 



Toxic 
form. 



Obscure 
cases. 



906 



MEDICAL DIAGNOSIS 



Mucus 



Misleading 
signs. 



A 

dubious 

condition. 



morning-malaise, nausea and perhaps vomiting, pyrosis, foul taste in the 
mouth, vertigo, palpitation, dyspnea, cough and a poor or variable appetite 
often associated with a sense of repletion after even a light meal. Morning 
vomiting occurs especially in the chronic gastritis associated with hepatic 
cirrhosis ("drunkards' catarrh"), and morning regurgitations before or 
after breakfast are even more common. 

Constipation, in some cases alternating with diarrhea, is the rule; there 
are usually evidences of a poor circulation, the tongue is coated and mar- 
ginally indented by the teeth, and nervous irritability is common. Marked 
loss of weight is seldom seen save in distinctly secondary cases, where it is usually 
due to the primary cause. 

The disease usually develops insidiously and progresses very slowly. 

Stomach Contents. — In advanced cases free HC1 is much diminished or 
absent, the total acidity is below normal, the total stomach content usually 
increased, mucus is abundant even in the empty stomach, and the digestive 
ferments are diminished. 

Hypertrophic Chronic Gastritis. — This is secondary to the simple form and 
represents a sclerotic process which results in marked destruction of the 
secretory glands. 

This may terminate in a general infiltration which greatly reduces the 
size and capacity of the stomach. It may so narrow the pyloric outlet as 
to simulate malignant stenosis, especially as an achylia or decided 
hypochlorhydria may be evident. Retention is marked] in duration, 
but the quantity of content is small. Even after the test meal, it rarely 
exceeds 30 c.c. 

Acid Gastritis. — This shows a remarkable conjunction of hyper chlor- 
hydria and excessive amounts of mucus in the removed test meal. 

We do not yet know its true place or the justice of its claim to be con- 
sidered a clinical entity, and a primary surgical source should be sought 
always. 

Differential Diagnosis. — All differential diagnosis in disease of the 
stomach is subject to limitations and exceptions, it being often impossible 
to draw hard and fast lines, and chronic gastritis must, like all others, be 
encountered in its early and its complicating forms, lacking in the one case 
its most characteristic symptoms and in the other blending with or over- 
shadowed by the primary disease. 

A chronic gastritis lacks the severe pain, extreme localized tenderness, hem at- 
( emesis and high HCl values of typical ulcer and usually the marked emaciation, 
! excessive lactic acid formation, abundant Boas-Oppler bacilli, and tumor, so 
generally present in cancer. 

Achylia gastrica lacks the mucus so characteristic of the usual form of 
gastritis, and in the neuroses, the asthenic psychasthenic or hysteric symp- 
toms, asthenic conformation, more trifling or inconstant disturbances of gas- 
tric secretion and the absence of an excess of mucus usually differentiate it. 

Prognosis. — This varies according to the cause. Many cases may be 
entirely cured; others, never. 



GASTRIC AND DUODENAL ULCER 



907 



GASTRIC AND DUODENAL (POST-PYLORIC) ULCER 

GASTRIC ULCER. — Definition. — An ulcer of the gastric mucous mem- 
brane, usually single but often multiple and tending either to an acute course 
followed by complete or partial healing, extreme chronicity, or, to perforation, 
either prompt or long delayed. 

As to ulcers in close proximity to the pyloric ring, whether proximal or distal, 
no distinct line can or need be drawn. The so-called duodenal ulcer is actually 
a post-pyloric gastric lesion, for in 95 per cent, of all such cases it occupies the 
"first portion of the duodenum," embryologically and anatomically an integral 
part of the stomach. 

Etiology. — Aside from direct irritation or traumatism, toxemia, hyper- 
acidity with deficient mucous secretion and devitalizing anemia, appear to 
be the most important associated conditions. The true cause is not known,* 




Fig. 463. — Prepyloric acute ulcer with total spasm of the pyloric antrum and decided 
retention. Such a case would show high HC1 values. (After von Bergmann.) 

but the organisms contained in cryptogenetic septic foci may prove the 
important antecedent factors or even the determining causes. All of the 
older theories are imperfect and unconvincing. 

Both anemia and toxemia are factors in delayed healing. 

Sex. — About 60 per cent, of acute gastric ulcers occur in females. The 
chronic forms on the other hand show decided male predominance. 

Age. — It occurs most commonly between the ages of twenty to forty, 
least often, yet occasionally, in babies, f young children, and elderly persons, 
and there is probably little or no hereditary element. 

Acute ulceration is encountered chiefly between the ages of 20 and 30. 
About 70 per cent, of all ulcers are recognized between the ages of 30 and 50. 
As between the age periods of 50 to 60 and 60 to 70 there is little difference 
in the ratio of incidence, which is about one fifth of that of the fifth decade. 

* Recent investigations indicate the existence in the normal stomach of protective anti- 
enzymes, but under what conditions their activity fails is as yet unknown, 
t Doubtless the post-pyloric ulcer is a cause of " melena neonatorum" 



Still 
unknown. 



go8 



MEDICAL DIAGNOSIS 



Certain Predisposing Factors. — Direct injury, as from blows, tight lac- 
ing, pressure, the ingestion of corrosive drugs and such occupations as lead to 
anemia, irregular or hasty eating and the use of improper food, are held to be 
important factors, and at least figure prominently in the statistical reports. 
No statistics are available so far as the author knows, which would bear 
actuarial criticism. 

In one clinic, located in the midst of an agrarian population, the farmer 
may be found to furnish the highest percentage of ulcer cases; in another, 
the weaver; in yet another, domestics; the results depending chiefly upon 
the location of the clinic and the occupational trend of its patients. 




Fig. 464. — Typical ulcer ("penetrating") with spasm of the segments. Note small 
projection toward spine on left side of constriction. (After von Bergmann.) 

Varieties. — (a) The "Acute" or acutely relapsing chronic ulcer of pro- 
nounced and definite symptomatology termed by Welch " gastralgic-dys peptic." 
(b) The latent acute and chronic forms. Single or multiple ulcers may exist for 
years and ultimately perforate or spontaneously heal without localized symptoms: 
probably more than one-half of the cases are unrecognized clinically, (c) The 
acute perforating form. In this there is a rapid advance and perforation, (d) 
The acute hemorrhagic form. In this the symptoms are usually vague, of brief 
duration or may be entirely absent until profuse hemorrhage occurs. Other 
types occasionally described are relatively unimportant. 

PATHOLOGY AND MORBID ANATOMY.— The ulcers vary in size 
from mere erosion to necrotic areas measuring from 4 to 6 inches in diameter. 
The acute ulcers are ordinarily small (}i to % inch) round and clean-cut, with 



GASTRIC AND DUODENAL ULCER 909 



little or no induration of the base or the margins, though if chronic they may 
be irregular or sinuous with terraced sides and will show always marked infil- 
tration or induration. 

Acute Ulcer may heal and leave no scar or one so slight as easily to escape 
observation even at autopsy. Its depth may be merely that of erosion or 
extend to or through the serous coat. In most instances they are not pal- 
pable even when the stomach is exposed at operation and may readily be 
missed even though its inner surface is under the direct vision of the operator. 
On the other hand, it is the form most likely to present the typical symptoms 
of ulcer as set forth in our older text-books. 

Chronic Ulcer is, as a rule, productive of quite opposite conditions. There 
are periods of activity, partial healing, sluggishness or latency and the 
tendency to infiltration is decided. They are usually palpable or even 
visible at operation, but most inconstant and variable in their clinical 
symptoms. 

They are ordinarily single, but not infrequently (20 per cent.) there are two, Usually single. 
very rarely a score or more. 

Location. — Acute ulcers occur with about the same frequency in the 
cardia, midzone and pyloric region. Chronic ulcer '•straddles'' the lesser 
curvature in from 80 to 85 per cent, of all of the cases not definitely post- 
pyloric (duodenal). They are relatively rare at the cardia and on the Rare at cardia. 
greater curvature. 

Gastric ulcers of severity show a marked tendency to recur, usually within 
the old scar of a healed ulcer. In rare instances, true carcinoma may develop 
its own primary ulcer* on an old simple ulcer base and many ulcers doubtless 
undergo during years, recurrent partial healing only to break down again Self 
and may thus renew repeatedly the active symptoms of the disease. 

Thus is developed the significant but not distinctive history of recurrent, dis- 
tinctly painful, dyspepsia, of greater or less degree and duration, with 1 anger or 
shorter intervals of immunity. 

This is a common feature of the histories of certain chronic types of gastric 
ulcer, but not at all uncommon in cases other than ulcer. 

Healing. — They heal by granulation and in cases of extensive ulcer may 
produce deformity, such as the hour-glass contraction, but more commonly a 
pyloric stenosis, tw of the three conditions always justifying operation. 

As stated, toxemia, anemia, and, in some cases, hyperchlorhydria and 
hypersecretion are factors of some importance in the prevention of healing. 
Far more important is intermittent spasm or increased peristalsis. In this 
respect, as in relation to pain, the nearer the ulcer (gastric or duodenal) to 
the pyloric ring, the worse are the conditions. 

Perforation. — Perforation may result in general peritonitis demanding 
surgical interference and tending to a fatal termination, or, adhesions mav 
form, limiting the spread of the infection and saving life. Manv such cases of ° ften 

overlooked. 

self-rimited perforation go unrecognized. The omentum, liver, gallbladder 
or pancreas may be involved, and adhesions thus formed complicate the 
* All primary carcinomata of the stomach begin as ulcers (Aschoff). 



910 



MEDICAL DIAGNOSIS 



Misinter- 
pretation. 



Obscure 
abscess. 



Fallacious 
figures. 



Frank cases. 



Obscure cases. 



Character- 
istics. 



clinical picture and lead to mistaken diagnosis. The author has observed in 
cases in which the gall-bladder was involved, symptoms exactly simulating 
gall-stones and leading to operation for their removal. 

The perforations of acute ulcer are usually direct and involve the gen- 
eral peritoneal cavity. Obscure abscesses may result in the chronic forms, 
subphrenic abscess and pyopneumothorax being sometimes observed and 
fistulous communication may involve tracts far distant from the original seat 
of trouble. The frequency of perforation as usually stated (13 to 18 per 
cent.) is certainly far too high, being necessarily based wholly upon cases 
yielding positive symptoms or coming to operation or autopsy, and, of course, 
omitting the clinically doubtful or larval cases which no doubt outnumber the 
others.* 

In private cases amongst the "well-to-do" it is relatively rare. In 
public cases its frequency depends largely upon the type of hospital popula- 
tion, and the efficiency of the medical staff organization and personnel. 

ACUTE ULCER. — The positive diagnosis of acute or subacute gastric ulcer 
still largely depends upon the concurrence of the old tetrad of symptoms, pain, 
localized tenderness, vomiting and hemorrhage, yet in most instances we meet 
cases which lack these franker symptoms wholly or in part.\ 

A large proportion demand the carefid balancing and analysis of a large 
number of factors which may be strongly suggestive individually, or only collect- 
ively significant, and fatal perforation or hemorrhage may occur in cases which 
have previously lacked the symptoms necessary to even a tentative diagnosis. 

Placing the determining diagnostic factors of acute ulcer somewhat in the 
order of their clinical importance, we have: (a) Hemorrhage, (b) Pain, (c) 
Localiced tenderness, (d) Vomiting, (e) Normal or but slightly changed 
hydrochloric acid values usually with lessened mucous secretion. (/) General 
dyspeptic symptoms, (g) Anemia, (h) Age. (i) Sex. (j) Occupation. 

Those fortunate enough to have at hand an expert roentgenologist may 
obtain much assistance. (See Roentgenology.) 

(a) Pain. — The characteristics of the pain of gastric ulcer are: (1st) its in- 
termittent and paroxysmal nature; {2d) its relation to the taking of special kinds 
of food; (3 J) its time of occurrence; (4th) its periodicity in the individual. 

Other factors are of some importance in differential diagnosis and amongst 
these are: The tendency of the pain or distress to increase its intensity as the 
attack progresses, the immediate relief, complete or decided, afforded by invol- 
untary or, more frequently, by induced vomiting. Any actual abdominal pain 
which occurs day after day during several weeks in the same region is almost proof 
positive of an organic lesion of the stomach, duodenum, appendix or gallbladder, 
though relaxed hernial openings or umbilical hernias must not be forgotten. 
If this pain observes a certain schedule with relation to its appearance in the 
particular individual under observation, varying only with the size of the meal 
taken and coming on more rapidly after light than after heavy meals, it is most 

* Correctly stated the figures represent the frequency of perforation in cases clinically 
or pathologically demonstrated. 

t The disease is often one of extremely insidious development. 



GASTRIC AND DUODENAL ULCER 



QII 



suggestive of ulcer of the stomach or duodenum. If the appetite is well preserved 
the significance is yet greater, although the same elements may be present in 
certain functional disorders. Mere discomfort, a "faint feeling," a "gone 
sensation" a "sense of fulness" and the like must not be construed as ulcer 
symptoms, save in the presence of strong corroborative evidence. Flatulent 
distention, often due to air-swallowing, may accompany ulcer pain as well as 
pure asthenic dyspepsia or purely temporary and trivial digestive disturb- 
ances. As stated previously one must carefully analyze the statements of 
nervous patients and allow for their almost invariable tendency to exaggerate 
their symptoms. 

It is not as a rule immediate, but usually becomes severe and even cramp- 
like in from half an hour to two to three hours after eating the ordinary meal Duration, 
and continues until the stomach is emptied by vomiting, stomach washing,* 
or by the natural mechanisms. Delayed pain {one, two or three hours) is far 
more common than was formerly believed and immediate pain the exception. 
Immediate pain usually means a lesion of the esophagus rather than the 
cardia. The onset of the pain is in large measure dependent upon the loca- Causes, 
tion of the ulcer, and its intensity upon one or more of several factors, i.e., 
peristalsis, spasm, acidity, character of the ingesta, irritability, congestion, 
inflammation and pyloric patency. 

The pain itself varies greatly in character and degree. In its typical form 
it is a boring, deep-seated pain, but is also described as burning, stabbing, Referred pain, 
cutting or cramp-like, quite frequently felt at the back, sometimes radiating 
upward to the region of the shoulder-blades. 

This typical pain is often replaced by that of a duller character and a sug- 
gestive feature when present, is the relief or intensification of pain accompanying 
changes in attitude both in the presence and absence of adhesions. \ 

Ulcer pain may be increased in standing or walking, and lessened in the 
dorsal recumbent position, but often intensified when the left lateral decubitus is 
assumed. If markedly intensified by standing, walking, or deep breathing, it 
suggests peritoneal involvement with perigastritis or adhesions and, some- 
times, an impending perforation. 

The writer believes with Bourget, that whether an ulcer be gastric or 
duodenal, the nearer it is to the pyloric ring the more intense is the pain.t 

Both the character of the pain and the area of tenderness are relatively fixed 
and show little variation even when the attacks recur over long periods. 

In some instances distress almost immediately following the ingestion of Helpful sign, 
very hot, cold or acid substances is significant. 

In certain cases, especially those of chronic ulcer, with hypersecretion, we 
find in addition, persistent pain of a duller character between meals and **™ istent 

* Hazardous in acute ulcer. 

t This is by no means distinctive if the relief of pain follows the assumption of dorsal or 
right lateral recumbency for these postures are peculiarly adapted to the relief of pain associated 
with visceroptotic dyspepsias. Actual severe pain is relatively rare, however, in the ordi- 
nary asthenic dyspepsias. 

% The same general rule may be applied to the occurrence of hyperacidity, though other 
factors are present in both instances. 



pain. 



912 



MEDICAL DIAGNOSIS 



Important 
points. 



Usually 
present. 



Site. 



Spinal areas. 



especially at night, which is relieved by taking food (hunger pain). Much 
stress has been laid upon the occurrence of such pain in ulcer cases, but in a 
mild form it is one of the common symptoms observed in various forms of even 
functional dyspepsia and particularly that associated with visceroptosis. 

The location of the pain necessarily varies somewhat with the position 
of the ulcer and of the stomach, being as a rule, lower in tightly laced women 
and in cases of ectasia or gastroptosis than under ordinary conditions. 

As five-sixths of the stomach lies to the left of the linea alba, and most ulcers 
are upon the lesser curvature, one usually rinds the pain at, or more commonly 
just to the left of, the median line, between the ensiform and the umbilicus, 
usually near, or nearer, the former. 

Should it be found that the seat of pain and tenderness shifts upward when 
the patient retracts the abdomen, assumes the recumbent posture {physiologic 
postural ascent of stomach) or downward in forced inspiration {respiratory move- 
ment) the evidence of an organic gastric lesion is thereby strengthened. Absence 
of such a shift is of little importance in negation. 

Localized Tenderness.- — The importance of this sign lies in the fact that a 
distinctly circumscribed superficial or, less often, deep tenderness and defensive 
rigidity, often extreme, is sometimes present and usually corresponds closely to 
the area of maximal pain. 

It is commonly epigastric, but is a trifle to the left of the median line and 
when localized constrasts sharply with the tenderness of gastric hyperesthesia 
which is usually much more diffused. About one-third of the active cases 
show a sharply localized area of superficial or deep dorsal tenderness, often 
extreme, slightly to the left of the lower dorsal spines (3 to 4 cm.). 

Rarely this is bilateral or on the right side alone and a second zone may 
be found occasionally at the level of the fourth and fifth dorsal spines. These 
areas seem to be associated with lesions at or near the pylorus, but thev are 
far from constant or pathognomonic. 

Hemorrhage. — Visible hemorrhage occurs in about one-half of recognized 
acute ulcers and, if massive, is always associated with a vomiting attack, 
usually subsequent to the pain crisis if this be present. It commonly 
occurs several hours after eating and often at night and is easily recognized 
visible Wood, as of gastric origin; but the smaller hemorrhages rapidly undergo such 
digestive changes as to closely simulate the small dark clots or coffee-ground 
I particles of carcinoma. Furthermore, severe or even fatal hematemesis 
may be due to gastric erosion or hepatic cirrhosis as well as ulcer. 

In many instances of acute ulcer (r5 to 20 per cent.) it constitutes the 
first decided symptom. 

The stools as well as the stomach contents should be carefully investigated 
for both visible and occult blood before declaring hemorrhage absent, and 
concurrent symptoms be carefully weighed before a frank hemorrhage is 
ascribed to ulceration. Under the restrictions and precautions previouslv 
laid down, the examination of the stool is far more important and productive 
of results than is that of the stomach contents. Blood may and does quickly 
pass from the latter viscus and furthermore both vomiting and the stomach 



Occult blood. 



Examine 
the stools. 



GASTRIC AND DUODENAL ULCER 913 



device. 



tube may cause slight hemorrhage. Enormous hemorrhage may be recovered 
from and but a small number die directly from it. 

Bassler has suggested the use of an extremely simple device for aiding in 
the diagnosis of ulcer or erosion by the swallowing of a silk string carrying a simple 
an ordinary shoe button at one extremity. This is swallowed by the patient : 
he is given sufficient "rope" and the free end is looped over his ear through- 
out one night. It is merely a simple and convenient application of the 
"string and bucket"' method of Einhorn and, if the string be blood stained 
when recovered, serves to prove the presence of blood, but little more. 

Vomiting. — Though often coincident with a painful crisis, spontaneous 
vomiting with or without hemorrhage is far from constant and self-induced 
vomiting is more often seen. If present, vomiting usually occurs at the acme 
of the pain and relieves or greatly modifies it. 

Persistently recurrent vomiting of a definitely periodic type is strongly 
suggestive of ulcer, either acute or chronic, but will usually be associated with 
other corroborative symptoms, viz., localized tenderness, visible hemorrhage 
in the acute, and less frequently in the chronic form , and in the latter especially 
with hypersecretion or hyperacidity. It frequently is the ''gush'' vomiting 
of hypersecretion. When less definitely periodic and persistent it suggests 
disease of the appendix or gallbladder. In a few instances the author has 
seen most misleading vomiting of this type in the crises of locomotor ataxia. 
The fact that occult or even visible blood may be present in this type of 
case without ulcer must be borne in mind. 

Most of the cases of anorexia nervosa or mere cyclic vomiting observed 
by the writer have been quite without the usual delay of ulcer appendicitis 
or gallbladder disease with respect to food ingestion — the return usually 
being more like regurgitation. 

In ulcer the delay may vary, but is likely to run between one and thre? 
hours with a regularity which is disturbed chiefly by the size and character 
of the meal taken. As possible causes, the crises of locomotor ataxia and the 
possible presence of incomplete hernia must not be forgotten. 

Acidity. — In acute ulcer normal or high-normal values probably are 
the rule; hyperacidity uncommon, subacidity the exception except after 
hematemesis. 

Hyperchlorhydria is a common condition without ulcer, so that even in 
relation to chronic lesions the symptom, while important, is only corrobora- 
tive; nevertheless decided hypo -acidity goes far to exclude ulcer, acute or 
chronic, or, if constantly diminishing and accompanied by a clear ante- 
cedent ulcer history, suggests that rare development, a carcinoma upon an 
old ulcer base. (Decided subacidity is usually associated with complicating 
catarrhal gastritis or ectasia or an antecedent hemorrhage of considerable 
amount.; 

The stomach tube must not be used if violent retching is thereby induced 
nor shortly after a hemorrhage. If vomiting is present in such cases a proper 
test meal sometimes may be taken and thus recovered, the interval being 
often sufficiently well observed. 
s8 



914 MEDICAL DIAGNOSIS 



The duodenal tube is well adapted to the recovery of stomach contents 
in acute ulcer cases in many instances. 

Marked or excessively high HCl values associated with clean-cut ulcer 
symptoms undoubtedly represent usually an active, or relatively recent ulcera- 
tion at or near the pylorus with prolonged retention of ingesta. 

The relief of pain following the administration of warm solutions of sodium 
bicarbonate or milk of magnesia will often assist diagnosis slightly, though in 
gastric neuroses with pylorospasm and hyperacidity the same result may be 
obtained. 

CHRONIC GASTRIC AND POST-PYLORIC (DUODENAL) ULCER.— 
Active or extremely irritable chronic ulcers may present the same fundamental 
symptoms as the classic acute or subacute ulcer, but show many and wide 
variations from the typical picture in the great majority of instances. 

"Hunger-pain." — As stated under " acute ulcer," when a distinct and 
more or less sharply localized pain or painful discomfort regularly appears 
when the stomach should be empty or nearly so, two, three, or four to six 
hours after a meal, or, on a fasting stomach, it constitutes a symptom of 
some importance and significance, somewhat intensified if the pain is relieved 
by the taking of food and if the duration of such amelioration or relief is 
more marked with a large meal than a small one. 

As stated elsewhere u hunger -discomfort," amounting to actual "hunger- 
pain" if much flatulent distention is present, is one of the commonest symp- 
toms of asthenic ("nervous") dyspepsia, and in such instances also the taking 
of food may give immediate and marked relief. In such instances, as 
stated, the element of exaggeration must be dealt with and may be most 
misleading. In general, however, the distress experienced is more diffused 
than in ulcer and the large meal may or may not prove more disconcerting 
than comforting. 

As one of several mutually corroborative symptoms " hunger-pain" is 
of importance. Existing alone it can merely excite suspicion, save when 
sharply localized and severe, and, in the presence of an anamnesis suggestive 
of preexisting ulcer. 

In any event it is evident that such a pain is not born of mere food con- 
tact, but distinctly suggests a direct relation to heightened peristalsis or 
spasm, with hypersecretion and heightened acidity or difficult emptying 
from any cause. 

The greater the part played by direct irritation, the more likely is a 
definite localization of the pain; i.e., the more active or irritable the ulcer 
and the nearer it lies to the pyloric ring. In certain cases of duodenal ulcer, 
unassociated with any hindrance, organic or spasmodic, to free emptying, 
hunger-pain may be present two hours after eating or even earlier. 

Hemorrhage in Chronic Ulcer. — Hemorrhage in chronic ulcer is less 
frequently visible (10 per cent.) than in acute ulcer and less constant and 
persistent as occult blood in the stools than is the case in carcinoma. 

Occult blood is nevertheless quite frequent, and, as in acute ulcer, but much 
less often, may be not only visible, but massive and even fatal. 



GASTRIC AND DUODENAL ULCER 



915 



77 should be remembered that a large hemorrhage may occur with pallor, 
faintness and even syncope, without vomiting, and be revealed later only by an 
examination of the stools. 

Repeated small hemorrhages may induce gradually and progressively a 
decided, though seldom extreme, anemia. 

Fatal hemorrhage occurs in only a small proportion of gastric ulcers, 
oftener in public than in private cases. The precautions to be taken in the 
examination for occult blood have been mentioned, but one properly may 
repeat the warning against accepting positives without an investigation of 
such common sources of oozing or active hemorrhage as the naso-pharynx, 
gums and rectum. 

Bright blood in the stools is, of course, never of gastric or duodenal origin. 

Persistence of bleeding in a case of supposed ulcer under proper condi- 
tions of rest and diet strongly suggests malignant growth and usually demands 
an exploratory incision. 

Hyperacidity in Chronic Ulcers. — In the predominating type of chronic 
juxtapyloric ulcers {prepyloric or post-pyloric) high acid values are present in 
between 80 and 85 per cent., and in the remainder the values are actually or 
approximately normal in nearly all instances. 

The importance of these facts is very great with relation to the early diagnosis 
of carcinoma or the rare instances of its development upon an old ulcer base. So 
important in fact that if decided symptoms and signs of chronic juxtapyloric 
ulceration are present and free HCl values are very low or progressively falling, 
an exploratory incision is imperatively demanded. 

In the ulcers outside of or distant from the pyloric segment normal acid 
values predominate (%-%) but very low acidity is present in only 10 to 12 
per cent. 

It must be remembered always that in early gastric carcinoma the gastric 
contents may show for a time merely low HCl values and lack both lactic acid and 
Boas-Op pier bacilli, though these last are present in nearly all cases. 

According to the author's experience, however, these HCl values steadily 
diminish. 

Hypersecretion. — Persistent or periodic hypersecretion is peculiarly 
frequent in association with chronic ulcer of the juxtapyloric type whether 
gastric or duodenal. The HCl values are usually high in the hypersecretion 
of chronic ulcer and more or less delay in emptying results from the tendency 
to pyloric spasm. The quantity of fluid obtained from the fasting stomach 
is above the normal though not necessarily extreme. 

After a test meal also the recovered gastric content shows clearly the 
predominance of the liquid element on standing and sedimentation, 60 to 90 
or 95 per cent, of liquid being often manifest. In ulcers of other portions 
of the stomach the viscus may empty readily and HCl is likely to be normal 
or but slightly high or low. 

In these cases two or more of the classic symptoms, i.e., pain, circumscribed 
tenderness, vomiting and hemorrhage are particularly likely to be present. 

Hypersecretion occurs frequently in simple atony, but is usually slight 



916 MEDICAL DIAGNOSIS 



and not as likely to show in the recovered test meal so great a predominance 
of liquid over solids. As stated previously, food retention, and even hyper- 
secretion alone, in a fasting stomach, associated with true hunger pain, 
strongly suggests a juxtapyloric ulcer. In duodenal ulcer with an unob- 
structed pylorus, the emptying may be more rapid than normal but is not as 
rapid as in simple achylia. Obviously, if one finds rapid emptying with 
achylia he need not ordinarily consider ulcer, for in the latter some grade of 
acidity is present unless a malignant transformation is developing. 

Tenderness and Defensive Rigidity in Chronic Ulcer.- — Both symptoms 
are variable and inconstant, but very important when present, and both 
suggest an active process in the area involved, or, marked irritability. As 
in the case of acute ulcer the location may vary quite widely, but diffuse 
tenderness is of no importance. 

As stated in connection with acute ulcer, if the position of any tender 
or painful point shifts upward, in changing from the erect to the recumbent 
posture or when the abdomen is strongly indrawn or shifts downward in 
deep inspiration, the suggestiveness of the symptom is intensified. 

Even a post-pyloric ulcer may reveal tenderness to the left of the median 
line and even in the left hypochondrium. In either gastric or duodenal ulcer 
it may be low as is readily understood by a reference to the illustrations of 
the gastroptotic and ectasic stomachs. 

Save in direct connection with roentgenologic studies the actual localizing 
value of tenderness is not great. On the other hand its mere persistent 
presence and strict adherence to site, under like conditions of posture and 
respiration, is valuable. 

RADIOGRAPHY IN GASTRIC AND DUODENAL ULCER.— The 
essential points are clearly set forth by Dr. Bissell in another section, but 
the topic may be touched upon here in direct connection with the symp- 
tomatology and the use of the stomach tube. 

It should be understood clearly that roentgenography and roentgenoscopy 
are invaluable aids in diagnosis, but that of and by itself roentgenology does 
not and cannot achieve a correct diagnosis in more than a large minority 
of the cases. 

Furthermore, in any hands save those of the trained expert they are 
likely to lead to most serious blunders and many futile and unnecessary 
operations. 

The all too prevalent hasty resort to exploratory operations and the over- 
confidence in roentgenologic findings so commonly observed at the present 
time have resulted in displacing to an unwarranted degree the careful, exact, 
and discriminating anamnesis and the results of test meals and investiga- 
tions of the gastric contents as determined by the stomach tube or more 
safelv in ulcer, by the partially introduced duodenal tube. 

One encounters in the arbitrary diagnostic ''formulae" offered the phy- 
sician by certain noted authorities an extreme example of an excessive and 
unwise dependence upon roentgenographic findings. 

As an adjunct, roentgenography is extremely valuable and oftentimes 



GASTRIC AND DUODENAL ULCER 917 



indispensable. As a sole dependence it is a broken reed and none are quicker 
.to proclaim this fact than are the best of our modern roentgenologists.* 

Proper Field in Gastric and Duodenal Ulcer. — To one so fortunate as to 
be able to combine roentgenology with careful and intelligent case-taking 
and modern clinical methods of a less objective type, the clarifying value of 
roentgenoscopy and serial roentgenography is clearly evident and the accu- 
racy of localization frequently obtainable is most impressive. The following 
facts should be held clearly in mind: 

(a) Simple acute or subacute ulcer yields, as a rule, slight distinctive 
roentgenographic signs, or, none at all, unless it is located so near the pyloric 
ring as to cause spasm and retention, or, perforates the wall and forms a 
diverticulum modifying the profile or capable of retaining a portion of the 
bismuth after the remainder has passed on. In rare instances the ulcer 
crater may hold a fleck of bismuth which is recognizable apart from the 
bismuth shadow within the stomach cavity. 

(b) Chronic infiltrating ulcers create the greatest disturbance in peristal- 
sis and those of the callous perforating type are recognizable in many instances. 
The fact that, in the standing position, the lesser curvature is shown in 
profile, and that 80 per cent, at least of chronic ulcers appear in this region 
makes possible the recognition of the projecting sac or pouch, an air bubble 
sometimes surmounting the surface of the bismuth. 

(c) Hour-glass contraction, spasmodic or true, is a readily recognizable 
roentgenologic phenomenon, not restricted to ulcer, but of decided importance 
as a corroborative sign. It may be true (permanent) or spasmodic and re- 
peated exposures or the administration of a tropin may be required to 
demonstrate its temporary nature. 

Either the false or true form may represent the result of gastric ulcer, and 
as between that due to malignant growth two chief differences exist. In ulcer 
the sulcus is band-like and smooth and the isthmus is not central, lying 
usually toward the lesser curvature by which, in fact, it is formed in most 
instances. In carcinoma the sulcus is usually broader and less regular, and 
the isthmus is centrally placed. 

In the very rare false hour-glass stomach which results from adhesions 
the appearance may be deceptive and in certain instances the hour-glass 
form is present only in certain positions of the body. 

SECRETION.— By the use of a "floating" and a " sinking" capsule the 
degree of hypersecretion or retention may be determinable roughly without 
the removal of the stomach contents or the administration of a bismuth 
meal, a measure of some special value in continuous or periodic hypersecretion 
from whatever cause. 

* The heavy expense involved in the maintenance and expert operation of a modern 
roentgenologic outfit places it beyond the reach of the average practitioner and the necessity 
and propriety of charging adequate fees for such work is as yet so little appreciated by the 
layman as to constitute a decided limitation to its much needed wider development. 

In such a book as this it is necessary therefore to emphasize those non-roentgenologic 
signs and symptoms of value to the general practitioner. 



918 MEDICAL DIAGNOIS 



Schwarz and others have devised opaque capsules of " gold-beaters' skin" 
which when introduced with the contained excess of pepsin and 4 grams of 
bismuth are thought to measure the degree of acidity through the time re- 
quired for their dissolution, compared with a standard table determined 
experimentally by digestion with fixed amounts of HC1 and an excess of pepsin 
in vitro. Neither method is as yet used widely or fully accepted. 

Form and Position of S/owac/z.— Gastroptosis, pyloroptosis, atony, and 
ectasia are beautifully and directly shown, and may markedly influence our 
judgment as to the meaning and importance of " retention" and " hyper- 
secretion" alike in cases of suspected ulcer lacking more definite symptoms. 

The gastroptotic atonic stomachs and their latent capacity as symptom 
producers in the presence of coexisting subnutrition and circulatory inade- 
quacy have led to a vast amount of unnecessary and futile surgery for the 
relief of purely suppositious ulcers or "relapsing appendicitis." Their pos- 
sessors constitute the least fit and most "operated" clinical type. 

Areas of Induration. — It is induration chiefly which makes the roentgeno- 
logic recognition of chronic ulcer possible in so considerable a number of 
cases. It produces a rigidity of the wall which persistently interrupts the 
peristaltic waves without of necessity producing a "filling defect" (alteration 
of the outline of the contained opaque meal) of the kind and degree encoun- 
tered in new-growths of the stomach. At all events when persistent it indi- 
cates an infiltrating lesion of some sort involving the stomach wall, and is to 
be considered and evaluated in connection with the anamnesis and the other 
symptoms and signs. 

In such instances the lesion is almost invariably chronic ulcer and one 
seldom lacking other corroborative evidence. Even though an actual "filling 
defect" is demonstrable it is rarely of such a character as to deceive 
the expert and lead to a roentgenographic diagnosis of carcinoma. 

Spasm and Incisurce. — These roentgenologic signs afford only indirect 
or presumptive evidence of gastric or duodenal ulcer and may be merely 
reflex manifestations of disease in other portions of the gastrointestinal 
tract, simple hyperacidity, hypersecretion, erosions, or purely nervous 
conditions. They are nevertheless of considerable importance if sustained 
by other corroborative signs and symptoms or a very suggestive anamnesis. 

Spasm of the Pyloric Antrum. — The lumen of the pyloric antrum may 
be so reduced as to contrast strikingly with the pars media and cardiaca 
and serial roentgenograms may reveal a resumption of normal proportions 
during periods of relaxation or a persisting diminution of caliber in long- 
standing cases or those of persistent and extreme irritability. 

Spasm not only extends the period of emptying but delays the beginning 
of expulsion which should commence immediately following the ingestion of 
the bismuth meal. This results in a six, eight, ten or even twelve hour residue, 
usually markedly exceeding in amount the residue of mere atony which is 
seldom greater than one-fourth of the total meal. In rare instances, how- 
ever, it may account for even a twelve-hour retention. 

The incisura is merely a slight spasmodic retraction of the circular fibers, 



GASTRIC AND DUODENAL ULCER 



919 



usually most marked at a point opposite the seat of irritation if due to ulcer. 
It may be fleeting or persistent, is often a mere indentation, but its impor- 
tance is in proportion to its persistence. 

Actual Pyloric Obstruction. — The benign type of pyloric obstruction is 
usually due to chronic ulcer (infiltration, scar formation and contraction) and 
is of excessively gradual production in most instances. This fact is of diag- 
nostic value within or without the field of roentgenology, for with a decided 
stasis and ectasia, i.e., a huge stomach with actual stasis, one is usually 
(not always) dealing with obstruction due to chronic ulcer, or adhesions. 
In new growth obstruction the stomach is usually relatively small, often of 
the steerhorn type. Furthermore in benign stenosis hypertrophy has taken 
place and peristalsis is likely to be very marked. The rule is only a general 
one, but is useful and usually borne out by the nature of the stasis as deter- 
mined chemically and microscopically. 

Post-pyloric (Duodenal) Ulcer. — When one speaks of "duodenal ulcer" 
to all intent and purpose he must mean ulcer of its first portion, which com- 
pose over 95 per cent, of the total and this tissue, as stated previously, is 
anatomically, embryologically, and, to a large degree, clinically, inseparable 
from the pyloric portion of the stomach. 

Roentgenologically the brilliant work of Lewis Gregory Cole has demon- 
strated the possibility of proving by serial roentgenography this portion of 
the gut " normal" or "diseased" in a large proportion of cases. By pains- 
taking work under his technic one may also demonstrate ulcer directly in 
many instances. Persistent failure of the stomach "cap" (Cole) to attain a 
normal outline means disease, if many confusing factors can be eliminated. 

It will suffice to say here that the demonstration of a wholly normal cap 
absolutely rules out any ulcer of the duodenum which represents anything more 
than erosion. 

Otherwise, aside from certain cases showing not only hyperperistalsis, 
which occurs in a considerable proportion of duodenal ulcers and in many 
other conditions, one must consider them merely as a variety of the juxta- 
pyloric ulcer already fully discussed. 

General Dyspeptic Symptoms. — These are more commonly associated 
with varying degrees of actual pain than is usual in other ailments. Because 
of normal or high acidity the digestion is normal or often more rapid than 
normal, the tongue relatively clean and the appetite usually good. Indeed 
true anorexia is an exceptional symptom in gastric ulcer, insufficient nutri- 
tion being ordinarily dependent upon the patient's dread of the pain and 
distress following the ingestion of food. 

Fever. — In cases of insidious obscure or wholly silent perforation which does 
not result in general peritonitis, a sluggish chronic fistulous abscess results in 
most instances. Any case combining suggestive symptoms with persistent low- 
grade fever should suggest ulcer as a possible cause, and such ulcers must be held 
in mind as possibilities in any obscure febrile case. 

Anemia. — The author feels that too little stress is laid by writers upon the 
frequency of obstinate or relatively intractable anemia and regards it as one of 



920 MEDICAL DIAGNOSIS 



the more important of the subordinate factors in diagnosis. It is probable 
that the anemia of gastric ulcer in some cases antedates the lesion, probably 
invites, and tends to perpetuate it. Whether antecedent or consequent, as 
the result of persistent or recurrent hemorrhage of varying degree, it assumes 
an intractable though not extreme type. 

Marked intractable anemia of the secondary type, in young persons, as- 
sociated with gastric disturbance and normal or high acidity is suggestive, and 
when accompanied by even minor degrees of persistent local pain and tenderness 
will justify the institution of medical treatment under a tentative diagnosis. 

The presence of an active irritable or infiltrating ulcer involving the 
pylorus or first portion of the duodenum tends to produce hyperacidity, 
hypersecretion, painful peristalsis, pyloro-spasm or true obstruction at the 
outlet. 

Such conditions yield signs and symptoms more or less complete, but 
usually sufficient to justify at least a tentative diagnosis of juxtapyloric ulcer 
and the institution of medical treatment. 

Simple hyperacidity is commonly temporary, intermittent, dependent 
upon known etiologic factors and usually lacks severe pain, localized ten- 
derness and hemorrhage. 

CERTAIN PRINCIPLES BASIC IN DIAGNOSIS.— From a study of 
the diagnostic factors as set forth in the preceding paragraphs and under 
Roentgenology it becomes obvious that certain facts of great value are 
fundamental in the diagnosis of gastric and duodenal ulcer. 

Primarily one must appreciate the fact that, in general practice, of iooo 
cases complaining of dyspeptic symptoms not more than 50 would show a 
gastric ulcer. On the other hand 700 or more would prove to be victims of 
asthenic ("nervous") dyspepsia. 

Hemorrhage constitutes a corroborative sign of value when present, 
greater when gross, massive, or merely visible, but very important even when 
manifested only by a positive thread test or the presence of occult blood in 
the stools or the gastric recovered content. Occurring initially in a case 
lacking a history of chronic intermittent dyspepsia it often constitutes the 
first sign of acute ulcer. Occurring unexpectedly in a case yielding a history 
of chronic painful " dyspepsia" intermitting or remitting periodically, it 
strongly suggests renewed activity in an old latent or sluggish ulcer. 

Pain. — The clinical significance of hemorrhage is greatly intensified if 
sharply circumscribed local tenderness or pain co-exists and, still more, if 
such pain bears a definite time relation to the taking of food, relatively con- 
stant for the individual affected, varying only with the amount and character 
of ingestae or the nature and degree of bodily activity following the meal. 

It is evident that the pain of ulcer may be that of direct irritation, attri- 
tion, food contact, stretching and contraction or compression of the affected 
area, extension of the necrotic process to sensitive tissues, or, the drag of 
adhesions. That in all save the wholly silent cases each of these factors, 
save the last, must play a part, and that in many all of them are involved is 
obvious. It is true, nevertheless, that in the case of the chronic infiltrated 



GASTRIC AND DUODENAL ULCER 92 1 

ulcers the most dominant factor is peristaltic activity. With this is combined 
that of hyperacidity and attrition in the case of all juxtapyloric ulcers, but 
to what degree these enter into the pain complex is difficult to determine. 

Anyone familiar with the phenomena of chronic sluggish or relapsing 
ulceration can readily understand the wide variations in the degree of pain 
or discomfort encountered which ranges from zero to that which may be 
termed fitly " atrocious" and it is equally easy to comprehend that in many 
instances direct surface irritation of any sort may be a trivial factor in pain 
production. In the case of acute ulcer this factor is of great importance 
at certain stages as is readily shown by the immediate painful effect so often 
produced by hot drinks, acids, and the like. 

The degree of surface irritability is no doubt largely determined by the 
particular stage of ulceration and the presence or absence of surrounding 
intense congestion or actual inflammation and a parallel doubtless is to be 
found in the varying pain response of an ulcerative stomatitis. 

Here also, however, we must deal with the question of peristalsis and this 
is true especially of acute juxtapyloric ulcerations. Acidity is less often 
excessive in these acute cases, but again recalling the varying but often 
exquisite sensitiveness of involved areas in stomatitis one can readily believe 
that excess of acid is not always necessary to a painful reaction. 

The administration of alkalis and the temporary partial or complete 
relief thereby afforded in most instances is only in part the direct effect of 
neutralization of acidity upon pain inasmuch as it secures also to a greater or 
lesser degree a diminution of peristaltic activity. On the other hand, it is 
well known that anesthesin and orthoform administered after an alkali will 
often reduce or abolish residual pain, whereas if given primarily and alone to 
the same patient little or no effect is evident in many instances. Their 
effect is largely that of a local anesthetic. 

Oil checks peristalsis and probably induces a periodic regurgitation of the 
alkaline duodenal contents. 

Circumscribed Pressure Tenderness. — Obviously the presence of this 
important though inconstant and occasionally misleading sign is dependent 
chiefly upon the acuteness of the ulcerative process, the depth of ulceration, 
the factor of irritability, per se, the presence or absence of adhesions, and the 
location of the lesion. It must be evident also that in many instances it may 
be wholly lacking or substituted by or associated with a diffuse tenderness 
clinically indistinguishable from that associated with asthenic dyspepsia, 
simple hyperacidity and hypersecretion, atony and other common gastro- 
intestinal disorders. When so diffused it loses all importance as an isolated 
symptom. When circumscribed it shows a peculiar fixity in location from 
day to day varied only by changes of posture or the phases of forced respira- 
tion in some instances. 

A point too little appreciated and emphasized is the fact that it may be 
present only at a specific interval after meals, corresponding to the period 
of maximal pain if this be a feature of the case, but manifesting sometimes 
the same periodicity in the absence of decided pain. 



922 



MEDICAL DIAGNOSIS 



Retention and Hypersecretion. — In juxtapyloric ulcers the factors of 
retention and hypersecretion are of cardinal importance and one readily 
understands that either pylorospasm, actual scar contraction or inflammatory 
tumidity may so interfere with the emptying of the stomach as to produce a 
condition of retention which in the case of organic obstruction may attain 
such proportion as to create ultimately a high grade of motor insufficiency 
and actual stasis of the benign type. 

Shortened Emptying Time. — Complete emptying of the stomach within 
two hours or less suggests achylia gastrica, duodenal ulcer and less often gall- 
bladder disease. According to the author's experience the stomach empties 
most rapidly in cases of achylia gastrica and in cases of duodenal ulcer well 
removed from the pyloric ring and associated with relatively low acid values. 
Hyperperistalsis is frequent in duodenal ulcer. 




Fig. 465. — Normal "cap." A, "cap;" B, sphincter; C, lumen of sphincter; 
genital fold; E,- terminal wave. (After Lewis Gregory Cole.) 



D, con- 



The hypertonic, "cowhorn" (steerhorn) stomach normally should dis- 
charge the standard bismuth meal completely in three hours. An ortho- 
tonic stomach of the "fish-hook" type carrying its lower pole at, or just 
above the navel usually is empty after four hours. If the pole lies below 
the navel the emptying time is usually increased to six or eight hours, or, by a 
period varying somewhat inconstantly with the degree of gastroptosis and 
latent or demonstrable atony or ectasia. In cases of demonstrable atony 
or atony and ectasia without actual pyloric stenosis the six-hour period 
may not be extended^decidedly, even in the presence of marked sagging and 
atony. An emptying time of twelve hours or more strongly suggests, and 
one of twenty-four hours or more, proves the existence of an organic obstruc- 
tion at the pyloric outlet. With respect to ulcer it is obvious that the 
question of induced pylorospasm and prolonged retention must largely 



GASTRIC AND DUODENAL ULCER 



923 



depend upon the proximity of the lesion to the pyloric ring and the activity 
or irritability of the involved area. 

A normal emptying time does not prove that ulcer is absent nor would 
one at this time accept Haudek's dictum that a retention period exceeding 
six hours is proof positive of an organic lesion of the stomach wall. 

The patient should not lie down during any tests for retention, unless 
for purposes of comparison. It should be remembered that a barium sul- 
phate meal requires much less time for complete expulsion than does that 
containing bismuth. 




Fig. 

Fig. 466. — Systole. 
Gregory Cole.) 

Fig. 467. — Diastole. 



466. 
A, "cap;" B, phincter; 

(After Lewis Gregory Cole.) 



Fig. 467. 
terminal wave 



(After Lewis 



Antiperistalsis. — The presence of antiperistaltic waves is a relatively 
common clinical phenomenon in stomachs distended by air or gas in the 
presence of organic obstruction at or near the pylorus and in connection with 
ulcer in the same region. Roentgenologically it is less often demonstrable 
under the use of the bismuth or barium meal, but its significance is the same. 

Ulcer with Adhesions. — The diagnosis of ulcer with adhesions depends 



924 



MEDICAL DIAGNOSIS 



largely upon the general symptoms of ulcer as stated, combined with those 
referred to adjacent organs and, sometimes, a sensation of dragging or pull- 




Fig. 468. Fig. 469. 

Fig. 468. — Postpyloric ("duodenal") ulcer. A, deformed cap; B and D, everted 
edges of ulcer; C, crater of ulcer. (After Lewis Gregory Cole.) 

Fig. 469. — Fleck of bismuth in crater of ulcer. (After Lewis Gregory Cole.) 




Fig. 470. — Ulcer on anterior wall of "cap." A, deformed "cap;" B, ulcer, seen full 
face. (After Lewis Gregory Cole.) 

ing experienced in certain movements or attitudes. Very often a tumor may 
be palpated, but many cases offer none but indefinite or misleading signs. 



GASTRIC AND DUODENAL II.CER 



925 



PERFORATION. — The symptoms of acute perforation into the free peri- 
toneal cavity arc those of sudden severe pain, and abrupt profound surgical shock, 




Fig. 471. — Post-pyloric ("duodenal") ulcer, non-obstructive, involving the sphincter. A 
"cap," deformed; B, ulcer; C, terminal wave (antrum). {After Lewis Gregory Cole.) 




Fig. 472. — Complete destruction of "cap" (first portion of duodenum). A, shows 
destruction of cap; B, terminal wave (antrum). (After Lewis Gregory Cole.) 

succeeded by symptoms of general peritonitis, and often, but by no means in- 
variably, occur in cases giving a clear history of ulcer. 



926 MEDICAL DIAGNOSIS 



Classification. — Complete perforation occurs in three forms, viz., 
i. The acute, as described above. 

2. The subacute, in which there may be less violent pain and a delay in the 
onset of peritonitis owing to primary limitation and secondary leakage into 
the peritoneal cavity. 

3. The Chronic Cases. — In perforating but contained cases not only may 
the symptoms of perforation be slight and ephemeral, but they may be 
wholly absent save in the form of a persistent or recurrent low fever. 

On the other hand, the violent symptoms of pain, shock and collapse in 
perforation into the general peritoneal cavity may be the first which suggest 
a chronic silent, slowly perforating ulcer, of years' standing. 

It is evident that gastric ulcer is not a single-symptom disease, but one that 
usually demands a careful grouping of probabilities and a thorough knowledge 
of all of the diagnostic factors involved. Xo doubt an immense number are 
overlooked and go on to spontaneous healing, certainly many exhibit hema- 
temesis or die of perforation without previous recognition. 

Having these facts in mind, the author believes that wherever any reason- 
able probability exists that a given case is one of ulcer, the physician should 
not wait for more light but should at once institute appropriate medical 
treatment. 

DIFFERENTIAL DIAGNOSIS.— Gastric erosions cause great dirfi- 
culty, but are in general to be distinguished by a more diffuse burning sensa- 
tion upon the taking of food, actual pain being as a rule, slight or absent. 

Pressure tenderness. is usually lacking and hyperacidity is the exception. 
The wash- water of the fasting stomach contains shreds of mucous membrane, 
but this may occur in other conditions. 

Finally, inasmuch as, aside from surgical intervention, which is distinctly 
contraindicated, a case of erosion demands much the same treatment as ulcer, it 
is not necessary to weigh too carefully those differential points which, the writer 
believes, must be taken cum grano salis, the points of distinction being less definite 
and absolute than are formally stated above. 

Gastric Hyperesthesia not only involves the whole stomach outline, but 
is associated with distinctive neurotic symptoms. 

Hyperacidity. — It is an extremely common condition, and in the absence 
of definite signs of ulcer, differentiation often proves impossible, but it must 
, be remembered that "hyperacidity " may accompany "asthenic " ("nervous ") 
dyspepsia, with or without marked atony, chronic constipation, hyperacid 
chronic gastritis, certain lesions of the appendix and gallbladder, rare in- 
stances of benign stenosis or early malignant growth, gastric syphilis, or 
mere lack of exercise and overeating. Fully one-third and, perhaps, one- 
half are associated with the stigmata of "congenital asthenia" and a nutri- 
tional deficit. 

In not more than one case in five of hyperacidity do we find ulcer, prepy- 
loric or postpyloric acute or chronic. In cancer it is rare, progressively dimin- 
ishing, and usually represents cases developing upon a preexisting ulcer. About 
one case in ten may be chargeable to the gallbladder or appendix. In one out 



GASTRIC AND DUODENAL ULCER 927 



of a hundred cases it may accompany benign pyloric stenosis. If, therefore, 
one were to make a diagnosis of ulcer upon the basis of existing hyperacidity 
he would be taking extremely "'long odds." It is convenient and proper to 
consider a free HC1 content exceeding 40, and a total of over 70, as 
representing "hyperacidity," although this amount of free acid or much 
higher values may produce no symptoms whatever, whereas lower values may 
excite them in other cases. 

The presence or absence of "hypersecretion" should be determined whenever 
possible. 

Hypersecretion. — The greater number of cases of hypersecretion represent 
motor defects of some degree and, indeed, this statement doubtless applies in 
a large degree to "hyperacidity." 

The sources and character of such defects are varied and the occurrence of 
either hyperacidity or actual hypersecretion is conditioned upon functional 
adequacy of the secreting glands. In congenital asthenia the structural 
conformation and functional and nutritional instability are ideally adapted 
to produce the two symptoms under consideration. In the gastric crises of 
locomotor ataxia and in ulcer upon the lesser curvature or just beyond the 
pylorus the element of obstructive spasm is clearly a factor quite apart from 
actual scar contraction or obstructive tumefaction in the ulcer cases. 

The element of spasm is undoubtedly the important one in reflex hyper- 
acidity or hypersecretion of disease of the appendix or gallbladder and 
in all the conditions mentioned heightened stimuli to secretion may be as- 
sumed. The occurrence of hyperacidity as a purely temporary and fleeting 
phenomenon in association with violent emotion or profound mental depres- 
sion is well known. To interpret recurrent periods of burning pain or dis- 
comfort, after eating, followed by intervals of entire immunity, as, of itself. 
constituting strong evidence of actual gastric ulcer is to raise to an exagger- 
ated level the commonest phenomena of functional gastric disorders. Such 
attacks coming on very late after meals or persisting over an interval of 
more than three or four hours, does at least suggest hypersecretion rather than 
mere hyperchlorhydria . This assumption is strengthened by the concurrence 
of late, and free, acid eructations ("water brash" . usually also a purely 
trivial and transient though troublesome phenomenon. 

Acute hypersecretion is due usually to spasmodic or organic narrowing 
of the pyloric outlet and copious vomiting of acid secretion in gushes and with 
little persisting nausea and in quantities wholly out of consonance to the 
stage of digestion and quantity of liquid intake is characteristic. * Such 
attacks may be transient, trivial and reflex but must never be accepted as 
such until an organic lesion of the nervous system or the gastrointestinal 
tract has been sought for and excluded. 

Chronic hypersecretion is evident if the fasting stomach contains fluid 
persistently exceeding in amount 25 or 30 c.c. and its significance depends 
largely upon its volume, the presence of free HC1. and the ratio of liquid to 



* The acid taste is important only as indicating the presence of acid. All normal 
gastric content is acid to the taste. 



928 MEDICAL DIAGNOSIS 



solids if the latter are present. The presence of visible food remnants proves 
retention from atony, spasm, or some form of actual pyloric obstruction. 

In other words, persistent hypersecretion represents chiefly motor defect 
and usually if not always a definite obstruction to outflow either organic or 
spasmodic. Furthermore the amount of fluid in the fasting stomach and 
the degree of hyperacidity increases in proportion to the grade and per- 
sistence of the obstruction and the amount of secondary atony and ectasia in 
all save the stasis induced by malignant growths in which acidity (free HC1) 
falls as obstruction, hypersecretion and retention increase. Continuous 
hypersecretion, i.e., the presence of an excess of gastric content in a fasting 
stomach is almost positive proof of ulcer, gall-stones, chronic appendicitis or 
disease of the intestines. In itself it strongly suggests but does not prove 
chronic ulcer. One of its most characteristic symptoms is epigastric distress 
upon arising in the morning. Hunger-pain or discomfort is of course pres- 
ent, but has been discussed sufficiently hitherto. 

Alimentary Hypersecretion. — This condition, a mere excessive amount of 
secretion attending the digestive* process, is of importance chiefly with rela- 
tion to asthenic dyspepsias and associated ptosis and atony of the stomach. 
The fasting stomach contains no excess of liquid and free HC1 is not of 
necessity present in excess. The relation of liquid to solid in a recovered test 
meal has been dealt with in another paragraph. The chief interest in this 
condition arises from the fact that the attacks of pain or discomfort resemble 
extraordinarily those of ulcer. Many cases are symptomless if acidity is 
low, nutrition well preserved, and no marked symptoms of nervous instability 
present. Severe attacks are so exactly like ulcer as to make differentiation 
impossible save in the presence of other distinctive signs and in many in- 
stances the patient's welfare may demand the institution of ulcer treatment. 
The condition is not a common one. 

Carcinoma of the stomach presents little difficulty save in the relatively 
rare achlorhydric "'ulcer" cases which almost always prove later to be early 
cases of malignancy. Those rare cases in which a carcinoma develops upon 
an old ulcer base may reveal more or less clearly and frequently the ante- 
cedent history of simple ulcer. 

The obstructive cases of gastric ulcer present the picture of benign stenosis 
elsewhere fully described, in striking contrast to that of the malignant form. 

With respect to early carcinoma, one of the chief factors in diagnosis is to be 
found in progressive persistent impairment of health and loss of weight together 
with steadily diminishing or wholly absent HCl values or actual achylia. 

The absence or presence of pain or even its character if existent is not dis- 
tinctive, though the dull relatively persistent character of the pain of cancer is, 
in general, suggestive. 

The pain of cancer is ordinarily less sharp and paroxysmal, and more con- 
tinuous, and the superficial or deep tenderness is usually slight or wholly 
absent. 

The roentgenologic evidence is conclusive in many instances. In many 
cases tentative treatment must be undertaken and the case judged by the 



GASTRIC AND DUODENAL ULCER 929 

relief of symptoms, improvement in nutrition and cessation of any bleeding 
which may have existed primarily. 

The infrequency of ulcer with very low HC1 values becomes a differential 
factor of considerable importance, and the age of the patient may aid the 
exclusion of malignant growth in young patients, though this factor must 
not be permitted to outweigh other important signs and symptoms. 

A palpable tumor makes its appearance in a large majority of the cancer 
cases and is usually solid and firm, whereas in ulcer, save in pyloric obstructive 
cases or where adhesion and perforation have occurred, if any tumor is felt 
on the wall it is usually thin and disc-like, representing the inflamed ulcer base. 

The nutrition suffers greatly in carcinoma and is associated with a striking 
persistence of symptoms, a progressive failure of strength and if not operated 
early the gradual development of the well-known cachectic appearance and 
morose facies. Hemorrhage is more consistently of the oozing type, appear- 
ing as " coffee-ground" detritus in the vomitus and stomach washings, and 
finally and most conclusively an analysis of the stomach contents reveals 
in most instances a total absence of free hydrochloric acid. In 60 per cent, 
or more lactic acid is present and in at least 90 per cent, the Boas-Oppler 
bacillus is demonstrable in large numbers in the stomach content or the 
stools. 

OPERATIVE CASES OF GASTRIC ULCER.— The tendency to perform 
radical surgical operations of the major type as a primary measure in gastric 
ulcer is to be deplored, and many such cases are undoubtedly those of simple 
erosion. Nearly every case even of true ulcer should first receive prolonged 
medical treatment and the knife be reserved for the obstinate, recurrent, persistently 
hemorrhagic, or perforative cases, for those associated with adhesions which tend 
to impair the health or persistently annoy the patient, or for actual pyloric 
stenosis and true hour-glass stomach* 

Closing Comment. — Surgical reports are valuable as showing the im- 
mediate mortality of operative procedure, but give only slight information 
as to the ultimate state of health of those operated. Medical reports are 
but little better. 

Autopsy records show so strong a tendency to multiple ulcerations 
(20 per cent, plus) as to make doubtful the entire adequacy of surgical 
excision. 

The general practitioner, especially, sees a host of " successfully " operated 
cases whose last state, months or years after, is infinitely worse than their 
first. 

The surgeon sees many cases of missed diagnosis on the part of the phy- 
sician, but with ready and confident recourse to the exploratory incision must 
still miss a considerable number and perform many futile and unnecessary 
operations. 

To balance fairly the present sins of medical omission against those of surgical 
commission is absolutely impossible. 

* One of the most eminent of American surgeons has stated recently to the author that 
he now operates primarily only upon perforated cases, "hour-glass stomach" and actual 
pyloric obstruction. 
59 



93Q 



MEDICAL DIAGNOSIS 



Occult blood. 



Causes 

unknown. 



To outline anything purporting to be an infallible formula for the diagnosis 
of gastric ulcer, with or without the knife, would be a futile and ridiculous 
procedure. 

We may only consider the typical picture which is reasonably clean-cut and 
definite save as to exact anatomic localization and set forth as clearly as may be 
the evidence which must be taken and sifted with respect to the many atypical 
forms. 

GASTRIC EROSIONS.— Under various conditions and influences, both 
local and remote, the gastric mucous membrane may show a surprising vul- 
nerability, and erosions are easily produced varying in size from that of a 
pin head to that of a lentil. Various names have been given to this condi- 
tion and Einhorn has described it as a separate disease; but in view of the 
fact that it may occur in the asthenic dyspepsias, in chronic gastritis, achylia 
gastrica, and, probably, as an early stage, in certain gastric ulcers, it should 
hardly as yet be dignified to that extent. 

Symptoms. — They may closely simulate the classic gastric ulcer with con- 
siderable or small hemorrhages, be entirely symptomless, or blend with the symp- 
tom-complex of the various diseases above mentioned. 

In those cases simulating clinical ulcer the pain is usually less intense than 
in typical ulcer, and comes on earlier, but may continue until the stomach is 
empty. 

Stomach washings may show tiny shreds of membrane, local tenderness is not 
marked and mucus is always present in excess in the vomitus or removed contents 
if a chronic gastritis is present. Diminution or even entire absence of 
hydrochloric acid is the rule. Occult blood in the feces and slight staining 
of the stomach washings are common findings. Under proper treatment re- 
covery is usually prompt though recurrences are common. 

Comment. — Differential diagnosis is important only as preventing un- 
necessary operations, as the medical treatment of the two conditions is almost 
identical. 

GASTRIC CARCINOMA 

Etiology. — Frequency and Predisposing Causes. — The stomach is more 
commonly the seat of cancer than any other part of the human body and 
50 per cent, of all cases of carcinoma in the male are gastric. 

Age markedly affects the ratio of incidence and the disease is largely one 
of the fifth (18 per cent.), sixth (28 per cent.) and seventh (28 per cent.) 
decades. About 8 per cent, occur during the fourth decade and 14 per cent, 
in the eighth. Such growths are rare between the ages of twenty and thirty 
(1.5 per cent.) but are always possible.* 

Sex. — It is slightly more frequent in males than in females and heredity 
is a factor of some slight importance. 

* The author recalls a serious and humiliating early blunder due to the fact that the 
extreme youth of the patient (fifteen) made him loath to accept what should have been 
regarded as positive evidence of malignant growth. 
At this age it is one of the rarest of diseases. 



GASTRIC CARCINOMA 



931 



It is wholly probable that the scar of preexisting gastric ulcer may, in 
rare instances, undergo malignant change.* 

The frequency of such a transformation as stated by modern writers 
varies from a fraction of 1 per cent, to 71 per cent.f The higher figures have 
gained only slight credence and the present consensus of opinion places its 
incidence at about 2.5 per cent. 

Traumatism seems in rare instances to be a factor and some authorities ; 
lay much stress on mental worry or strain and even upon the habitual use of 
hot drinks, but it is probable that these conditions exercise little influence. 

Varieties and Preferential Sites. — Cancer of the stomach is almost always 
primary though, rarely, secondary to cancer of the pancreas, esophagus, and, 
yet more rarely, the breast, uterus or other organs. Tlie most common form 
is the cylindrical-celled adenocarcinoma. Encephaloid is next in frequency, 
then scirrhus and colloid. 

Malignant growths of the stomach are frequently the source of metastases 
in their advanced stages. In nearly 80 per cent, the tumors develop between 
the orifices on the lesser curvature and at the pylorus. In the latter situa- 
tion they tend to cause early obstruction and, sometimes, dilatation. Growths 
at the cardia are next in frequency, are often associated with gastric atrophy 
and occasionally with marked esophageal distention and obstruction. The 
stomach may be greatly displaced in the case of pyloric growths, and adhe- 
sions may obscure and complicate the clinical picture. Such tumors are 
ordinarily, however, freely movable and in rare instances may be found in 
almost any part of the right half of the abdomen. 

Symptoms. — Cases may reach an advanced stage of development without 
producing any recognizable symptoms save those made evident by examination 
of the stomach contents, but, ordinarily one finds: 

(a) Dyspepsia. Eructations, pressure, heavily coated tongue, and foul 
taste in the mouth. 

(b) Progressive loss of weight unrelieved or but temporarily improved by a 
period of absolute rest and careful feeding. 

( c) Marked progressive impairment of strength and endurance. 

(d) Pain. — Usually dull, boring, and somewhat persistent. This symp- 
tom is present in 90 per cent., but is sometimes wholly absent in all stages 
(12 to 20 per cent). Usually epigastric, it may be referred, especially if 
adhesions exist or if the stomach is greatly displaced, and in rare instances it 
may be severe and spasmodic. 

Pain in the left upper or even in the lower quadrant is encountered 
occasionally. % 

* This was asserted by Cruveilhier, who first described gastric ulcer, and by Rokitansky 
in 1835. Later it was discussed by Brinton, Leube, Lebert, and especially worked out by 
Hauser in 1883. 

fL. B. Wilson and McCarthy, Amer. Jour. Med. Sci., Dec, 1909. 

% As in the case of the perigastritis of ulcer, the increase of pain on walking, deep breath- 
ing, strongly indrawing the abdomen or changing from the erect to the recumbent posture 
suggests peritoneal involvement. 



Usually 
primary. 



Types. 



Sites. 



Dislocation 
and adhesion. 



Seldom 
severe. 



932 



MEDICAL DIAGNOSIS 



Usually 
moderate. 



May be 
extreme. 



Resists 
treatment. 



Indicant and 
diazo. 



A terminal 
symptom. 



Common 
symptoms. 



Seldom 
lacking. 



Macroscopic. 



One must not forget that accession of pain following the ingestion of food 
and amelioration of such distress by alkalis may be present in 25 or 30 per 
cent, of cancer cases. 

Immediate pain upon taking food usually points to a cancer at the lower 
extremity of the esophagus. 

Persistence of pain under a short course of ulcer treatment is most suggestive 
of cancer. 

Associated tenderness may or may not be present and is usually not 
sharply delimited or extreme. It is most marked usually in the right epigas- 
trium and may be accompanied by sensitiveness in the lower dorsal region. 

(e) Anemia. — At first moderate but progressive, this may later become 
extreme, though usually preserving a definite secondary type (see "Anemia"), 
but advanced ulcerative cases show at times extreme grades closely simulat- 
ing the anemia of atrophic gastritis or pernicious anemia itself and it is more 
or less characteristically resistant to treatment. Leucocytosis is usually 
present in metastasis, or rapid ulceration. 

(/) Fever. — Fifty per cent, of the advanced cases are accompanied by a 
moderate fever of the hectic type, in rare instances associated with "chill 
and fever," due probably to septic absorption from an ulcerating surface. 

(g) Urinary Signs. — The only important urinary findings are indicanuria 
which is usually present to a marked degree, and the diazo-reaction, as 
reported by the author, in certain advanced cases. 

(h) Cardiac Weakness. — Marked cardiac weakness and edema of the lower 
extremities are usually terminal symptoms. 

(j) Anorexia. — This is usually marked and often associated with a some- 
what significant repugnance to red meat. 

It may be an early and very important symptom. 

(j) Nausea. — This is present in a great majority of the cases and may be 
extremely persistent and troublesome. 

(k) Vomiting. — A symptom present in 90 per cent, of the pyloric cases 
and occurring usually one or moire hours after meals. It is ordinarily oc- 
casional, early and irregular, but may be frequent or very rarely almost con- 
tinuous, tending to rapid exhaustion and death. 

Only in rare instances does it show the individual periodicity of ulcer. 

The relief afforded by vomiting is seldom complete and may even increase 
any preexisting pain or initiate the symptom. 

Evidence of the first statement is found in the relative rarity of self- 
induced vomiting in cancer cases, as compared with those of ulcer, simple 
hyperacidity or hypersecretion. 

In a surprising number of the author's cases the disease has been initiated 
by vomiting attacks resembling those of acute hypersecretion or gastro- 
enteritis. 

(I) Hemorrhage. — In from 20 to 30 per cent, there is recognizable hemor- 
rhage and it undoubtedly occurs in a much larger portion. Oozing is the 
more frequent form and in all cases of suspected cancer of the stomach, the 
stools should be examined as well as the vomitus and stomach contents. 



GASTRIC CARCINOMA 



933 



Bright red arterial blood in the vomitus is unusual, it being ordinarily in 
small dark grumous clots or "coffee-ground particles." 

Occult blood is a peculiarly constant finding in gastric carcinoma (90 per 
cent, on repeated examinations). 

(m) Cachexia. — In advanced cases the skin is pale, yellow, inelastic and 
ill-fitting, because of anemia, malnutrition and loss of weight, and often 
shows areas of pigmentation or pigment atrophy. A curious earthy pallor 
is often present and is more or less characteristic, and, quite as striking, is the 
peculiar facial expression often encountered in these cases, the patient ap- 
pearing saturnine, anxious and depressed. 

00 Tumor. — A palpable tumor may be found ultimately in about 80 per 
cent, of the cases, may occupy almost any part of the right upper quadrant 
and either be freely movable or attached by adhesions. Tumors of the cardia 
or pylorus, if so fixed, may be entirely obscured by the ribs and liver, respec- 
tively ; tumors of the fundus are less movable in respiration than are those of 
the pylorus. Examination both when the stomach is full and when it is 
empty should be the rule and immersion in the warm bath, or even narcosis, 
may be necessary. Tumors of the cardia with rare exceptions produce a 
stenosis readily recognized by the tube or esophageal bougie. The liver 
surface and margin should in all cases be carefully examined for the presence 
of metastatic nodules. 

Stomach Contents. — To obtain the stomach contents one should thor- 
oughly wash out the stomach in the evening and give a retention meal, 
followed by a test breakfast if desired the following morning, and should use 
a Boas test meal, or the shredded wheat breakfast. The preliminary washing 
may show an excessive quantity of fluid or give evidence of imperfect diges- 
tion, impaired motility and pyloric obstruction with stasis and fermentation.* 
On the other hand, pyloric incontinence or duodenal stenosis may be indicated 
by the persistence of excessive quantities of bile. 

Chemical Findings. — Hydrochloric acid is rarely present in any consider- 
able quantity. It is probable that most of the rare cases in which high per- 
centages of free hydrochloric acid are found have their origin in an old ulcer 
base or scar and in such cases a progressive diminution is of diagnostic 
significance.! 

The ferments vary pari passu with the HC1 but usually are entirely absent 
or greatly reduced. Lactic acid is usually present in quantity if stenosis 
exists, t 

Microscopic Findings. — The microscope may reveal fragments of growths 
and evidences of hemorrhage, the Boas-Oppler bacillus in great numbers if 

* Substances are sometimes retained for many days as was the case with a segment of 
orange brought in by a patient under the impression that it was a cyst, its residence in 
the stomach having completely changed the appearance of the undigested food. 

t B. Moore, Lancet, p. 11 21, 1905, reports gastric subacidity or anacidity in two-thirds 
of all cases of cancer affecting other organs, confirming that of the elder Fenwick. 

J Estimation of the albumin contained in the normal saline solution used for washing 
the previously emptied and washed stomach involves too much handling, as it is present 
only in ulcerating carcinomata or occasionally in gastric ulcer. 



"Coffee 
grounds." 



Wasting. 
Pallor. 



Location. 



Source of 
error. 



General 
findings. 



HC1 absent. 



Lactic acid. 



Boas-Oppler 
bacillus. 



934 



MEDICAL DIAGNOSIS 



and achlorhydria co-exist and the significant absence or sparseness of 
yeast fungi or sarcinae. 

Early Diagnosis. — This is of cardinal importance in the light of modern 
surgery and the following points are helpful: 

i. Anorexic amounting to loathing may be an early symptom, 
but is common also in simple atony and certain asthenic functional 
dyspepsi 

2. .4 persistent subjective or visible distention unaffected by dietetic 
restriction. 

3. Vomiting when present procures but little relief to any existing pain. 

4. Failure to regain weight under rest and feeding, an extremely important 
symptom. 

5. Progressive loss of strength is another symptom of great importance. 

6. Onset of symptoms, usually supen-ening upon a good, or fairly good, 
iigest ive record. This is said to be the exception by some surgical authorities, 
but the author's experience agrees with that of most internists in support of 
the general statement. 

An abrupt but persistent gastric upset has been the first definite disturb- 
ance recognized by the patient in some instance s 

7. Persistence of pain under rest and a bland diet. 

8. Persistence of occult blood under same conditions. 

9. Peculiar persistence of any existing epigastric discomfort. 
Differential Diagnosis. — The following facts should be borne in mind, viz., 

that in chronic gastritis, the hydrochloric acid may be diminished or absent 
and the ferments more or less inactive, but in this disease lactic acid is not 
7 resent, pain is absent or slight, hemorrhage does not occur except in connec- 
tion with simple erosions or cirrhosis of the liver, emaciation is seldom as early, 
progressive or extreme, and a tumor is not to be found. 

In achylia gastrica, hydrochloric acid, lactic acid and the ferments are 
absent, there is usually no pain or hemorrhage and never tumor. Emaciation 
is usually not marked or progressive until the condition has lasted for long 
periods and symptoms usually are readily relieved, though occasional excep- 
tions occur. 

In gastric ulcer, hydrochloric acid is usually in excess, less often normal, 
rarely km . 1 absent, lactic acid is usually absent, ferments are normal, 

emaciation is ordinarily less extreme and decidedly less persistent than in cancer, 
and a tumor is absent save in the rarer instances when one may feel the infiltrated 
base of an ulcer, a thickened pylorus or a mass of adhesions. 

In such cases one may encounter both obstruction and stasis but the benign 
character of the latter is established readily. 

Ulcer has only pain and hemorrhage in common with carcinoma. Its hemor- 
rhage is usually arterial, its pain more paroxysmal, directly related to the tak- 
ing of food, and usually marked or completely relieved by emptying the 
stomach or by the ingestion of bicarbonate of soda. Cancer occurs somewhat 
more frequently in the old, ulcer more frequently in the young. 

tally. — The diagnosis of cancer must rest chiefly upon the presence and 



GASTRIC CARCINOMA 



935 



group value of some or all of the following symptoms, viz.: persistent anorexia; 
intractable, progressive, dyspeptic symptoms, especially in middle-aged and in 
elderly people; the presence of lactic acid in excess after a shredded wheat test 
meal preceded by lavage; stasis and fermentation with achylia; evidence of hemor- 
rhage; Boas-Oppler bacilli in quantity; persistent anorexia, early and progressive 
loss of strength; emaciation, and tumor. 

Vomiting is an inconstant symptom and is usually late and the same state- 
ment applies to the presence of lactic acid, the Boas-Oppler bacillus, and in 
less degree, to the achlorhydria. 

Pain. — Actual pain is likely to be a late symptom, but is seldom wholly lack- 
ing and a persistent distress is both usual and significant. 

It bears a much less constant relation to food ingestion and ejection or re- 
moval of the stomach contents, than is the case in ulcer. 

The evidence of the X-ray is often either conclusive or extremely suggestive 
and it should be remembered that actual stenotic stasis and fermentation with 
absent hydrochloric acid, Boas-Oppler bacilli, constitute a practically pathogno- 
monic group, subject to only rare exceptions. (See also "Roentgenology.") 

As compared with benign stenosis the stomach is often small and seldom 
attains either the degree of ectasia or the vigor of peristalsis seen in simple 
chronic obstruction. 

Every case of suspected carcinoma should if possible undergo a short course 
of antiluetic treatment; all, a Wassermann and a luetin test. 

Syphilis of the stomach is more frequent than had been supposed prior to the 
introduction of these specific tests. 

Consistently early, absolute, diagnosis is impossible save by some purely 
fortuitous circumstance. Timely diagnosis, from the present surgical point of 
view, is less exacting but will probably prove disappointing in end results of 
operations. In all cases one must seek to find and combine as many symptoms 
as are ascertainable. 

The author depends chiefly upon the X-ray findings, anorexia, persistence of 
pain and dyspeptic symptoms despite treatment, weight loss and weakness resist- 
ing rest and dietetic management, diminishing or absent HCl and retention of 
food remnants, all these occurring at the cancer age. 

Coexistence of anorexia, persisting pain or painful distress, blood, and low 
ECl values is a combination of importance. 

One cannot exact even this complex in its entirety and make early diag- 
noses — a mere strong probability often justifies exploratory incision. 

The Abderhalden test has been proven worthless whether as a test for 
cancer or for pregnancy by the complete and exhaustive work of D. D. Van 
Slyke and associates at the Rockefeller Institute. The many other tests 
assumed to be relatively or actually specific, also have fallen by the 
wayside. 

GASTRIC CRISES. — Lightning-like attacks of agonizing cramping epi- 
gastric pain, associated violent vomiting, at first of but a few minutes 
duration, later persisting for hours, or days, separated at first by long inter- 
vals, but progressively increasing until for a period of weeks they may occur 



Tabes. 



Variations. 



936 



MEDICAL DIAGNOSIS 



Three cases. 



daily, are characteristic of tabes dorsalis in most instances* and may con- 
stitute the first symptom. 

The recession is usually as abrupt as the onset, but unusual cases are en- 
countered in which the pain is absent from the complex or the critical ter- 
mination may be replaced by slow tedious improvement. 

Intestinal and rectal crises of much the same type also occur. As an early 
symptom it is rare but important and would be extremely difficult to place 
in the absence of tabetic symptoms because of its resemblance to many other 
conditions. Proof of syphilis and the increasing frequency and duration of 
the apparently causeless attacks combined with their dramatic suddenness 
of onset and recession are valuable suggestive factors in differential diagnosis. 

The Deep Reflexes. — The loss or marked disturbance of tendo achillis response 
and the knee-jerks will almost invariably precede the true crises and with rare 
exceptions no error is possible if the examination, includes these tests, as every, 
examination of a patient should. 

SPASTIC SPLANCHNIC ABDOMINAL CRISES.— Frequent attacks of 
severe paroxysmal pain of brief duration (fifteen to thirty minutes) in- 
duced by exertion or emotion and frequently by the recumbent position, 
if occurring in men past forty, suggests spasm of the splanchnic vessels, 
hypertension or cardiac angina with predominant epigastric localization. 
The aortic region is usually tender and another type is actually combined 
with true angina pectoris. The attacks may show the same tendency to 
progress over a period of many years as is the case in tabetic crises, but 
are more frequent, less sudden in onset and recession and lack the gastric 
disturbance. The age, the presence of arteriosclerosis and hypertension, 
the lack of relation to meals or constant gastric findings should suffice to 
exclude ulcer. Max Buch claims that the relief afforded by diuretin, 3 to 4 
grams and tincture of strophanthus, 15 to 24 minims daily, is of diagnostic 
importance.! 

SYPHILIS OF THE STOMACH.— At the period of general infection 
dyspeptic symptoms are not uncommon, though usually indeterminate or 
taking the form of hemorrhagic erosions due to specific endarteritis. Gastric 
syphilis is by no means as uncommon as formerly supposed and, clinically, 
may be represented by diffuse gastritis, ulcer, gumma, diffuse pyloric infil- 
trations, or by gastric adhesions, and hence may resemble simple chronic 
gastric catarrh, ectasia, erosions, ulcer or carcinoma. 

Three- particularly interesting examples may be quoted from those which 
have come under the author's observation. In one, an extremely puritanic 
old gentleman, of seventy, there was a palpable pyloric tumor, stenosis with 
marked dilatation, extreme gastric intolerance, tenderness and emaciation. 
The cause was suggested by Hutchinsonian teeth in a daughter. 

* Similar crises may be encountered in developed spinal paralysis, multiple sclerosis, 
morphinism, lead colic, etc. 

f These attacks may be entitled to separate and specific description, but as stated 
previously, the personal experience of the author has not convinced him that they differ 
often in significance frcm ordinary angina pectoris with epigastric pain maximum. 



THE FECES 937 



Another was a steeple climber, formerly a sailor, of thirty-five, who pre- 
sented a flat, definite and exquisitely tender area in the left epigastrium 
and atrocious paroxysmal pain. The third was a young man of twenty-seven, 
who presented the clinical symptoms of malignant pyloric stenosis. In all 
three specific medication promptly relieved the pain and resulted in complete 
disappearance of all symptoms. 

Excessive pain and tenderness with signs of carcinoma were the prominent 
features and in all the evidence of past syphilis was directly or indirectly 
adequate to justify a diagnosis. Coffee-ground vomitus w r as present in the 
first and third. The first and second cases were remarkable because of the 
palpable tumors. 

Whenever possible, a brief intensive course of antisyphilitic treatment 
should be instituted in all doubtful cases of the ulcer or carcinoma-like types, 
as a part of the diagnostic procedure. 

A Wassermann or luetin test also should constitute a part of the procedure 
in appropriate cases, but negative results should not halt the tentative ther- 
apy, which, moreover, will often enable one to avoid the raising of the ques- 
tion of lues in sensitive patients. 

TUBERCULOSIS OF THE STOMACH is so rare as a primary disease 
as to be a clinical curiosity. Secondary lesions are common in pulmonary 
tuberculosis. The signs of ulcer, the presence of the tubercle bacillus and the 
preexisting disease in secondary cases make the diagnosis. 

CONGENITAL STENOSIS OF THE STOMACH.— This interesting 
condition has been reported sufficiently often by reliable observers to entitle 
it to a definite place in clinical medicine. Its symptoms are vomiting, con- 
stipation, dilatation, increased peristalsis and, in most instances, palpable 
tumor representing the thickened pylorus. In some instances a tumor has 
not been felt and in a recent case (McCaw and Campbell) the obstruction 
was apparently due to redundancy of the mucous membrane with obstruct- 
ing folds, a condition encountered, very rarely, in adults. 

THE FECES 

Lines of Investigation. — Careful inquiry should be made as to antecedent 
diseases, especially dysentery, typhoid fever and appendicitis, and in the case 
of the latter often necessitates a careful cross-examination covering the 
actual symptoms present in w r hat may have been misnamed attacks. 

As in disease of the stomach, the habits of the patient as regards smoking, 
drinking, meal hours, the time consumed at meals, character of the diet, and the 
condition of the teeth are important. 

The character of the stools demands attention. Their consistence, size, 
number, form, quantity, color and the admixture of mucus or blood are the 
chief features. 

The presence of constipation, diarrhea or pain and the relation of the two 
latter to meals or a fasting period should be thoroughly gone into. In mak- 
ing inquiry concerning constipation it is best to ask w r hether the bowels move 



933 



MEDICAL DIAGNOSIS 



Suggestive 

types. 



daily without medicine. In the case of diarrhea one should know whether it 
is nocturnal or diurnal and induced or increased by mental excitement or 
emotion. In certain forms the loose stool invariably follows a meal. 

Finally it should never be forgotten that the stomach may be at the bottom of 
the intestinal disturbance. (Late achylia gastrica and chronic gastric catarrh, 
hyperchlorhydria, etc.) 

Clinical Significance of Abnormal Findings.— .4 bsence of HCl and the gas- 
tric ferments is suggested by defective conversion of gluten and connective 
tissue. 

Pancreatic inadequacy leads to the imperfect conversion of both proteins 
and fats. Absence of bile will result in faulty digestion of the fats without 
of itself affecting protein conversions. 

Normal Content. — Normally the stools consist of food remnants digested 
or undigested, fatty acids, epithelium, salts, mucus, bacteria, which consti- 
tute nearly one-third of the weight of the normal stool and represent 48 
species, and traces of the digestive fluids. 

The color depends upon the diet and is normally light brown or brownish 
yellow, because" of the presence of hydrobilirubin, being darker on meat diet, 
light yellow on milk diet or in conditions where the usual bacterial decompo- 
sition processes are temporarily absent and bilirubin is present unchanged. 
Certain drugs, as iron and bismuth, produce a black stool; senna, rhubarb, 
santonin and calomel a greenish-yellow tint; certain fruits a reddish or black 
color. When bile is deficient a putty or clay-colored stool results as in ob- 
struction of the common duct in gall-stones or catarrhal jaundice. A very 
similar stool due to a failure of fat absorption may be encountered in pan- 
creatic disease or a tubercular peritonitis. 

Form. — In prolonged constipation and in certain forms of chronic obstruc- 
tion or atony, balls or other scybala may be encountered of various forms 
and sometimes grooved by intestinal folds . The "goat droppings "' aggrega- 
tions are encountered especially in spastic constipation. The pipe-stem or 
ribbon-like stools when persistent, suggest but do not prove organic obstruc- 
tion in the terminal portion of the lower bowel and may also be present in 
spastic constipation or cases of channeled fecal impaction. 

On the other hand, all grades of liquid or semi-liquid stools may be met 
with in the diarrheas; such as the so-called "pea-soup'' stool of early typhoid 
or the brilliant ochre liquid of the later stage and the peculiar rice-water 
stools of true cholera and cholera nostras. 

Food remnants consist chiefly of undigested vegetable matter; never, 
macroscopically, of meat, save in the serious intestinal diseases. 

Blood from the lower bowel lies usually on the surface of the stool. It is 
usually red, if from the rectum . and even if darker and of higher origin in the 
bowel, is not usually coagulated. 

In such cases '''piles'' or fissure should be looked for and, if absent, atten- 
tion is at once demanded by the segments higher up; carcinoma, polypi, or 
ulcer, being suggested. 

Blood from the stomach or upper bowel is incorporated with the stool 



THE FECES 939 



and usually presents a "tarry" appearance but it should be remembered that 
in diarrhea these distinctions of color may in part be lost. 

Mucus may appear as a membrane (mucous colitis or enteritis); as an 
envelope, covering the stools; in long strings or spawn-like masses; or inti- 
mately mixed with the feces (catarrhal enteritis). 

Pus if present proves a lesion of the lower bowel and fragments of tumor may 
yield information of value. Intestinal parasites are considered elsewhere. 

Collecting the Specimen. — The simplest method consists in the use of 
one of the covered receptacles which can be placed within and rest upon the 
basin of a water-closet or directly under the patient lying in bed. These can 
be procured with a removable wire screen which is useful in washing the stools 
for concretions. As an emergency measure any receptacle may be used and 
for a sieve one may employ ordinary mosquito screen fastened to an extem- 
porized hoop. 

Microscopic Examination. — The portion to be examined is prepared by 
adding a small amount of physiologic salt solution and a few drops of 1 per 
cent, formalin solution. 

If one has excluded or completed the examination of living organisms 
turpentine may be used to cover the specimen under the microscope and thus 
avoid odor. 

Normally the appearance varies with the diet. In ordinary mixed diet 
there are various vegetable cells, usually characteristic; free starch granules 
are, normally, absent, but if present are readily demonstrated by a drop of 
Lugol's solution. Their presence is pathologic for, normally, only starch 
enveloped in cellulose should be present. 

Meat fibers in small numbers may be recognized, as may elastic and con- 
nective-tissue fibers, and indicate impaired or absent gastric digestive agents. 
Oxalate of lime and fatty acid, calcium carbonate and calcium and ammonio- 
magnesium phosphate may be present in characteristic crystals. 

The Char cot-Ley den crystals occur in pulmonary tuberculosis, typhoid 
fever, dysentery, and with intestinal parasites. Ruby-red or orange-yellow 
rhombic plates of hematoidin, or its amorphous forms, may be present in 
hemorrhage or severe catarrhs. 

Fat may also be present as characteristic highly refracting globules, and 
both fat and fatty acid crystals are increased in diseases of the liver or pan- 
creas, and in acute enteritis. 

Blood cells may be present if the bleeding originates in the lower bowel, 
and pus corpuscles if there be an ulcerative process or discharging abscess. 

Tumor fragments, mucin threads, and the large variety of bacteria may 
beiound, most important of which pathologically are the Boas-Oppler bacillus, 
the colon bacillus, and the tubercle bacillus. 

The Boas-Oppler bacilli are extremely plentiful in the stools of most 
patients suffering from established stenotic gastric carcinoma, a fact of value 
when a patient is not fit for the use of the stomach tube.* 

* Bassler also points out the value of a smear taken from the back of the tongue in such 
cases as have been vomiting. 



Sieves. 



94° MEDICAL DIAGNOSIS 



SCHMIDT'S METHOD.— A formal and extended examination of the 
feces is ordinarily too exacting and time-consuming for the general practi- 
tioner, but one of the simplest methods is here given for the sake of 
completeness. 

Test Diet. — This, as given by Schmidt, outlines the following procedure: 

In the morning: 0.5 liter milk [or, if milk does not agree, 0.5 liter cocoa 
(prepared from 20 Gm. cocoa powder, 10 Gm. sugar, 400 Gm. water, and 100 
Gm. milk)], to this 50 Gm. zwieback. 

In the forenoon: 0.5 liter oatmeal gruel [made from 40 Gm. oatmeal, 10 
Gm. butter, 200 Gm. milk, 300 Gm. water, 1 egg (strained)]. 

At noon: 125 Gm. chopped beef (raw weight) broiled rare, with 20 Gm. 
of butter, so that the interior will still remain raw, to this 250 Gm. potato 
broth (made of 190 Gm. mashed potatoes, 100 Gm. milk, and 10 Gm. butter). 

In the afternoon: as in the morning. 

In the evening: as in the forenoon. 

This diet thus consists of: 1.5 liters milk, 100 Gm. zwieback, 2 eggs, 50 
Gm. butter, 125 Gm. beef, 190 Gm. potatoes, and, as gruel, 80 Gm. oatmeal. 
It contains about: 102 Gm. albumin, in Gm. fat, 191 Gm. carbohydrates, 
or a total of 2234 calories (raw calories). The test is generally given for 
three days, until a stool is obtained which represents the test diet. 

Steele's Method. — Breakfast. — Two eggs, one-third of the amount of 
toast and butter, two glasses of milk, oatmeal with milk and sugar. Dinner. 
The steak and potatoes, one-third of the amount of toast and butter, one and 
one-half glasses milk. Supper. Two glasses of milk, remainder of toast and 
butter, one or two eggs if desired. 

Initiation of Tests. — These' test meals need be given for only two or three 
days, a capsule (0.3) carmin being given with the first meal. The appearance 
of the dye in the stool determines the beginning of the examination and 
serves to measure the time of passage. 

One then proceeds to determine consistence, color, and odor and reduces 
the feces to a liquid form in a mortar with distilled water. The ordinary 
blacked plate or a Petri dish placed over a black background then facilitates 
the examination. 

Macroscopic Findings. —Normally there should be nothing except the 
indigestible oatmeal hulls and sago-like particles of potato. 

Pathologically one may find: {a) Mucus appearing as glassy flakes some- 
times stained yellow, (b) Remnants of potato the resemblance of which to 
mucus may require the microscope for differentiation, (c) Remnants of mus- 
cle fiber indicating impaired intestinal ferments, absence of enzyme (entero- 
kinase) or abnormal motility, (d) Crystals of magnesium and ammonium 
phosphates indicating fermentation, (e) Connective-tissue remnants differen- 
tiated from mucus by their yellowish- white color and their toughness. (/) 
Pus or blood, (g) Parasites, (h) Concretions, (i) Foreign bodies. 

Microscopic Examination. — The microscopic examination merely con- 
firms and somewhat amplifies the findings mentioned in the foregoing paragraph. 
It is recommended that three special mounts be made: (1) A drop of the 



THE FECES "* 941 



prepared material. (2) Same + acetic acid. (3) Same as No. 1 + a drop 
of dilute Lugol's sol. (lodin 1, potas. iodide 2, water 50). 

No. 2 is heated to boiling before covering and upon cooling will show fatty 
acid crystals set free by the acetic acid; if reheated these will form droplets. 
No. 3 shows the violet-blue reaction of potato cells and certain spores. 

Chemical Examination. — The chemical examination consists of three 
routine tests: (1) The reaction, obtained by dropping the prepared material 
into a few cubic centimeters of dilute aqueous litmus solution. 

(2) The sublimate test. (Equal parts of the prepared material and a sol. 
of mercuric chloride (25 per cent.) should strike a pinkish-red color indi- 
cating hydrobilirubin.) Unchanged bile pigment yields a green color and 
is pathologic. 

(3) The fermentation test. Five cubic centimeters of formed feces, or 
its equivalent if liquid, are prepared with sterile water and poured into the 
bottle of Strasburger's instrument or the simple and easily cleaned modifica- 
tion of Steele which can be made by anyone.* 

The tube surmounting the bottle is filled with water, the parallel tube 
remaining empty. If kept at blood heat for twenty-four hours, gas will rise 
and displace the water in the first tube, forcing it into the outer parallel tube 
whose air finds an outlet through the longer inner tube; thus the amount of 
water displaced is a measure of the amount of gas formed. One-third dis- 
placement is distinctly pathological. Albuminous putrefaction is indicated 
by a foul smell and alkaline reaction, carbohydrate fermentation by 
acidity. 

Inferences from the Tests. — Color. — A pink color reaction in the case 
of the sublimate test (test 2) is normal; the green indicates increased motility; 
absence of any color, a fat stool or absence of bile. 

Meat Remnants. — Whether of muscle or connective tissue and even if 
microscopic, an excess of either is pathologic. In the case of connective tissue, 
deficient gastric digestion is indicated or excessive gastric motility. In the 
case of the muscle the digestive trouble is probably intestinal. 

An excess of fat merely indicates deficient digestion of that material, but 
suggests hepatic, pancreatic or intestinal disease; fermentation means either 
poor starch digestion or intestinal disturbance. 

Albumin fermentation, indicates either deficient gastric or intestinal diges- 
tion or increased motility. 

Value of Results Obtained. — As a matter of fact it may be stated, with 
regret, that up to the present time the amount of information gained is too slight 
to compensate the busy practitioner for even the small amount of time necessarily 
consumed. Nothing but constant practice will suffice to establish proper 

* The materials needed are a large-mouthed medium-sized bottle carrying a rubber 
cork, perforated by a glass tube. Two test-tubes are prepared each having a rubber cork 
with two perforations. Both are inverted and connected by a U-tube the extremities of 
which project slightly above the inner surface of the cork, one is then pressed down over the 
vertically projecting tube of the bottle and holds the other tube parallel with it by virtue 
of the connecting U-tube. Test-tube No. 2 is fitted with a small glass tube which goes 
nearly to the top and projects below. 



942 



MEDICAL DIAGNOSIS 



Site. 



Etiology. 



Source of 
error. 



Appearance. 



Fecal masses. 



standards representing the normal and the abnormal and, finally, proteid 
fermentation is more easily estimated by testing for indoxyi. 

Concretions. — Enteroliths. — Enteroliths originate usually in the small 
intestines, are small, light in color and ordinarily of no importance, con- 
sisting chiefly of magnesia and lime. 

Coproliths. — These hard sausage-shaped fecal concretions are most 
frequent in the cecum, sacculations and rectum, rarely they attain con- 
siderable size and may cause obstruction. 

Pancreatic Calculi. — These may be faceted, but are usually rough and 
friable; they contain no bile pigment and cholesterin, and are soluble in 
chloroform. 

Biliary Calculi. — These occur as well-known faceted bodies, or, if in the 
form of sand, may require chemical tests for their identification.* 

The cases of " intestinal sand" (supposedly associated with neurotic 
states and mucous colitis) which have been observed by the author have 
almost invariably proven to be associated with gall-stones. 

HEMORRHOIDS (Piles). — This common condition, rare in children, 
most frequent in men, consists of a diffuse or circumscribed varicosity of 
the hemorrhoidal veins, either in the lower portion of the rectum (submucous) 
or at the anal margin (subcutaneous). 

The condition is induced by constipation, continuous standing or sitting 
(i.e., sedentary occupations), the habitual use of cathartics, pregnancy, the 
pressure of tumors, or, obstructed portal circulation from whatever cause, 
and is favored by the lack of valves in the hemorrhoidal veins. 

They are frequently a source of recurrent hemorrhage which in turn may be 
the actual cause of an obscure anemia, often of a most severely pe. Furthermore, 
the frequency of the lesion may lead to the too ready acceptance of the 
patient's own diagnosis and a failure to search for and detect the existence 
of rectal fissure, foreign body, malignant growth, tuberculous or syphilitic 
ulceration or fistula. 

The rectal examination is too often neglected, though its disagreeable 
features are in part removed by the use of the rubber glove or finger shield. 
Hemorrhoids are easily recognized if superficial, the patient being asked to 
strain and bear down, when the reddish-blue nodules will become evident. 
Skin tags and condylomata are common but easily differentiated. Internal 
hemorrhoids may require the use of the speculum, though usually recognized 
by digital examination. Retained fecal matter has a characteristic feel and 
malignant growths are peculiarly indurated and firm. 

In any rectal examination the tonus, i.e., the resistance and grasp of the 

* Test. — Powder the stone or gravel, add 20 c.c. of ether, mis thoroughly, filter, and 
evaporate filtrate, divide residue in three portions. Xo. 1 is dissolved in hot alcohol, 
allowed to evaporate without heat and the residue examined for the rhomboid crystals of 
cholesterin. No. 2 is treated with HC1 and a trace of ferric chloride; a blue color on evapora- 
tion indicating cholesterin. No. 3 is placed on a slide, treated with a drop of concentrated 
sulphuric acid and covered. The cholesterin crystals show carmine margins. Another 
portion may be treated with dilute HC1, heated, cooled and treated with chloroform; to 
the chloroform extract Gmelin's test for bile pigment is applied. 



INTESTINAL DISEASES 



943 



anal sphincter, should be noted. It is markedly relaxed in certain organic 
nervous diseases and in obstruction of the rectum and sigmoid flexure. 

MECKEL'S DIVERTICULUM.— Persistence of the omphalomesenteric 
duct may be of slight consequence unless its extremity is fixed by adhesions 
or remains attached at the navel. 

Either acute or chronic intestinal obstruction may result in the latter 
instances. Rarely it may be involved in or imitate an intussusception or 
volvulus or become the seat of abscess and perforation. 

ENTERITIS 

Primary Divisions. — In the diarrheal diseases one must distinguish those 
affecting the small intestine alone from those involving the colon exclusively or 
in part. 

The latter, more severe and likely to be attended by serious complications, 
are described under ''dysentery" and "enterocolitis; nearly all forms of 
enteritis are trivial and temporary in the case of the adults, but may assume 
considerable importance in the case of infants and young children, occurring 
usually under conditions of improper sanitation or still more frequently in 
artificially or badly fed infants. 

Bowel disturbances in breast-fed infants are rare and usually temporary 
and trivial unless secondary to some grave primary condition. All varieties 
are prone to appear during hot weather, particularly when extreme variations 
in temperature and humidity are present, and reach their maximum in preva- 
lence and mortality in July and August. 

Milk and water are probably the chief vehicles of contagion, but the dem- 
onstration of a specific bacillus for the ordinary diarrheal diseases must 
await further investigation, inasmuch as a large variety of organisms are 
found, many of which are quite competent in themselves to produce decided 
symptoms or to act with and intensify the virulence of others.* 

CLINICAL VARIETIES.— We recognize: (i) Acute Intestinal Indiges- 
tion. (2) Acute Fermentative Diarrhea. (3) Cholera Infantum. 

Morbid Anatomy. — The pathologic changes in enteritis vary from a mere 
congestion or catarrhal inflammation of the mucosa, with slight infiltration 
of the submucosa and enlargement of the lymph follicles, to actual ulceration. 
Ulcerated areas are ordinarily limited, originating at the follicle but extend- 
ing by the coalescence of contiguous ulcers. In combined lesions of the upper 
and lower bowel one may of course have all the changes described under 
" dysentery." In the more severe types, particularly the combined form, 
complicating broncho-pneumonia is common and the other viscera present 
evidence of severe toxemia. 

* Much interest attaches to a bacillus recently discovered by Duval and Bassett which 
closely resembles Shiga's bacillus of dysentery and has been found in a large number of 
cases of the summer diarrheas of children. Certain normally harmless bacteria seem to be 
capable of assuming virulent characteristics. Bacillus dysenteriae, the colon bacillus and, 
in the small intestine especially, the bacterium lactis aerogenes, may be active. 



Tonus. 



Enteritis vs. 
Colitis/ 



Variable 
severity. 



A common 
ailment. 



944 



MEDICAL DIAGNOSIS 



Acute Intestinal Indigestion. — Colicky pain, tympanites, and diarrhea 
may come on suddenly, immediately or from several hours to a day after 
some dietetic indiscretion or, without apparent cause;* the fever is usually 
moderate and of brief duration, the pulse rate is increased and in the child 
may be extremely rapid. The stools are at first fecal, then watery and con- 
tain mucus and food particles imperfectly digested. Such an attack is ordi- 
narily cut short by the administration of some appropriate cathartic, such 
as castor oil. 

. Acute Fermentative Diarrhea. — This is characterized by more marked 
symptoms throughout and may come on suddenly or succeed a milder attack 
of acute intestinal indigestion. Vomiting is usually present, the fever may 
reach io5°F., the pulse is rapid, nervous symptoms are pronounced, exhaus- 
tion marked and, in children, convulsions are not uncommon at the onset. 
The stools are more frequent than in the simple form, rapidly become watery, 
are green in color and contain much mucus. The disease is ordinarily of 
brief duration and favorable termination, but may prove the commence- 
ment of an ileo-colitis and may terminate fatally by coma, exhaustion or 
broncho-pneumonia. 

Chronic Enteritis. — This hardly justifies a separate description, being 
characterized by intermittent or persistent symptoms of a mild sort which 
mirror the acute attacks. If long-continued it impairs strength and nutri- 
tion and it may be associated with mild daily diarrhea, mere unformed stools, 
or obstinate or alternating constipation. 

In every such instance the condition of the stomach, duodenum, appendix, 
and gall bladder should be investigated thoroughly and the stools carefully 
examined. 

CHOLERA INFANTUM.— This ailment, remarkably fatal and prevalent 
in the large cities among the poor, may affect the children of any age and is 
both sporadic and endemic. The onset is usually sudden, with high tempera- 
ture, f Vomiting is usually present, and the stools, at first fetid, may reach 
20 or more daily and rapidly become watery, light yellow or greenish, then 
colorless and odorless. There is marked thirst, the urine is scant and often 
albuminous and the disease usually terminates fatally, often with delirium, 
stupor or coma and perhaps convulsions. Marked tympanites is not present 
nor is the abdomen tender, but there is evidence of profound collapse, the 
features being pinched, the skin ashy-gray and the surface usually cold even 
though rectal temperature may be high. 

Ileo-colitis is predominatingly a dysentery and will be described under 
that heading; the small intestines seem to be primarily involved, but symp- 
toms very soon become distinctly dysenteric. 

MEMBRANOUS ENTERITIS {Membranous Diarrhea, Mucous Colic) — 
Definition. — An affection characterized by the presence of mucus, in quantity, 
in the feces. 

Etiology. — More common in women than in men, this affection long has 

* These attacks are frequently of gastric origin. 

t This must be taken by rectum or vagina because of low surface temperature. 



DYSENTERY 



945 



been regarded as largely dependent upon the elements of hysteria and func- 
tional nervous states. It may nevertheless be associated with chronic ap- 
pendicitis, gastric ulcer, and gallbladder disease, but is a relatively rare con- 
dition, most frequent in connection with an enteroptosis or achylia gastrica. 

According to the author's experience this condition is associated with two 
conditions aside from the causes mentioned, which may or may not co-exist. 
These conditions are impaired general nutrition and spastic constipation. 

As spastic constipation demands an entirely different line of treatment 
from that usually adopted in simple constipation and is very often quite 
overlooked, the condition usually goes unrelieved by medical means. 

Symptoms. — Following an attack of obstinate constipation, violent, 
colicky pains occur associated oftentimes with diarrhea, perhaps of a dysen- 
teric type, and more or less decided dyspeptic symptoms. Mucous masses are 
discharged which are usually grayish- white, ribbon-like or membranous, rarely 
forming complete molds of the intestinal canal (tubular form) or occurring in 
masses like frog spawn. Their nature may be proven by Pariser's method.* 

DYSENTERY 

Definition. — A term applied to a group of diseases characterized by acute 
or chronic inflammation and ulceration of the lower bowel, diarrheal stools, 
containing blood and mucus, and associated with colicky pain and tenesmus. 

Etiology. — The disease may be primary or secondary, acute or chronic. 
The secondary cases depend upon a primary cause, such as tuberculosis, 
syphilis or Bright's disease. The primary cases fall under three heads: 
(i) Amebic dysentery. (2) Acute specific dysentery (tropical dysentery). (3) 
A cute catarrhal dysentery (acute ileo-colitis) . 

The Cause of Amebic Dysentery. — The ameba dysenteriae now known to 
be the Entameba tetragena, representing actually, merely the end stage of 
Entameba histolytica, was described first by Losch in 1875 and first identified 
in hepatic abscess by Kartulis (1887), but to Shaudinn's description (1903) 
and careful work we owe most of our knowledge of the characteristics of the 
specific organism. It is from 15 to 20 ju in diameter, i.e., about twice the 
diameter of the red blood cell. See Fig. 404. 

Entameba histolytica "(tetragena) causes from one-third to one-half of all 
cases of tropical dysentery, and if a warm slide is used for examination the 
amebae may be readily identified by their structure and movement and are 
usually contained in the flakes of mucus or pus of the. fecal discharges or may 
be obtained from abscess or stained in situ in tissues. f 

The description of the methods of "laboratory diagnosis," immediately 
following is taken from Stitt's admirable little book on "Tropical Diseases." 

Laboratory Diagnosis. — In the fresh specimen of the milky mucopurulent 
mass of bacillary dysentery one observes large numbers of pus cells and par- 

* They are treated with sublimate alcohol and then yield a green color with Ehrlich's 
triacid stain, in contrast to fibrin which stains red. 

f Immunity to the pathogenic entamebae is pronounced in many individuals, only 
the lesser proportion of individuals carrying them being seriously affected. 
60 



Amebae 
readily 
recognized 



946 



MEDICAL DIAGNOSIS 



ticularly very large phagocytic cells which greatly resemble amebae. Upon 
staining with Gram's stain one may find numerous Gram negative bacilli in 
the cystoplasm of the cell. 




Fig. 473. — Important pathogenic protozoa of the intestinal tract, (ia) Motile E. 
coli. Note large amount and peripheral arrangement of chromatin in nucleus, (ib) En- 
cysted E. coli. Note larger size than E. histolytica cyst, its 8-ring form nuclei and absence 
of chromidial bodies. (2) Motile E. histolytica from acute dysenteric stool. Note histoly- 
tica nucleus with scanty chromatin. (3) Tetragena type of E. histolytica from case of 
chronic dysentery. Note greater amount of chromatin and central karyosome with cen- 
triole. (4a) Preencysted E. histolytica from carrier. Note small size and heavy periph- 
eral ring of chromatin in nucleus making this feature of chromatin in nucleus similar 
to the larger E. coli. (4b) Encysted E. histolytica from dysentery convalescent. Note 
small size, 4-ring nuclei and a dark chromatin staining mass, " chromidial body." (5a and 
5b) Motile and encysted cultural amebae from Manila water supply. (6a and 6b) Oocyst 
and sporozoite production in 4 spores of Eimeria stiedoe. (7a and 7b) Oocyst with 2 
sporoblasts and oocyst, with 2 spores containing 4 sporozoites of Isospora bigemina. 
(8a and 8b) Vegetative and encysted Trichomonas intestinalis. (9a and 9b) Vegetative 
and encysted Lamblia intestinalis. (10) Balantidium coli. Illustrations of amebae from 
Walker— others from Doflein. (Stitt.) 

" The large cells which resemble amebae are often vacuolated, thus intensifying the simi- 
larity. They are nonmotile, however, and do not show the small ring nucleus which is so 
characteristic of the vegetative human amebae. The nucleus of the confusing cells is also 
larger, approximating one fourth the size of the cell. 

" For bringing out the nuclear characteristics of human amebae Walker recommends fix- 
ation of thin moist smears in sublimate alcohol (absolute alcohol 1 part, sat. aq.sol. bichlor- 
ide 2 parts) for 10 to 15 minutes. These smears are then well washed with water and 
stained with alum haematoxylin for five minutes. The nuclear characteristics are noted 
under etiology. With vegetative amebae I have obtained beautiful results with vital 
staining which can best be done by tinging the feces emulsion with a 1 per cent, aqueous 
solution of neutral red. I have also had good results by emulsifying the feces in a drop of 
1 or 2 per cent, formalin and then adding a drop of 2 per cent, acetic acid. The mixture is 
then tinged with either neutral red or methyl green. 

" For distinguishing the encysted form of Entamoeba coli one can obtain beautiful re- 
sults by emulsifying the feces in Gram's iodin solution. Owing to the glycogenic 
reaction given by E. coli, the round amebae, with its 8 nuclei, stands out very distinctly." 



DYSENTERY 



947 



" For diagnosing the four-nucleated cyst of the pathogenic ameba one gets 
better results with hematoxylin as this brings out not only the four nuclei 
but the chromidial bodies as well. It was formerly customary to recommend 
the administration of salts prior to examining for amebae. Walker warns 
that such a procedure gives us amebae which are difficult to differentiate, the 
nuclear characteristics of E. coli and the tetragena nucleus of E. histolytica 
being much alike as they both contain much chromatin. In a dysenteric 
stool the histolytica type of nucleus, containing but little chromatin, does not 
resemble the nucleus of E. coli" 

Walker's Differential Table " 
Motile Stage 



A. Entameba histolytica 



B. Entameba coli 



i. Appearance hyaline. 

2. Reflectiveness more feeble. 

3. Movements active in the fresh stool. 

4. Nucleus more or less indistinct. 

5. Chromatin of nucleus scanty. 



1. Appearance porcelaneous. 

2. Refractiveness more pronounced. 

3. Movements sluggish. 

4. Nucleus distinct. 

v Chromatin of nucleus abundant. 



Encysted Stage 



A. Entameba histolytica 



B. Entameba coli 



1. Cyst smaller. 

2. Cyst less refractive. 

3. Cyst usually contains elongated refract- 
ive bodies known as "chromidial bodies." 

4. Nuclei never more than 4. 

5. Cyst wall thinner. 



1. Cyst larger. 

2. Cyst more refractive. 

3. Cysts do not contain "chromidial bod- 
ies." 

4. Nuclei 8, occasionally more. 

5. Cyst wall thicker. 



The recent experiments of E. L. Walker and A. W. Sellards have shown 
that amebae cultivated from " water or other non-parasitic sources" or, 
Entameba coli, are non-pathogenic. 

The former do not appear in the stools at all subsequent to feeding. The 
latter may be recoverable from the feces over long periods but produce no 
symptoms. 

Walker's individual experiments with Entameba hemolytica from normal 
stools of carriers showed that parasitization was readily produced, 17 of 20 
volunteers showing parasites within an average period of nine days. 

One of the three remaining was parasitized by three feedings. In the 
two others no further feedings were administered. 

Only four of the eighteen parasitized men developed dysentery, after 
periods of 20, 57, 87 and 95 days. 



94 8 



MEDICAL DIAGNOSIS 



General type. 



Emaciation 
and 

exhaustion. 



Often malarial. 



Usually 
amebic. 



It would appear that entamebic dysentery is conveyed chiefly through 
the encysted forms from the stools of healthy or convalescent carriers. The 
motile forms of active dysentery are not highly infective, and are but slightly 
resistant. 

Acute Specific Dysentery ("Acute Tropical Dysentery"). — Practically all 
tropical dysenteries not due to Entameba histolytica are caused by Shiga's 
bacillus which produces the disease in animals by inoculation and is aggluti- 
nated by the blood serum of affected patients. 

Acute Catarrhal Dysentery (Acute Ileo-colitis, Follicular Dysentery). — 
This is the ordinary well-known form of dysentery encountered in the 
temperate zone. No specific germs have been isolated but a large variety 
have been described as associated with the process. 

Diphtheritic Dysentery.— This is characterized by diphtheritic inflamma- 
tion with extensive infiltration and formation of sloughs. It is often second- 
ary to exhausting chronic diseases, such as chronic nephritis, heart disease 
and malaria. 

SYMPTOMATOLOGY OF DYSENTERY.— This is essentially the same 
for all varieties though varying greatly in degree. Any form may become 
chronic, tropical forms are both endemic and epidemic, and for their develop- 
ment all forms of primary dysentery elect hot weather. It will be noted that 
the symptoms are precisely those that might be expected to follow inflammation 
of the lower bowel plus widely varying degrees of toxemia. 

The amebic form is essentially chronic and recurrent, although acute 
cases occasionally are encountered. 

The onset is sudden and violent in all bacillary tropical forms, being often 
associated with chill, whereas the milder variety is often preceded by an 
initial diarrhea. Abdominal distress and fever are likely to be high during the 
active stage of all forms, and febrile phenomena are marked. 

Essential symptoms: Purging, marked tenesmus, severe colicky pains, 
constant desire to go to stool, excessive thirst, great prostration, and tender- 
ness of varying degree over the descending colon are symptoms common to 
all forms. 

The stools : These contain mucus, blood and scybala, and in the severer 
forms pus and sloughs. The number of stools varies greatly, but may reach 
ioo or more in the twenty-four hours. They tend to become fetid and sani- 
ous in severe and unrelieved cases. 

The exhaustion is great, yet vomiting and gastric irritation are often 
absent. Emaciation is of course rapid and in severe cases extreme. 

Ileo-colitis is usually preceded by a short period of ordinary diarrheal 
stools and it must be remembered that in children mucus and blood may 
appear in any severe diarrhea. 

Chronic Dysentery. — Chronic indigestion, recurrent dysenteric attacks 
of varying degrees of severity and marked emaciation are the chief features 
in chronic cases. Many of these have been found to be due to the persistence 
of a malaria in soldiers returning from the tropics, many more to the persist- 
ence of the entameba histolytica (telragena) but any form occasionally may 



INTESTINAL NEUROSES 



949 



become chronic and the irritability of the lower intestinal tract may last for 
a few weeks or months or even for many years. 

Twenty per cent, of the amebic form develop abscess of the liver. 

Differential Diagnosis. — The peculiar character of the diarrhea with its 
bloody stools and marked tenesmus serves to distinguish the acute form. 
Entameba should be searched for in all dysenteries and the specific agglutina- 
tion reaction of the Shiga bacillus, the forms of Flexner and Strong or the 
u y n strain of Hiss and Russell, sought with known immune sera when such 
are obtainable. 

The serum of an active case possesses but slight agglutinating power 
until ten or twelve days have elapsed, too late to be of much value in diag- 
nosis. 

Typhoid fever, of the rare dysenteric type, is readily differentiated by its 
gradual onset, diazo-reaction, rose spots, temperature curve and finally and 
conclusively by the agglutination test with the typhoid germ. As it ordinarily 
wholly lacks the characteristic dysenteric phenomena, confusion can seldom arise. 

Tuberculous or malignant ulcers and foreign bodies in the rectum may 
cause attacks more or less closely simulating chronic dysentery, but the asso- 
ciated lesion and the results of local and microscopic examination will ordi- 
narily distinguish them. 

Mortality and General Comment. — The death rate is of course highest 
in the severe tropical forms but dysentery of the temperate zone is seldom 
fatal except in children and old people or persons exhausted by disease. 

On the other hand, the total mortality in chronic dysentery under con- 
ditions of poor food, overcrowding and general insanitation may be very 
heavy. The United States government is still paying a large number of 
persons for disability attributed to chronic dysentery of the Civil w T ar, and 
the deaths during that four-year period reached an enormous total. The mor- 
tality in Japan for the decade following the first introduction of the disease 
reached 247,000. 



MISCELLANEOUS INTESTINAL NEUROSES 



Rectal spasm is almost invariably secondary to inflammatory or ulcera- 
tive processes either of the rectum itself, the colon, the anus or neighboring 
organs. Rarely it is supposed to be primary. Defecation is intensely pain- 
ful, the anus sensitive and resistant, an anesthetic being required for an 
examination. 

Peristaltic unrest associated with borborygmi may be primary or second- 
ary. The former is a pure neurosis, the latter may be associated with vari- 
ous gastric disturbances or with actual obstruction. The condition is usually 
accompanied by constipation and in its primary and severe form by hysteria, 
psychasthenia or hypochondria. It is, as a rule, trivial and unimportant. 

Meteorism. — Gaseous distention is a mere symptom too well known to 
require extensive description and results chiefly from "air swallowing" or the 
fermentation of carbohydrates or proteids, is usually temporary and purely 



Asthenic 

women 

chiefly. 



Sometimes 
serious. 



95o 



MEDICAL DIAGNOSIS 



Often obscure. 



Regional 
variations. 



neurotic, but is also an important manifestation in true obstruction and 
peritonitis. It may prove a troublesome and dangerous condition in the 
typhoid state or any virulent infection, and is particularly dangerous in 
pneumonia and chronic incompensated disease of the heart. 

Enteralgia has more basis in fact than gastralgia, being descriptive of 
ordinary colicky pain of intestinal origin, whether it be primary or secondary. 

Hypogastric Neuralgia. — This term has been applied to a painful con- 
dition localized in the epigastrium and lower part of the back and associated 
with sense of pressure in the rectum, bladder, uterus and vagina. It is 
purely a symptom, undoubtedly dependent upon uterine, ovarian, hemor- 
rhoidal and other similar conditions. 

Hyperesthesia, Paresthesia, Anesthesia. — The intestines share with 
other portions of the body these symptoms of hysteria or psychasthenia and 
they not infrequently take the form of aura in epilepsy. They are important 
only to the possessor of them save in actual disease of the brain and cord 
when rectal anesthesia may be associated with sphincter paralysis, or in the 
cases where the anesthesia leads to a serious accumulation of fecal masses. 

Intestinal neurasthenia is given a place by most authors, but deserves no 
such distinction. The term really applies to the asthenic-psychasthenic state 
with predominance of abdominal symptoms. 

Paralysis of the Intestines. — This has already been referred to elsewhere. 
The condition may be a very serious one and presents many of the symptoms 
of obstruction. 

It is associated with direct abdominal trauma, sepsis, chronic inflamma- 
tion and ulcerative diseases of the intestinal tract, with profound hysteria, 
melancholia, hypochondria or actual organic disease of the brain and cord 
and is frequently observed in prolonged and massive fecal impaction. 

CHRONIC INTESTINAL OBSTRUCTION.— Acute obstruction has 
been dealt with already. Chronic obstruction may be due to the same factors 
and one is chiefly concerned with its recognition. 

Symptoms. — These are extremely variable and often obscure. The 
history of previous ailments is important as is the history of constipation, 
diarrhea, or symptoms suggesting possible ulceration or appendicitis. Little 
stress should be laid upon the pipe-stem or tape-like conformation of the 
stools as these may be met with in spastic constipation or anal spasm. 

The gradual onset of the symptoms is usually characteristic. At first 
hardly noticeable, they may become severe and troublesome and always 
depend greatly upon the site of the obstruction. 

Duodenal stenosis produces symptoms strongly resembling pyloric ob- 
struction and is frequently associated with the vomiting of bile in quantity, 
thus indicating a stricture below the papilla of Vater. 

Any marked obstruction in the small intestine will be accompanied by 
a great increase of indoxyl, and the more remote it is from the stomach the 
more will the colicky pains and constipation predominate over the gastric 
symptoms, nausea and vomiting. 

If in the lower ileum or colon, there may be no gastric symptoms. Local 



OBSTRUCTION AND CONSTIPATION 



951 



Tumor and 
bloody stools. 



after 
appendicitis. 



distention of the abdomen or visible peristalsis may give a clue to the site, 
and gurgling and bubbling sounds may be audible and palpable with or with- 
out the pressure of the hand. It may be possible to recognize the large peris- 
taltic waves of the colon as compared with those of the lesser intestinal coils, 
but it is evident that this sign must often fail. 

Chronic intussusception is usually associated with palpable tumor, 
bloody stools and tenesmus as in the acute form, its most frequent site being 
at the ileo-cecal valve. Old appendiceal adhesions may produce chronic 
obstruction in the same region, but lack all distinctive symptoms of intus- 
susception. In this connection it may be said that following appendicitis, 
adhesions may occur about the cecum or the ascending portion of the colon | Adhesions 
producing obstinate constipation and frequent attacks of more or less ex- 
treme pain, though the appendix is found at operation practically normal and 
free. 

Lane's Kink. — Sir Arbuthnot Lane lays extraordinary stress upon the 
presence of accessory peritoneal bands which may produce "kinks" of the 
colon at any one of the three flexures or similarly affect the lower ileum or 
even the pylorus. 

That they possess anything approximating the importance or frequency 
of occurrence ascribed to them, or that they often demand or justify the 
radical surgery advised may well be doubted.* 

Doubtless, cases arise in which persistent symptoms of duodeno- jejunal 
block occur which may demand surgical interference, rather than lying down 
after meals, proper support to the abdominal viscera, or a few days or weeks 
devoted to rest and efforts to improve nutrition, but the tendency to turn 
too readily to extreme surgical measures is unfortunate. 

A surprisingly large number of cases presenting both subjective and 
fluoroscopic evidences of such a condition wholly and completely recover with- 
out surgical intervention, or, prove phantom findings (George and Leonard). 
Furthermore, these cases occur chiefly in the congenitally asthenic viscerop- 
totic cases which, as most surgeons now have decided, are bad subjects for 
any operative procedure. 

CONSTIPATION. — This common and often troublesome symptom 
may be caused: (a) By the character of the food taken, being more common in 
those taking an exclusive meat diet than in vegetarians, (b) Disturbances of 
innervation, more frequently than from any other cause. It is seen in 
hysteria, neurasthenia, brain injuries, simple neglect or lack of proper habit, 
injuries and disease processes affecting the peritoneum, lead poisoning, nerv- 
ous dyspepsia, hyperchlorhydria, etc., etc. (c) Mechanical causes, among 
which are weak abdominal musculature, strictures, growths and the recumbent 

* The extreme views advanced, and the tremendously radical surgical measures under- 
taken, represent at once the revival and the maximal exaggeration of the most extreme 
views of Glenard and Bouchard. 

The author notes with gratification the reaction against this operative procedure is 
growing rapidly and, indeed, has been emphatically expressed by one of the most brilliant 
and ultraradical of American surgeons. 



Etiology. 



05 2 



MEDICAL DIAGNOSIS 



posture, (d) Reflex causes and direct irritation, as in fissure of the anus, 
hemorrhoids, rectal ulcer, prostatitis, and displacement of the uterus or 
ovaries, (e) Fever and other conditions associated with profound toxemia, 
diminished secretion or excessive abstraction of fluids. (/") Chronic disease 
of the stomach, colon or small intestine. 

To an astonishing degree so-called " constipation" depends upon the fail- 
ure of the individual to go to stool regularly, regardless of the absence of the 
usual suggestive or impelling "call," such signal being readily diminished or 
wholly lost save under intensive stimuli in victims of the vicious cathartic 
habit. 

Another factor of primary importance is the position assumed. In every 
instance of supposed constipation the patient should be instructed to bring 
the knees together and lean as far forward as possible when straining. Actual 
atony of the bowel is a relatively unusual factor, as compared with a weak and 
unreenforced abdominal musculature. 

Clinical Divisions. — One distinguishes an atonic and a spastic form, 
the former representing either a weak intestinal musculature or impairment 
of its nervous mechanism. This is seen in chronic venous congestion (chronic 
heart disease, hepatic cirrhosis, etc.) or in states of profound general debility, 
asthenia, hysteria or certain organic nervous ailments. 

Spastic constipation is characterized by permanent increased tonus of 
the intestines and the rectal segment. The spasm may be of variable dura- 
tion and involve one or many intestinal segments in varying degree. If the 
whole small intestine is affected, a scaphoid abdomen is produced as is seen 
in spinal meningitis or in certain irritative cerebral lesions. More frequently 
the colon is involved and yields no symptoms on inspection save that the 
stools resemble round hard balls, often like goat droppings, or the pipe-stem 
or tape-like forms. One somewhat characteristic symptom of spastic con- 
stipation is intermittent pain in the left lower abdominal segment relieved by 
stool or enema. This at times is very severe and constitutes a type of colon 
colic. 

FECAL ACCUMULATION is most common in persons suffering from 
profound toxemia in the acute infectious diseases, such as typhoid, in the. 
insane, or in profoundly hysteric or neurasthenic individuals. Careless 
physicians, house officers or nurses encounter them in their patients with 
especial frequency. They are sometimes associated with profound auto- 
intoxication, partial or complete intestinal paralysis and acute gastric 
dilatation. Such masses frequently produce neuralgic symptoms or even a 
sciatica and, if the condition be of long duration, the utmost difficulty may 
be encountered in attempting to relive it by enema or by physic. 

Rectal obstruction is easily diagnosed by the finger and speculum. It may. 
take the form of irregularity, greatly diminished frequency, or a mere dim- 
inution in quantity, the fecal passages being chronically insufficient. In 
fecal impaction and indeed in almost all forms of constipation palpation of the 
rectum or even the relaxed abdominal wall is sufficient for the detection of 
fecal masses. . If actual obstruction occurs from this cause ileus is closely 



APPENDICITIS 



953 



simulated, otherwise the symptoms are too well known to require description. 
(See also remarks on " Abdominal Tumors.") 

THROMBOSIS AND EMBOLISM.— This rare condition results usually site, 
from a clot in the left auricle in cases of mitral disease, thrombosis being the 
common form and the superior mesenteric the almost invariable site. The 
condition can seldom be recognized ante-mortem. Septic emboli carried obscure, 
into the smaller branches of the intestinal arteries from an endarteritic or septic 
focus also may cause infarction and produce the same severe colicky pain, 
localized tenderness, abdominal distension and bloody diarrhea. 

TUBERCULOSIS OF THE INTESTINES.— This is rarely primary, 
but a common secondary manifestation, occurring in a large percentage of 
the advanced pulmonary cases. It affects chiefly the lower portion of the 
ileum and may extend downward even to the rectum or to a variable extent 
upward. The ulcers are irregular in shape with unclean bases and bright Ulcers. 
red margins which are usually undermined or overlapping. They readily 
form adhesions and hence seldom perforate. Owing to their tendency to 
encircle the intestine they may in rare instances heal and produce cicatricial 
stenosis. Diagnosis is evident from the pus, blood and tubercle bacilli in 
the stools, associated with localized pain and tenderness, and, usually, a 
preexistent known tuberculosis. 

SYPHILIS OF THE INTESTINES.— Syphilitic ulcers formed by the 
softening of gummata occur, congenitally, in the small intestines, but in 
the acquired form, chiefly in the colon, rectum and anus. They present a 
bacon-like appearance, with well-defined margins and an indurated base. 
Ulcers are occasionally observed in secondary syphilis and a form of ulceration 
cf indefinite causation termed "toxic" occurs occasionally in connection with 
the cachexias of leukemia, scurvy, nephritis and the like. 

ENTEROPTOSIS {Glenard's Disease). — This syndrome represents a ptosis 
involving the stomach, intestines, kidneys, liver and spleen and is, for the greater 
part, only a major portion of the general visceroptosis of u chronic congenital 
asthenia" {Stiller) elsewhere described. (See " Congenital asthenia") . 

The name "Glenard's disease" might well be applied only to cases of the j Two types. 
type associated with extreme relaxation of the abdominal wall, either from 
repeated pregnancies or recurring ascites, which often involves separation 
of the recti (diastasis). 

APPENDICITIS 



The remarkable prevalence of acute appendicitis as a disease is due merely 
to its separation under correct pathology from the blanket term "peritonitis" 
which formerly covered appendicitis together with its secondary and most fatal 
sequence. 

Nowadays, aside from traumatism and perforating ulcer of the stomach 
and duodenum, acute general peritonitis is rare in the male save as a result of 
appendicitis, while, in the female, appendiceal peritonitis is overwhelmingly 
predominant, though the pelvic structures share the dubious preference. 



Q54 



MEDICAL DIAGNOSIS 



Age. 



Sex. 
Occupation. 



Essential 
symptoms. 



McBurney's 
point. 



Afebrile cases. 



Obscure cases. 



Frank cases. 



Mortality. — Appendicitis causes upward of 2 per cent, of all deaths in 
the United States, a higher mortality than is shown by the statistics of 
foreign countries. 

Etiology. — The disease is more prevalent in the young, being most frequent 
under the age of thirty and comparatively rare as a primary lesion in persons 
of middle age. It is slightly more frequent in the male than in the female and 
in the latter is frequently combined with inflammation of the pelvic viscera.* 
Occupation may be a factor, especially that involving hard muscular work or 
severe strains, such as lifting. 

One cannot but believe that most of the factors usually detailed under 
etiology are inoperative in the primary attack, though possibly more or less 
potent in recurrences. As a matter of fact one is dealing with vestigial 
tissue of low vitality and one peculiarly susceptible to the attacks of micro- 
organisms. 

Its peculiar form and its calibration, choked at its beginning at the cecum, 
is well adapted to make it an incubator for bacterial flora. 

The frequency with which foreign bodies derived from the food are found 
in its cavity emphasizes its unfortunate construction as a blind pouch with a 
constricted opening. A large number of microorganisms are competent to 
produce appendicitis of varying severity and course and. of late, much em- 
phasis has been laid upon the possible importance of the bacterial flora of 
the mouth, tonsils and nasal-accessory sinuses. 

Certainly one properly may assume that any hidden foci of infection in the 
form of diseased tonsils, sinuses, teeth, gall bladder, and the like are matters of 
decided or even cardinal importance in etiology. 

SYMPTOMS. — Acute appendicitis yields symptoms which vary with the 
nature and extent of the inflammatory process,, but show usually certain well- 
defined characteristics. 

The subacute and acute catarrhal ^ endo-appendiceal) form in which the local 
changes are slight may yield neither definite symptoms nor signs, or dispropor- 
tionately and mislead in gly severe ones. 

The acute diffuse form is associated with an active inflammation and infil- 
tration with retention of exudate and often with erosions of the mucosa, and 
produces usually but not always marked symptoms. Purulent and gangrenous 
forms of appendicitis are advanced forms of the same primary lesions. 

Severe abdominal pain, nausea and vomiting, fever, rigidity and localized ten- 
derness, are the essential features of all acute forms. Pain of sudden onset and a 
tendency to localize itself within a few hours, at a point representing the inter- 
section of the outer edge of the right rectus with a line drawn from the anter- 
ior superior iliac spine to the umbilicus (McBurney's point), the associated 
localized rigidity, tenderness and fever really make the diagnosis. 

Fever. — Without fever a positive diagnosis of acute appendicitis is often 
difficult. Cases rarely occur in which local and even general peritonitis are 
present without fever and remembrance of the fact may prevent error. 

* Dr. A. MacLaren and other surgeons of wide experience believe this male predomi- 
nance a mvth. 



APPENDICITIS 



955 



Vomiting, usually delayed for a few hours, and constipation, may be 
marked features, and children may show diarrhea. 

PHYSICAL SIGNS. — Early in the disease there may be none of impor- 
tance save the evident pain and distress and fever, although rigidity is seldom 
long deferred. 

Palpation may show a distinct defensive rigidity {muscular rigidity) with 
or without tenderness, localized or maximal, in the region of McBurney's 
point, but in some cases this symptom is delayed for twenty-four hours or more. 
Doubtful early cases justify McMonagle's maneuver, i.e., fixation of the knee 
in extension and asking the patient to attempt flexion of the thigh on the 
abdomen against resistance, while the unoccupied hand palpates the abdomen. 
Cutaneous hyperesthesia of the eleventh dorsal nerve may be present. The 
relaxation of muscular rigidity under anesthesia in perforative cases is said 
to occur last over the exact site of the perforation. 

Rectal or vaginal examination may yield important information in obscure 
cases and should never be omitted. 

Percussion is of no special value and auscultation is negative. As the 
disease advances exquisite local tenderness develops, there is a tendency for 
the patient to draw up the leg of the affected side, and in certain cases palpa- 
tion may reveal an actual induration, sometimes in the cecal region, more 
often just above Poupart's ligament. 

Bladder irritability is common and, in the female, involvement of the 
appendages by inflammatory adhesions is frequent. 

It is said that in certain instances the genito-crural nerve may be involved 
and pain radiating to the testis and associated retraction of that gland has 
been noted. The author has had no personal experience with such cases.* 

The sudden primary pain is usually merely that of a severe colic though it 
may be extreme and agonizing and is often epigastric or so widely diffused as 
to be misleading. 

In such extreme forms it often indicates actual perforation in a fulminant case. 

Early tenderness is also misleadingly diffuse in many instances. 

It should be remembered that defensive rigidity may antedate the pathog- 
nomonic localization of both pain and tenderness. 

Abnormal Localization of Tenderness. — The appendix varies widely in 
position and for that reason one may find the tender point some distance 
removed from the typical circumscribed location. 

Leucocytosis is present in most cases and high figures are occasionally 
noted but little dependence can be placed upon it as a guide to treatment or 
an aid in prognosis. 

On the other hand it is a most valuable and important corroborative sign. 

Perforation and General Peritonitis. — In perforation of the stomach, 
duodenum or appendix the typical, and usual, evidences of rupture of the 
viscus are often almost identical save for the location of maximal defensive 
rigidity or tenderness. 

*The author has seen a number of cases of renal colic in which a primary diagnosis 
of appendicitis was made. 



Lacking early. 



Defensive 
rigidity. 



McMonagle's 
maneuver. 



Tenderness. 



Misleading 
signs. 



Sudden violent 
pain. 



Important 
points. 



956 



MEDICAL DIAGNOSIS 



Atypical cases. 



Shock and 
collapse. 



Suggestive 
conjunction. 



Examine urine. 



Pelvic disease. 



A source 
of error. 



Avoidable 
error. 



Pain usually is atrocious and abrupt, "cutting,'' " stabbing" 'or "bursting" 
with wide areas of lancinating radiation, and "shock" is evident. 

Tenderness is usually acute, easily recognized, and associated with a marked 
and progressively intensifying defensive rigidity tending to extend the area of 
primary localization and often attaining a board-like hardness. 

Unfortunately typical cases are not constantly encountered and both ex- 
treme pain and shock may be absent. 

Rigidity never has been wholly lacking in the author's cases. 

In such atypical cases fever may be low or absent, the pulse slow, any 
antecedent pain may suddenly have disappeared and the patient believe him- 
self better, but soon the facies assumes the Hippocratic cast, the abdomen is 
distended, motionless and strikingly resistant. Both knees are drawn up, the 
pulse becomes rapid, wiry, and small, the tongue dry. 

77 should never be forgotten that in the earlier stages of appendicitis the pain 
and tenderness may be general, and that in perforation and general peritonitis 
the patient's sensations and the body temperature may be most misleading. 

Differential Diagnosis of Acute Appendicitis. — Any sudden attack of 
acute abdominal pain attended by fever should at once suggest appendicitis 
as the cause, the suddenness of the onset followed by or concurrent with 
fever being an important though no absolute distinction as regards cases of 
typhoid, too often operated under a mistaken diagnosis of appendicitis. 

Renal colic may prove deceptive in two forms '.first, the so-called Dietl's 
crises which usually lack the ultimate localization of appendicitis and are 
exceedingly rare. Secondly, the passage of calculi through the ureter and 
especially such as are temporarily lodged in its lowest and narrowest portion. 
The recognition of renal colic should offer no difficulty by reason of the local- 
ized original pain over the kidney and its distribution. Furthermore, even 
the ureteral cases are usually made clear if the urine be examined as it always 
should be before any operation is undertaken. Several times in the author's 
experience such patients have narrowly escaped the knife. 

Gall-stone colic is usually definitely localized both as regards points of 
tenderness and referred pain. Pelvic peritonitis presents bilateral rigidity, 
hypogastric pain, and localizing symptoms per vaginam, but nevertheless, 
acute tubal or ovarian inflammation or a pelvic situation of an inflamed appen- 
dix may complicate the diagnosis, and a local examination is always necessary 
in women. 

Pneumonia and pleurisy at the base not infrequently cause temporary con- 
fusion if, as occasionally happens, the pain is referred to the abdomen, although 
the relation of the pain to respiratory movement is usually in itself distinctive. 

Strangulation and intussusception differ from appendicitis in the fecal 
vomiting of the former and bloody stools of the latter. 

The number of conditions which may confuse diagnosis are many and various, 
but those which may rightly do so are few in number, if the case is not wholly 
atypical, if the cardinal symptoms and the mode of onset are remembered, the 
urine examined and the lungs carefully interrogated. 

Of the thirty odd conditions which may be associated with individual symp- 



APPENDICITIS 



957 



ioms of acute appendicitis, not one lesion combines in itself the complete picture 
represented by the cardinal factors in the diagnosis. 

Perforated gastric or duodenal ulcer, though usually showing early localized 
defensive rigidity and decided and easily detected localizing tenderness may in 
some instances be indistinguishable 'from appendiceal perforation. 

In cases seen only after general peritonitis has developed, the differentiation 
between primary appendicitis with rupture and that due to perforating gastric 
or duodenal ulcer is as unimportant as it may be difficult. 

The commonest error associated with the diagnosis of appendicitis occurs in 
the early, not the later stages, when the "colicky" pain is regarded as a simple 
colic and castor oil or some similar cathartic is administered. 

In all abrupt, severe febrile colics, however simple in appearance, and even if 
associated with a history of dietetic indiscretion, the question of appendicitis 
should arise in the physician's mind and be given expression in orders that stop 
all food and limit purgation for a few hours. 

The temperature should always be taken and relief of a simple colic 
may be secured by repeated hot enemata and the hot water bag pending further 
investigation. 

Prognosis. — Mild cases may discharge into the cecum -and recover with- 
out operation after a few days' illness,, those going on to suppuration may 
result in a general peritonitis, gangrene, or perforation attended with exten- 
sive purulent inflammation in remote regions, one of which is the peri-renal 
tissue. Certain of the acute suppurative cases rupture into the bowel, 
thus draining the abscess cavity, and may show a remarkable freedom from 
recurrence. 

The question of surgical interference in appendicitis is a difficult and impor- 
tant one. An immediate surgical consultation should be the invariable rule; 
early positive diagnosis usually justifies immediate operation, ' and surgical 
judgment should ordinarily be accepted. 

Xo matter how mild the case, a second attack usually calls for operative 
interference and in those who live in, or whose duties take them to remote regions, 
a primary or interval operation shoidd be the invariable rule* 

The frequency, of relapse is so great and interval operations so safe under 
conditions which include expert service, that in general such operations should be 
advised. 

CHRONIC APPENDICITIS.— As physical signs may be wholly lacking 
and the symptomatology suggestive of disease of other organs, the diagnosis 
usually depends upon recurrent localized tenderness or a definite history of 
antecedent acute, subacute or recurrent appendicitis, which may masquerade 
under the title of " typhoid fever," "inflammation of the bowels," "constipa- 
tion," "gall-stones," "renal colic," l< gastralgia," " hyperacidity" or "ovarian 
trouble." 

Occasionally there is an enlarged and thickened appendix or old inflam- 
matory masses that may be palpated. Quite frequently there are mild but 

* In children primary operation is usually indicated if the diagnosis can be made within 
the first twentv-four hours. 



Site often 
obscure. 



Important 
precaution. 



Wide 
variations. 



Bowel 
drainage. 



Often 
misnamed. 



One definite 
syndrome. 



958 



MEDICAL DIAGNOSIS 



definite localizing symptoms and slight fever (99.5°?) at the time of ex- 
amination. 

Suggestive symptoms are: pain over the stomach, gallbladder and umbilicus, 
increased by appendiceal pressure rather than by pressure at the site of pain; 
hyperesthesia over the right edge of the rectus, dull or colicky pain on exercise 
and pain associated with visible peristalsis in the ileocecal region {obstructive 
adhesions) . 

Right-sided dysmenorrheal pain following an acute illness suggesting ap- 
pendicitis; diminished power of endurance and persistent malnutrition, are fre- 
quently present and a dull aching or even colicky appendiceal pain may come 
on at the height of digestion. 

It should be borne in mind that chronic appendicitis is frequently associated 
with gallbladder disease, chronic indigestion, obstinate constipation, alternating 
diarrhea and constipation and mucous or membranous colitis. Further, that 
symptoms of obstruction may be caused by an old appendicitis with dense 
adhesions. 

The relation of pain to meals may be constant or very variable. 

Dyspeptic symptoms which are intensified by physical exertion suggest 
appendicitis or relaxation of the hernial openings, but may also occur in a 
wide range of conditions. 

The location of the pain is usually epigastric but may radiate downward or 
lie at a lower level and once started may persist for twenty-four or even 
seventy- two hours even though the patient is fasting.* 

Hunger pain and pyloric spasm may occur, as in prepyloric and post- 
pyloric ulcer, but neither are peculiar to either condition. 

Several special maneuvers are useful as affording confirmatory evidence 
of the existence of an inflamed and more or less hypersensitive appendix two 
of which are worthy of special notice: (1) Severe localized pain or tenderness 
induced by pressing the fingers deep down along the inside of the iliac crest 
outside the cecum and making pressure backward and toward the median 
line. (2) Sharp localized pain attending the full inflation of the colon (Bas- 
tedo's sign).f 

The very existence of a true " chronic appendicitis" is doubted by many 
surgeons and pathologists at the present time, and a large proportion of appendices 
removed fail to show pathologic changes of clinical importance. 

Differential Diagnosis of Chronic Appendicitis. — This must depend upon 
the factors already given. In most instances the past history and the acute 
or subacute attacks are the determining factors. 

Roentgenologic Aids to Diagnosis. — With relation to chronic appendicitis 
the work of J. T. Case and of George and Leonard is of great interest. The 
latter have stated recently their belief that using their technic, one may 
demonstrate the patent appendix in every instance. They believe that the 

* Undoubtedly, many of the gastric symptoms attributed to the appendix represent 
unrecognized acute prepyloric and postpyloric gastric ulcers. 

t This is closely related to Rovsing's palpatory method of distending the ascending 
colon. 



APPENDICITIS 



959 



use of their contrast meal is indispensable to accuracy and report but slight 
success with bismuth enemata. 

This meal consists of 90 grams of bismuth or barium in a pint of butter- 
milk. They also lay great stress upon the necessity of careful plate work, 
stating that in many instances the detection of the appendix involves a study 
of fine detail. Case's adoption of the horizontal position has been followed, 
plates being taken both from the front and back and when necessary in the 
erect posture or by the lateral oblique method in retrocecal cases. 

Manipulation may be necessitated in some instances and the use of the 
screen may be of value in the diagnosis of adhesions. The appendix may lie 
vertically behind the cecum, horizontally along the pelvic brim, high above 
the iliac crest or low in the pelvis. It should be freely movable under palpa- 
tion, varies in length from one to eight or nine inches, and may be " straight, 
curved, or, obtusely angulated. ; ' Appendiceal abnormality is suggested by: 

(a) Absence of the appendix shadow, indicating obstruction of the lumen. 

(b) Concretions, (c) Immobility under palpation, (d) Dilatation (rare). 
(e) Sharp kinks. (/) A definite correspondence of the visualized structure to a 
point of localized tenderness, (g) Prolonged retention of the bismuth. 

A retrocecal appendix need not be abnormal but is regarded as suspicious. 

The translation of such findings into terms of surgical interference is at pres- 
ent largely a matter of individual judgment, but the coexistence of tenderness with 
or without a past history of acute or subacute appendicitis would give special 
meaning and importance to findings which considered alone might by no means 
justify surgical interference. In the case of the appendix as in other abdominal 
diseases a most gratifying tendency to surgical conservatism is becoming evident. 

The Exploratory Operation. — In no other field is the exploratory operation 
better justified or more abused. When one has exhausted all other rational 
methods of diagnosis, and only then, is it justifiable, in the presence of sug- 
gestive troublesome or threatening symptoms and the absence of patent 
contraindications. In the recent past the relative ease and safety afforded by 
modern surgical technic has encouraged both the fit and the unfit to use the 
knife almost as light heartedly as one would employ percussion or ausculta- 
tion and with respect to the appendix especially the mere detection of some 
slight departure from the absolute anatomic normal has been regarded, quite 
illogically, as a sufficient justification for surgical procedure. This unfor- 
tunate attitude has been a cause of infinite damage to one class of patients 
especially, viz., the chronic congenital asthenic (visceroptotic), and, further- 
more, by the encouragement it has given the unskilled operator has resulted 
in a heavy mortality amongst individuals with clinically normal appendices. 

ACUTE INTESTINAL OBSTRUCTION (see u Pain— Abdominal"). 

ACUTE PERITONITIS.— Acute peritonitis is now essentially a surgical 
disease and needs but scant notice in this volume. It may be local, diffuse 
or general and its causes are too numerous for detailed description, but 
resolve the cases into primary and secondary groups. 

The so-called primary or idiopathic peritonitis is a dubious clinical entity. 
Secondary peritonitis means an extension of inflammation from any structure 



Primary rare. 



960 



MEDICAL DIAGNOSIS 



Etiology. 



Misleading 
forms. 



Usual type. 



Attitude. 



Vomitus. 



Wasting and. 
tenderness. 



A common 
misconception. 



Fluid. 



Various con- 
fusing 
conditions. 



to the adjacent peritoneum. Thus it may arise from traumatism including 
operation, from extension, in the severer inflammation of the intestinal tract, 
from perforation due to abscess or ulcer, and from chronic ailments, such as 
cancer and tuberculosis. Furthermore, the lowering of vitality in certain 
chronic diseases seems to render the peritoneum less resistant to the action of 
germs. 

The evidences of infection of the peritoneum are extremely varied, cer- 
tain cases associated with profound collapse and death subsequent to abdom- 
inal operation showing no lesion save perhaps points of congestion. In some 
there is little fluid or fibrinous exudate, in others a large amount, the fluid 
being serofibrinous, purulent, putrid, or in wound infection, carcinoma and 
some tuberculous cases, hemorrhagic. 

The two most common organisms are the colon bacillus and the pyogenic 
streptococcus, but any one or more of a larger number of bacteria may be 
active. The infection is usually mixed, but with one organism dominant. 
In general, the staphyloccocus cases produce little or no pus or at best a 
seropurulent exudate. The streptococcic form is distinctly dry, but the 
virulent strains of the colon bacillus produce thick, creamy foul-smelling 
pus in quantity. Adhesions are extensive and often almost universal and 
the exudate may be confined in pockets. Friction should always be sought 
especially over the liver and spleen. It is by no means constant but in some 
instances is an early and helpful sign. 

Symptoms. — In general peritonitis of the perforative or septic type the 
fades assumes the Hippocratic type, there is usually sever-e initial pain and 
evidence of marked prostration or collapse, fever may be preceded by chills and 
rise rapidly to a high point, of chill, fever and pain be absent. Continuous 
high fever is seldom seen. Painful vomiting and frequent micturition are 
common. The urine is scant, indicanuria is marked, the pulse is small and 
tense, and the position is rigidly dorsal, with the head high, the knees drawn 
up and the abdomen tense, usually distended, but occasionally flat, the 
vomitus is yellow and bile-stained, or, later pure green or even brownish 
black and of fecal odor. Wasting is rapid, distention tends to increase, 
rigid tympany being marked, and there is generalized tenderness of an 
extreme degree. 

It should be emphatically stated that obliteration of splenic and hepatic 
dulness is not confined to perforative peritonitis but may occur in any 
extreme case of tympanites. Dulness in the flanks is usual, indicating 
fluid, and the difficulties of diagnosis in these cases are chiefly related to the 
identification of the primary lesion. 

"Hysterical peritonitis" may, however, produce a typical clinical picture 
on inspection, but fever, wiry pulse and indican increase are usually absent. 
Obstruction of the bowel offers great difficulty at times and demands a care- 
ful consideration of the factors stated under that head. Ruptured tubal 
pregnancy, acute hemorrhagic pancreatitis, ruptured appendiceal abscess, 
perforating gastric or duodenal ulcer and various other lesions may demand 
the surgeon's knife for specific etiologic 'differentiation. 



PERITONEAL DISEASES 



961 



LOCALIZED PERITONITIS.— In the male the most frequent cause of 
localized peritonitis is appendicitis; in the female, tubal or ovarian inflamma- 
tion. A great number of localized inflammatory conditions of the viscera 
give rise to limited areas of peritonitis, the degree of inflammatory change 
and its nature depending upon the primary cause. An extended discussion 
of these forms belongs to surgical text-books. 

The lesser peritoneum, however, must receive special attention because of 
its frequent involvement, its importance and the obscurity of its symptoms. 
The lesser cavity is bounded in front by the gastro-hepatic omentum, the 
anterior layer of the great omentum and the stomach; below, by the upper 
layer of the transverse mesocolon, and it extends from the splenic to the 
hepatic flexure of the colon and from the hilus of the spleen to the foramen 
of Winslow. Above lies the transverse hepatic fissure, and that portion of the 
diaphragm covered by the lower layer of the right hepatic lateral ligament. 

In the presence of septic inflammation its communicating opening lead- 
ing to the greater cavity (foramen of Winslow) may be shut off so that in- 
flammatory exudate may cause a tumor in the upper abdominal quadrant. 
This is markedly affected by inflation of the stomach which tends to obscure 
or obliterate the dull note or even the palpation outline of the tumor, and 
an inflated colon does not cross it, but lies below it. 

This constitutes one form of the purulent circumscribed peritonitis known, 
because of its peculiar anatomic position, as "subphrenic abscess." 

SUBPHRENIC ABSCESS.— Its most frequent cause is perforating 
gastric or duodenal ulcer and carcinoma of the stomach. Appendiceal 
abscess accounts for 50 per cent, of all of the remainder. 

Differential Diagnosis. — When obtainable, a history of a preexisting 
adequate case, such as gastric or duodenal ulcer, appendicitis or gastric 
carcinoma is of great assistance. A clear history of shock may also aid 
diagnosis. _ 

The symptoms are usually abrupt and associated with pain, vomiting, dysp- 
nea and signs of sepsis. A tumor may be palpable in some portion of the upper 
quadrants, cyst-like in feel, markedly obscured by stomach inflation, and not 
crossed by an inflated colon, and when the accumulation is immediately be- 
neath the diaphragm and intraperitoneal the symptoms strikingly resemble 
empyema {or pyopneumothorax if gas is present) and the abscess may rupture 
through the lung, the pus appearing in quantity in the sputum (see also "Hepatic 
Abscess"). 

The author believes that such cases may in some instances be differen- 
tiated from empyema by the absence of respiratory lateral displacement of 
the heart. // gas be present (about one-fourth of cases) pneumothorax is 
simulated, but usually is easily distinguished upon X-ray examination by the 
high position of the diaphragm and the characteristic upper luminosity and lower 
liquid shadow of the underlying areas as well as by the atypical lung compression 
picture. The fact that the abscess may appear on either side and point either 
anteriorly or posteriorly makes this sign extremely variable. 

In some instances downward displacement of the liver is very clearly 
61 



Appendiceal or 
pelvic. 



Other causes. 



Boundaries of 
lesser cavity. 



Stomach 
inflation. 



Offers great 

difficulties. 



9 6: 



MEDICAL DIAGNOSIS 



Adhesions. 



Valuable 



Sr:eai:ug 
inflaniu:a'.::u, 



An apt 

c:-:iri = :-. 



Friction. 



A : a i s e 

of error. 



An ob = c-.-e 
condition. 



See-: a primary 
[ocas. 



definable. S also, the lower chest may bulge and widening of the epig 
angle may occur. The mortality in this condition is enormous (80 per 
cent. plus). 

CHRONIC PERITONITIS.— The plastic lymph associated with all peri- 
toneal inflammations, acute or chronic, tends to form adhesion bands of 
greater or less extent, density and permanence, and movable viscera often 
drag agglutinated surfaces apart to form false bands. 

I: should be remembered that in any condition si mutating local peritonitis 
the abdominal wall lacks the persistent involuntary general or localized rigidity 
characteristic of the true ailment* 

In both acute and chronic forms, moreover, the ease with which the in- 
flammation may spread from peritoneum to pleura and vice versa must be 
taken into account. As Edmund Owen says, "the peritoneum acts in inflam- 
mation much like an inflamed joint" i.e., it seeks junctional rest and 
quisitely tender, whence arises the characteristic rigidity, constipation and 
localized tenderness and the fact that pressure which relieves ordinary colic is 
intolerable in peritonitis. 

Further, as in pleurisy, auscultation may reveal areas of friction parti cularly 
in the region of the subdiaphragmatic organs which move in inspiration 
(chiefly the liver and spleen). 

Chronic adhesions in the form of false bands may cause intestinal obstruc- 
tion, but in the ordinary form they may be symptomless or give rise to mis- 
leading and troublesome symptoms, as in two cases recently observed by 
the author in which a chronic appendicitis with acute exacerbation; 
exactly simulated by an extensive adhesion in its neighborhood, the ap- 
pendix being nonr 

PROLIFERATIVE PERITONITIS.— This is characterized by marked 
thickening without extensive adhesions and is usually associated with hepatic 
cirrhosis, more rarely with chronic passive congestion, tumors and similar con- 
ditions. The effusion is usually small, the viscera may be included in the 
thickened layers and the peritoneum may be divided into several chambers. 
Shrinkage of organs may be produced and the rolled omentum usually forms 
a transverse tumor at the lower border of the stomach. Nodular growths simu- 
lating tubi malignant nodules may be present. 

TUBERCULOUS PERITONITIS.— This condition varies exactly as do 
pulmonary tuberculous lesions, there being an acute miliary, chronic ulcerative 
and chronic fibroid for 

It may be primary but is usually secondary being frequently associated 
with intestinal tuberculosis or disease of the Fallopian tubes and almost 
invariably with antecedent pulmonary- lesions. 

The prostate or seminal vesicles may be primarily involved; and invariably 
these structures together with the spermatic cord should be examined. 

The incidence as regards sex is about equal until the age of pulr 
after which female predominance is decided. As regards age it is most 

* In chronic tuberculous peritonitis it is a peculiarly "boggy" indeterminate rigid 



PERITONEAL DIS1 



963 



Tenderness. 



"Bogginess.' 



Tumor and 
exudate. 



frequent in children and young adults, diminishing pr g 1 ly in incidence 

during the third, fourth and fifth cK - is regards race, more common in 

the colored than in the white. Traumatism, cirrhosis oi the liver and hernia 
are associated conditions in many cases. 

Symptoms. — As with tuberculosis elsewhere, the disease may be symptom- 

md is usually less pronounced than other forms of peritonitis; more rarely 

the onset and course are extraordinarily severe. In general, there is tenderness, 

localized or diffuse, and a temperature sometimes continuous, more often liectic 

in type, usually of sligJU range, and, a moderate, Korrhagic ascites. 

The ;> boggy" indeterminate rigidity so generally encountered has been 
mentioned elsewhere. 

Deep pigmentation of the skin or jaundice is sometimes observed and. Pigmentation, 
especially in the upper abdominal quadrants, tumors are encountered due to 
inclusion and contraction of intestinal coils, encysted exudate and adherent omen- 
tum, or, in children, to enlarged mesenteric glands. Peritoneal friction may be 
audible or palpable in respiration and the tumors may simulate enlargement 
of the spleen, stomach, or other abdominal viscera to which they may be Friction. 
adherent or in deceptively close relation. 

Differential Diagnosis. — Cases with acute onset and violent symptoms 
may be unrecognizable as tuberculous; those with continued fever are diner- obscure cases. 
entiated from typhoid by the absence of the Widal reaction and the continued 
development and predominance of peritoneal symptoms. Usually, however, 
the disease is strikingly chronic. 

Omental tumors are usua :■: and somewhat characteristic in 

their shape and knobby "feel." The presence of an exudate greatly assists 
diagnosis. 

In most instances a suggestive family and personal history or the exist- 
ence of tuberculous pulmonary, intestinal or tubal symptoms assist differ- 
entiation. 

Furthermore, the coincidence of a doughy abdomen, a chronic continuous. 
intermittent or remittent fever with obstinate canstipation or diarrhea, digest::-: 
disturbance, ascites (in the exudative form) irregularly localized or general tender- 
ness and progress:: :::;■:. with vt without tumors, is 

Pain is usually slight or absent, but may be marked and paroxysmal. - 

A succinct and derinite portrayal of this condition is impossible, because 
of its variable pathologic manifestations. 

CANCER OF THE PERITONEUM.— Secondary cases need no special 
description, they take the form of growths, generally distributed and varving varied types 
from the miliary nodule to large umbilicated growths. The omentum is 
frequently involved and forms a peculiar tumor as in tuberculosis. Primarv 
disease is extremely rare and most often is endothelioma. 

Diagnosis. — A positive diagnosis is easy in secondary cases if the primarv 
source be manifest, but is always difficult in the rarer primary forms; indeed often 
a positive differentiation is hardly possible without exploration, the symptoms 
being almost identical with those of tuberculosis or echinococcus infection 
in most instances. 



Transverse, 
tumor. 



impossible. 



964 



MEDICAL DIAGNOSIS 



Primary 
necrosis 



Necrosis and 
hemorrhage. 



Gangrene 
follows. 



DISEASES OF THE PANCREAS 

ACUTE HEMORRHAGIC PANCREATITIS.— Etiology.— Infection 

through the gallbladder and ducts is the chief source of this disease, though 
bile itself, if forced back into the pancreas by obstruction to its normal out- 
flow, may produce the necroses and hemorrhage by activation of its own 
ferments. It may also be involved in septicemia, by traumatism, or, second- 
arily, in the extension of inflammatory processes from neighboring organs.* 

Symptoms. — These closely simulate perforation, particularly that of duo- 
denal or gastric ulcer, the onset being sudden with violent colicky pain in the 
epigastrium, associated with vomiting and collapse, with subsequent epigastric 
swelling. It is evident that a positive diagnosis is often impossible. The 
maximum of tenderness may clearly follow the outline of the pancreas 
and there may be a suggestive history of antecedent disease of the gall- 
bladder. 

Diagnosis. — The diagnosis must be based upon the sudden onset with pain 
and vomiting, symptoms of collapse and, several days later, the appearance of 
a fever amd fixed tumor corresponding to the position of the affected organ. 
The diagnosis is usually though not always made by exploratory section. 
The urine may show leucin and tyrosin after treatment with basic lead ace- 
tate, filtration, treatment of the filtrate with hydrogen sulphide and evapor- 
ation. 

Prognosis. — Recovery is the exception. 

ACUTE SUPPURATIVE PANCREATITIS {Pancreatic Abscess).— Sup- 
purative pancreatitis is associated with preliminary digestive disturbance, 
fever, possibly of a septic type and what is more important, by a fixed epi- 
gastric tumor. 

GANGRENOUS PANCREATITIS may result from hemorrhage or rarely 
suppurative inflammation. It has no distinguishing symptom aside from 
those of the primary hemorrhagic or septic pancreatitis, followed by 
collapse and death in a few weeks or days. ^The distinction is made 
post-mortem. 

CHRONIC PANCREATITIS closely resembles histologically in its two 
forms, atrophic and hypertrophic cirrhosis of the liver, the former condition 
is frequently associated with diabetes. It is seldom recognizable. 

PANCREATIC CYSTS.— The chief characteristics are recurrent colic 
associated with nausea, vomiting and progressive abdominal distention, 
glycosuria, emaciation and a fixed median tumor, cystic in feel, and lying 
above the inflated colon and below the stomach. They may attain great 
size. 

CARCINOMA OF THE PANCREAS.— Primary carcinoma involves 
usually the head of the gland. Metastasis or direct invasion of other organs 
is frequent; the condition is rare. 

Symptoms. — These are chiefly progressive emaciation, anemia, intractable 
dyspepsia, and dull or severe epigastric pain, the stools are often light and 

* The actual causes are not yet well understood. 



PANCREATIC DISEASES 



965 



merely. 



pasty, muscle fibers of ingested meat may result from faulty pancreatic secre- 
tion, and jaundice and ascites are not infrequent. The fixed tumor is 
median unless the tail of the pancreas be the part involved and glycosuria, 
jaundice and various pressure symptoms may be present.* 

Jaundice is present from obstruction and the gallbladder is enlarged in 
about 75 per cent, of the cases, the latter being usually of delayed and gradual 
development. 

PANCREATIC CALCULI.— The rough round or spiculate stones are, in 
rare instances, associated with violent epigastric colic and may be found in 
the stools. Ordinarily they produce an interstitial pancreatitis or lead to 
abscess. 

Such stones are composed chiefly of carbonate and phosphate of calcium 
and magnesium and sodium phosphate. 

The Cammidge Test and Loewi's Test. — The many reports at home and Suggestive 
abroad indicate that these two tests are no longer regarded as of diagnostic 
importance, and with the simpler and more direct methods now available 
through the use of the duodenal tube any such usefulness as the former may 
have had has passed. 

The diseases of the pancreas are essentially surgical and best dealt with in 
surgical treatises. 



DISEASES OF THE LIVER AND THE BILIARY PASSAGES 



CONGENITAL ANOMALIES.— An extraordinary variety may be found, 
including abnormalities in the size, number and position of the lobes, the 
presence of accessory masses of tissue, complete absence of the organ, ab- 
normal mobility, and even its transfer to the left side, as is seen in complete 
situs inversus. It has been found within the thorax in cases of diaphragmatic 
hernia, or following injury, and may be markedly displaced downward, or 
grooved, swollen, and thickened by tight lacing. Multiple depressions of a corset liver, 
similar sort may appear upon its superior surface, and are not satisfactorily 
explained. The gallbladder may be entirely lacking and curious variations 
occur in the size, number and distribution of its ducts. 

INFLAMMATION OF THE LIVER (Acute Hepatitis).— Etiology.— 
Inflammation may result directly from injury or follow an infection, diseases 
of the stomach and intestines or portal veins, and may be either simple or 
suppurative in character. 

It is rare in temperate climates and relatively common in the tropics. Tropical iii 
It constitutes one form of the ''tropical liver" and its chief symptoms are 
fever, pain, tenderness, and enlargement, with or without decided jaundice. 

In hot humid climates the transition from functional hyperactivity and 
its secondary phase, stasis, tends to invite actual acute hepatitis, and com- 
paratively slight blows, chilling of the body surface and like trivial causes 
may excite an acute attack. 

* See also "The Examination of the Duodenal Contents." 



9 66 



MEDICAL DIAGNOSIS 



Usually 
secondary. 



Associated 
conditions. 



Tropical 
abscess. 



Usually pro- 
nounced. 



Pain variable. 



Localizing 
signs. 

Edema. 



Adhesions. 



Sepsis. 



A variable 
sign 



Sequelae of 
perforation. 



ABSCESS OF THE LIVER.— Pyemic abscess, whether single or, as is 
usual, multiple, may result from infection conveyed, directly or indirectly 
through arterial, venous, or lymphatic channels. Any form of pyemia or 
general septic absorption may result in infective embolism of the hepatic 
artery, many of the suppurative and ulcerative lesions of the abdominal tract 
result in portal embolism and almost any severe acute infectious disease may 
produce hepatic abscess. Among the vast number of associated con- 
ditions one may mention appendicitis, ulcer and cancer of the stomach 
and duodenum, spinal caries, renal or perirenal abscess, the echinococcus, 
ascarides and liver flukes, Balantidium coli, inflammation and malignant 
growths involving the pancreas, gallbladder or its ducts, and any ulcerative 
and suppurative process in and about the intestines, such as typhoid fever, 
dysentery, appendicitis, cystitis, prostatitis, and tuberculosis. The so-called 
tropical abscess is almost invariably solitary and associated with amebic 
dysentery. 

Symptoms. — These, usually pronounced and localizing, more rarely 
latent and obscure, are chiefly: enlargement of the hepatic area or localized 
swelling, leucocytosis (save in amebic cases), pain, and sepsis. 

The pain may be entirely lacking for long periods, is not severe until the 
abscess reaches the surface, and is not distinctly localized, but felt both 
over the liver and in the region of the right shoulder-blade and, in some 
instances, chiefly at a point to the left of the median line, below the costal 
margin. 

Enlargement of the liver is an almost invariable symptom and when present 
is usually marked; hence both the upper and lower hepatic borders should be 
examined and the condition of the lower interspaces investigated. The right 
lobe is oftenest affected. A localized swelling corresponds to the "pointing" 
of the abscess and, when present, is invariably accompanied by edema of 
the superficial tissues, and in some instances may show fluctuation. 

Auscultation may reveal peritoneal friction, due to capsular involvement, 
and adhesions may limit movement. 

Loss of strength and weight and appetite is marked, morning vomiting and 
pronounced dyspeptic phenomena are usually present. 

Fever is either definitely intermittent or decidedly irregular and is usually 
associated with chills, and severe nocturnal sweats and jaundice may or may 
not be present. The decubitus of such a patient is not characteristic, as the 
right knee may be drawn up and the right shoulder lowered in any disease 
affecting this region and, moreover, this posture is far from constant. 

Persistent sweats or sweating constitute a symptom of decided importance 
because of its relative constancy as a symptom. 

Roentgenology. — Roentgenography may be of the greatest service in 
many instances. The tube should be at the back at the level of the sixth 
and seventh dorsal vertebrae, and so placed as to direct the rays slightly 
downward. 

Complications. — Perforations. — An hepatic abscess may burrow in many 
directions and discharge its contents with disastrous results. 



HEPATIC ABSCESS 



967 



Perforation mav occur outward through the skin, 



after the formation 
through a sinuous 



of adhesions, either directly or, more frequently, 
burrow. 

Perforation into the peritoneal cavity is very rare, as is that involving the 
portal vein, the inferior vena cava and the right kidney. 

The discharge of pus through a bronchus is not uncommon, for it may reach 
the pleura and lung and cause empyema or abscess even on the left side, or 
perforate the pericardium. It is usually preceded by severe cough and the 
expectoration of bright-red sputum.* Sometimes, though the physical find- 
ings are negative, the patient, during a violent fit of coughing, will raise 
a considerable quantity of pus intermixed with blood, often brown or bile- 
stained and not infrequently containing shreds of lung tissue. Perforation 
upward occurs in more than 50 per cent, of all cases. These cases may go on 
for long periods with a daily expulsion of quantities of pus, and spontaneously 
subside, leaving only a certain amount of lower chest deformity and a crip- 
pled lung, but the aid of modern surgery is, however, always needed. 

Differential Diagnosis. — Too often this surgical condition is misconstrued 
or entirely overlooked and great stress should be laid upon the existence, of 
possible causative factors. Furthermore, enlargement of the hepatic area is 
almost invariable. Jaundice when present (20 per cent.) is extremely sug- 
gestive; sallowness and decided cachexia are seldom absent in the established 
case. Localized swelling, whether over the free surface of the liver or the 
lower right interspace, is most important when present, but, unfortunately, 
is often absent. A distinctly septic trend of the symptoms, especially sweating, 
at once suggests abscess. The spleen is enlarged and there is marked leucocy- 
tosis which may exceed 50,000. As between hepatic and subdiaphragmatic 
abscesses, a surgical exploration is often required for positive differentiation. 

Resort to the roentgenogram or, better, both that and roentgenoscopy, as 
stated, may be productive of results. Exploratory incision is often required and 
friction over the hepatic area should always be sought. 

Exploratory puncture is still employed, though less frequently than 
formerly, and is seldom attended by untoward results if the rules of asepsis 
are observed. 

Prognosis. — The prognosis depends upon three factors, i.e., the number 
of abscesses and the promptness of diagnosis and surgical relief. Cases of 
multiple abscess are practically hopeless. 

HEPATIC HYPEREMIA.— Transient active hyperemias are unimportant 
save in the tropics where they often constitute the usual first stage of an 
acute hepatitis. 

Chronic hyperemia is invariably due to obstructed flow of blood from liver 
to vena cava. Among the causes are: chronic heart disease, especially such 
as results in dilatation of the right heart, asthma, emphysema, bronchiectasis, 
pulmonary fibrosis and portal thrombosis. Such a congestion results in the 
production of central lobular congestion, peripheral anemia and fatty degen- 
eration. The liver is large, though in the presence of long-continued con- 

* In amebic abscesses the pus is of a peculiar "anchovy sauce" character. 



Pulmonary 
form. 



Error 

frequently 

possible. 



Blood. 



Exploration. 



Secondary. 



;c> 



MEDICAL DIAGN 



ges tion it may undergo a certain amount of contraction attended by the 
formation of a finely nodular surface, the section showing dark red markings 



Wataec 

Itrer." 



Nodaies. 



T'zz :-: = s::e, 



E = : : : i : . 



Prints :: 
e-™i.^;e, 



on a light background 



liver. 



Symptoms. — The essential symptom is increase in size, as recognized by 
palpation or percussion, with especial reference to the lower border, or, lack- 
ing this, increased density associated with a certain amount of pressure 
tenderness particularly over the left lobe, the secondary symptoms (such as 
chronic gastric catarrh and intestinal disturbance) and the existence of a 
primary cause. Ascites may or may not be present, according to the degree 
of change produced,, and hematemesis is rare. 

TUMORS OF THE LIVER.— Primary malignant disease of the liver, 
whether sarcomatous or carcinomatous, is excessively rare. Secondary 
carcinomatous growths are common, sarcoma most unusual. 

Secondary carcinoma most often follows involvement of the stomach, 
pancreas, kidney and intestines, and usually first appears in the right lobe. 
As the process advances, the nodular masses tend to soften and become 
umbilicated by central absorption^ this condition being oftentimes distinctly 
palpable. 

Cystic tumors are rare and usually small. They ordinarily originate in 
the gall-ducts, and yield a clear or slightly yellow fluid. 

PARASITIC TSYOLYE'MEXT—Entameba histolytica (tetragerta) is the 
ouise :: practically all tropical hepatic abscesses, being found sometimes even 
in the absence of dysenteric symptoms. The echinococcus 
is the most important of the various other forms :: 
parasites encountered. 

ECHEN'OCOCCUS CYSTS (Hydatid Cysts).— These 
are due to the activity of the embryo of the " echinococ- 
cus granulosus TT (tenia echinococcus). a tape worm, which 
is rarely encountered save in Ireland and Australia, 
though found occasionally in Germany, and now and 
then met with among the Icelanders who have settled 
in British Columbia. The worm is not more thar. % 
inch in length, and belongs properly to the dog. It is 
composed of three or four segments and the mature 
terminal portion is but 2 mm. long and 0.6 mm. wide, 
though it may contain several thousand eggs. The 
head shows a rostellum, four suckers and two rows of hooklets: the 
embryo, provided with six hooks and arranged in pairs, makes its way 
through the intestinal wall and may enter the portal vessel and be carried 
from the liver and the systemic vessels by which it reaches the brain or other 
distant organs, or it may remain encysted in the peritoneal cavity or the 
surrounding muscles. 

It is thought that this embryo may find entrance through infected dust 
as well as through drinking water, and in Australia and Iceland, where the 
disease is most prevalent, the dogs are very generally infected and the 
relation between them and their masters is very close. 




7: :- _-_ — Ten::. 
Echinococcus. 
(Bran*.)* 



ECHINOCOCCUS CYSTS 



969 



General Symptoms of Hydatids. Diagnosis primarily depends upon 
the presence of a cystic tumor and upon the recovery of hooklets from fluids Hookiets. 
discharged or obtained by puncture. The presence of hydatid disease in 
other portions oi the body is of course suggestive. In the liver the symptoms 
are more distinct . owing to the fact that these cysts when superficial yield Tumor, 
to the pleximeter finger upon percussion a peculiar echoing vibration known 
as the "hydatid" thrill. They may be large, and, in this location, produce Percussion 



Such 



thrill. 



Four varieties 



various pressure symptoms, or pyemic symptoms if they suppurate 
cysts, like hepatic abscesses, may rupture in almost any direction. 

The complement-hxation test is referred to elsewhere. It would seem 
probable that it is not specific for Tenia echinococcus, but for the group of 
Tenia, 

CIRRHOSIS OF THE LIVER 

Basic Pathology and Varieties. — The central factor in all forms of cirrho- 
sis of the liver is the increase of connective tissue. 

We have to deal clinically with four varieties: 

(1) Laennec's cirrhosis, the common form of the disease as encountered 
in every clinic. (2) Hanot's cirrhosis. (3) Syphilitic cirrhosis. (4) Chronic 
perihepatitis or capsular cirrhosis. (5) Banti's Disease (see " Splenomegaly).* 

LAENNEC'S CIRRHOSIS.— Etiology.— To an extent etiologically 
signincant it affects the male (75 per cent.), and though encountered in Many factors, 
rare instances in young children it is essentially a disease of the fifth and 
sixth decades of life. Certain of the infections, both acute and chronic, 
may result in cirrhotic changes. Chronic obstruction of the bile ducts, 
chronic passive hyperemia and anthracosis are to be numbered among 
the etiologic factors. Alcohol being the most constant associated factor in Alcohol the 
Laennec's cirrhosis, information concerning the extent and duration of alcoholic 
indulgence is always important. Gout, lead poisoning and the excessive 
consumption of highly spiced and over-rich articles of food, though con- 
tributive factors, are seldom of primary importance. 

Lacking a history of prolonged use of alcohol, a positive diagnosis, though 
justifiable, will often prove erroneous, while a knowledge of previous alcoholic 
indulgence, even though moderate, may explain many obscure gastrointestinal 
symptoms and justify a tentative diagnosis. 

It is possible that syphilis will be found to play a larger part than was 
supposed prior to the introduction of the Wassermann and luetin tests, f 

Morbid Anatomy. — True Laennec's cirrhosis, or " gin drinker s } liver," of 
the classic type is small, hard, resistant to the knife, has about the consistence 
of ''wet leather" and is irregularly lobulated or nodular. It is true, never- 
theless, that as encountered in ward work the cirrhotic liver is a large or 

* The cirrhosis due to chronic disease of the heart or lungs (nutmeg liver) is discussed 
under " Chronic Hyperemia," and a large number of minor forms of minor or trifling path- 
ologic and etiologic interest need not be specially considered in this volume. 

t Although the author's cases arousing this suspicion may have been wholly cases of 
accidental concurrence. 



A diagnostic 
aid. 



"Hobnail 
liver." 



970 



MEDICAL DI 



Source of 

ij~z-.:~i. 



Hi':::;. 



C :-cr;;:Tr 

5j=i;::-5. 



Lata 

recognition. 



normal-sized liver in at least 50 per cent, of the cases, yet possessing other- 
wise all of the characteristics of Laennec's cirrhosis. The little nodules may, 
by the contraction of the fibrous bands, become prominent, and thus form 
the "hobnail liv called from their resemblance in size and general 

appearance to hobnails in a shoe. The color is yellow, and the cut surface 
is mottled with color running from yellow to brown. 

Microscopically, the changes consist in the formation of new connective 

ue around the sheath of the veins, and this, contracting, causes compres- 
sion of the portal capillaries, portal obstruction, and, therefore, congestion 
of all the territory normally drained by the portal vein. 

It tka shronic passive congestion which produces most of the clinical 
symptoms of the disease, such as ascites, chronic catarrhal gastritis, enteritis, 
hemalemesis, bleeding hemorrhoids, hemorrhoidal varices and that distention of 
the superficial abdominal veins known as the Caput Medusa, this last symptom 
appearing, usually, if at all, after the oncoming and long persistence of ascites, 
which is a direct and important contributory factor. 

Symptoms of Laennec's Cirrhosis.— As suggested previously, diagnosis of 
the ordinary form of cirrhosis of the liver depends ordinarily to an unusual 
degree upon the knowledge of the patient's habits and the proper interpreta- 
tion of secondary symptoms. 

Given any case presenting a history of immoderate or even moderate alcoholic 
indulgence extending over a period of many years and showing symptoms of 
chronic gastric catarrh or chronic catarrhal enteritis, even though a history of hem- 
orrhoids and hemalemesis is lacking and the physical signs are indeterminate, 
a tentative diagnosis of an existing hepatic cirrhosis is justified. 

The fact that, at present, the disease is seldom recognized or suspected until 
well advanced, is no doubt due in many instances to a failure to appreciate the 
significance and value of grouped etiologic and diagnostic factors. 

Physical Signs. — The physical signs of the advanced disease may or may not 
be well defined. By arts : ultatory and direct percussion and by palpation one 
ma} - jften make out a decided shrinking in the hepatic outline, especially 
that representing the left lobe, and special stress should be laid upon the fact 
that the early shrinkage is most marked over the left lobe. Quite as often 
the liver is distinctly large though hard (fatty cirrhosis) or, even if of normal 
size, may appear large because of the obligatory descent of its inferior border 
in the event of associated emphysema and resultant low diaphragm. Even 
though the right lobe appears hypertrophic one may often find relative left 
lobe retraction of decided degree. 

The spleen is moderately enlarged, usually just palpable, or but one or 
twe zr^rerbreadths below the costal margin. 

Its degree of enlargement measurably corresponds to the grade of hepatic 
cirrhosis and both it and the liver may undergo considerable fluctuations 
I in size under rest, cardiac stimulation, or the free use of saline cathartics. 

Furthermore, the spleen may undergo decided shrinkage during the ter- 
minal stages of the disease and in some instances weighs no more than the 
normal spleen at autops; 



HEPATIC CIRFH"MS 



971 



Preatrophic 
stage. 



Seldom 
marked. 



The so-called preatrophic stage of mere engorgement is so seldom positively 
determined that it might as well be discarded as unproven. Another fallacy 
is that pertaining to the direct recognition by palpation of the hobnail pro- 
jection on the liver surface. These can sometimes be felt very plainly 
through a thin wall, but no stress should be laid upon negative findings. 
When the atrophic liver con be palpated, the sharp firm edge indicating indura- 
tion is most suggest he and valuable. Any co-existent ascites prevents accurate "Dipping." 
palpation of the liver or spleen until after aspiration of the ascitic fluid. The 
"dipping"' method which consists in burying the ringers by a sharp stroke 
upon the abdominal wall in order to displace the fluid and meet the descend- 
ing liver edge in inspiration is often successful. 

Ascites occurs only in about 60 per cent, of these cases and is always a 
relatively late symptom. 

Hematemesis (from esophageal varices) is absent in about 80 per cent, of cases. 

All definite symptoms relating specifically to the liver itself may be lacking 
until the later stages. 

The Caput Medusa?, so called from its fanciful resemblance to the Medusa 
head, is formed by the enlargement of the superficial veins of the abdomen 
and. when present, is a symptom of much interest and importance, but is a 
comparative rarity, often confounded with the general distention of the 
superficial abdominal veins met with in various conditions producing pres- 
sure and obstruction in the abdominal circuit. 

Diagnostic Summary. — To summarize : The diagnosis of atrophic and fatty 
cirrhosis alike must rest upon mosaic groupings or upon all of the following data : 
a A history of high living, overfeeding, and in nearly every instance alcoholic 
indulgence, (b) Loss of appetite, morning nausea and vomiting, irritable 
stomach, excessive fermentation of the non-stenotic type, constipation or inter- 
mittent diarrhea, and various other symptoms of chronic gastric or intestinal 
catarrh, (c) The recognition of a shrunken, large, or normal-sized, hardened 
liver and a palpable spleen, (d) Loss of weight, strength, activity and color 
(though a ruddy color may persist until late in the disease), (e) Hemorrhoids, 
blind or bleeding, (f) Ascites, (g) Hematemesis. (h) Jaundice. 

This last is an unusual symptom in atrophic cirrhosis, though the author 
has frequently encountered it in a form so extreme and so bronze-like as to 
produce a color strikingly like that seen in typical Addison's disease, though 
diabetes was lacking. The combination of '* bronzing," cirrhosis of the liver, 
and glycosuria forms a syndrome often described but rarely seen. 

It must never be forgotten that the ascites of atrophic cirrhosis ordinarily 
precedes any marked general edema or anasarca and remains usually for a Edema slight. 
long period quite alone or associated with a moderate edema of the lower extremi- 
ties. These cases furnish some typical examples of the u poached-egg belly. " 

Prognosis. — The disease is slowly progressive and beyond curative ther- 
apeutics, though the cessation of the use of alcohol or of any other habits of 
a similar nature, attention given to the heart and stomach and a thoroughly 
hygienic life will do much to lengthen the patient's term and ameliorate his 
discomfort. 



Incurable. 



9/2 



MEDICAL DIAGNOSIS 



Unimportant. 



Readily 
recognized. 



Probably an 
infection. 



Suggestive 
course. 



Marked 
icterus. 



Differential Diagnosis. — Simple atrophy of the liver. This condition 
accompanies various cachexias, characterized by profound exhaustion and 
marasmus, is suggested by such conditions, and is of no great clinical interest 
or importance. 

Xutmeg Liver. — An atrophic nutmeg liver may give rise to much diffi- 
culty, but the preexistence of disease of the lung or heart, and the fact that 
it does not present a primary ascites, but one secondary to or associated with 
a general anasarca, usually suffices for its differentiation. 

Fatty Cirrhotic Liver. — A very considerable number of the cases of cirrho- 
sis that we meet with are cirrhotic fatty livers, a form easily recognized by 
palpation, the organ being enlarged decidedly and of firm consistence. It 
presents no essential difference in symptomatology from that of the ordinary 
atrophic form, and has been included in the description above given. 

Portal phlebitis a)id thrombosis. The diagnosis of this condition depends 
chiefly upon the existence of a potent cause, such as ulceration, gall-stone and 
suppurative diseases, and generally the condition is suggested by a I 
rapid onset of ascites, splenic enlargement, and the other symptoms of por- 
tal obstruction, together with the rapid recurrence of ascites after paracente- 
sis, though this sometimes occurs in true cirrhosis. 

The specific gravity of the clear ascitic fluid is nearly always below 1015 
in the case of cirrhosis, whereas in chronic peritonitis it is distinctly turbid, 
and, in ovarian cyst, of higher specific gravity and containing a greater 
amount of albumin. 

HYPERTROPHIC BILIARY CIRRHOSIS [Hanoi's Disease).— Called 
also "hepatogenous"' and "biliary," this rare disease is characterized by a 
general increase in size and less firm resistance to section than is present in the 
atrophic form. The weight may be double that of the normal liver. Both 
the outer and the cut surfaces are comparatively smooth, much like the sur- 
face of morocco leather and the term unilobular as opposed to multilobular 
is applied to this condition, because of the involvement of individual 
acini rather than of groups. The process is practically a pericholangitis, 
and there is much evidence to support the theory of direct infection as a 
primary cause. 

Cardinal Symptoms. — In its early stages the disease presents the picture 
of recurrent attacks of "catarrhal jaundice." 

It is extraordinarily and insidiously chronic, affecting the general health but 
slightly for years. 

After a time the jaundice and digestive disturbances though mild become 
persistent. The spleen, which previously may have been palpable only 
during the attacks, progressively enlarges and very slowly the case reaches a 
stage justifying the following description. 

The liver is decidedly enlarged; the spleen, always greatly increased in 
size, may attain a weight of even ten times the normal; icterus is intense, progres- 
sive and persistent, and the secondary symptoms of portal obstruction are 
entirely absent, ascites if occurring at all. coming on late as a part of the general 
cachexia. 



BILIARY AND LUETIC CIRRHOSIS 973 

The color of the stools wrongly suggests an intermittent bile secretion.* 
the urine is abundant as contrasted with that of atrophic cirrhosis and con- Urine, 
tains urobilin, bilirubin, and oftentimes albumin. The disease is one of In- 
duration, lasting on the average from rive to ten years. 

SYPHILITIC CIRRHOSIS.— This disease, usually congenital and chiefly Two forms, 
affecting young male adults, may assume either an atrophic or hypertrophic 
type and represents a genuine interstitial syphilitic hepatitis. As seen in 
the adult it is more commonly atrophic: in children, ordinarily hypertrophic. 
A positive diagnosis is never possible, but is rendered probable by the history 
of or by marked external evidence oi syphilis and a positive Wassermann or 
luetin test. 

Symptoms. — The liver edge is peculiarly sharp and indented and the 
surface is grooved and sometimes nodular. Such livers are often fixed by 
adhesions to the abdominal wall or viscera in contact with them. 

In many of these cases one detects the friction of perihepatitis if ascitic 
fluid is absent, as is likely to be the case until late in the course of the disease. 

The spleen is enlarged, ascites is absent or is late in appearing, icterus is 
relatively common as compared to the ordinary cirrhosis and the urine is 
dark and usually albuminous with or without bile pigments. 

SYPHILITIC GUMMATA OF THE LIVER.— These may occur at any 
age as a result either of congenital or, more frequently, acquired syphilis and XodoJes 
vary greatly in size. The clinical picture is that of hepatic cirrhosis, but 
after the removal of any ascitic fluid that may be present, the nodular outline 
of the liver is often appreciable. Pain may be decided and troublesome as 
in the case of hepatic carcinoma. Fever may or may not be present. 

Perihepatic friction and fixation by adhesions are commoner in lues than 
in cancer. The nodules, if palpable, are usually smaller and less progressive 
in growth than those of carcinoma, but may be of great size in some instances. 

Certain cases show a peculiar latency as regards general symptoms. Latent cases. 
though representing marked and easily recognized tumors. 

The most important clinical inference is that when one meets with a nodidar Therapeutic 
liier, with or without symptoms of cirrhosis or history of syphilitic infection, he test " 
should apply the therapeutic test of mixed treatment, and indeed this should be 
applied in practically all cases of solid growths in the abdominal region A 

ACUTE PERIHEPATITIS.— This condition, invariably secondary to 
other diseases of the adjoining viscera, or to direct injury, may take on any of 
the forms of mrlammation common to serous membranes. 

Symptoms. — Pain, both in respiration and passive movement of the liver. 
friction, usually both audible and palpable, and fever, are the important 
symptoms. 

CAPSULAR CIRRHOSIS.— This is merely a chrome capsulitis, the liver 
substance taking little or no part in the process. The same process in the 

* A finding unjustified if interpreted as meaning that no bile passes from the liver to 
the gut It is always present in the duodenal content in biliary cirrhosis in sufficient amount 
to respond to the appropriate tests. 

t As should both Wassermann and luetin tests. 



974 



MEDICAL DIAGNOSIS 



Secondary. 



Characteristic 
picture. 



AJchinical 
curiosity. 



Progressive 
icterus. 



Variable 
fever. 



Profound 
exhaustion. 



Shrunken 
liver 



spleen and peritoneum is said to be its almost invariable accompaniment, as 
is also chronic interstitial nephritis. There are two types, one associated 
with the ordinary symptoms of cirrhosis, the other with adherent pericardium 
and chronic mediastinitis (Pick's disease). 

AMYLOID LIVER (Amyloid Degeneration of the Liver). — This condition 
is invariably secondary to some severe derangement of metabolism, especially 
those associated with inveterate syphilis, chronic septic absorption, as in 
cases of caries of bones and pulmonary tuberculosis of the advanced type. 
It may also be the result of chronic and neglected syphilitic infection. The 
liver is quite firm, insensitive, painless, extremely hard with rounded edge, 
and smooth. All symptoms of portal obstruction are absent and icterus is 
seldom present. The disease almost exclusively affects males (80 to 90 per 
cent.), and is invariably fatal. 

ACUTE YELLOW ATROPHY 

Etiology. — This excessively rare disease chiefly affects women and falls 
mostly upon the third decade. It is frequently associated with pregnancy, 
and has followed profound emotion or shock, syphilis, alcoholic excess and 
various other ill-determined factors. 

Morbid Anatomy. — The liver cells are necrotic, and there is a general 
catarrh of the finer bile ducts associated with hemorrhage between the liver 
cells. The organ itself is greenish yellow, greatly shrunken, flabby, with a 
loose capsule, and on section appears mottled with yellowish brown and red. 
The heart may show fatty degeneration, the spleen is usually enlarged and 
the kidneys may also be degenerated. 

Symptoms. — The picture is primarily that of a catarrhal jaundice succeeded 
in a few days or perhaps two or three weeks by vomiting, perhaps hematemesis, 
subcutaneous and mucous hemorrhage, headache, delirium, muscle tremor and 
sometimes convulsions. 

The jaundice deepens with the onset of the graver symptoms. There is usually • 
no fever, rarely a marked pyrexia. The general condition is that of the typhoid 
state and ordinarily the condition terminates in coma. 

Shrinkage of the liver may greatly reduce or entirely obliterate its normal 
area of dulness. The urine contains bile, frequently albumin, albumose and 
casts. Leucin and tyrosin are frequently but not constantly present, the 
stools are clay colored, urea is diminished but ammonia-nitrogen is increased. 

Differential Diagnosis. — The interesting symptom-group differentiates 
this disease from all others except phosphorus poisoning, in which the three 
leading symptoms, viz.: hemorrhage, profound jaundice and shrinkage of 
the liver may occur. The examination of the luminous vomitus and history 
of the case are the chief distinguishing points. Grave symptoms may occur 
in connection with other diseases associated with jaundice, but the picture of 
acute atrophy is seldom present. 

WEIL'S DISEASE {Acute Febrile Jaundice).— -This disease is with diffi- 
culty distinguishable from an acute catarrhal duodenitis of the severe epi- 



AiTTE YELLOW ATROPHY AND CHOLANGITIS 



975 



demic type. It is supposed to be caused by a Leptospira icterohemorrhagica 
chiefly among butchers and is ordinarily a disease of warm weather, affects 
young and middle-aged adults, and is characterized by early jaundice, 
tenderness and tumefaction of the liver and spleen, severe headache, pain 
in the legs, arms and lumbar region, and, oddly enough, in the masseter muscles. 
The stools are often light as in actual obstructive jaundice. The disease 
lasts for a week or two, the temperature is septic in type, may be moderate 
or high and albuminuria may be present. 

Differential Diagnosis. — The peculiar symptom-complex just described 
offers the only means of differentiation from the ordinary acute catarrhal 
duodenitis which may be but a mild variant of the severer ailment. Malaria 
in its remittent form would show the parasite in the blood, phosphorus 
poisoning by the history of its ingestion, and the odor and phosphorescent 
character of the vomit. The disease is rare and seldom fatal but may 
occur in epidemic form. 

From the most recent reports of Trembur and Schallert, Huebener and 
Reiter and certain Japanese investigators it would appear that a specific 
spirochete {"nodosa") is constantly present in this disease. 



DISEASES OF THE GALLBLADDER 

CATARRHAL JAUNDICE {Cholangitis catarrhalis) .— This is essentially 
a part of a catarrhal gastro-duodenitis, and is clinically an incompletely 
obstructive jaundice; inflammatory products and swelling narrowing the 
caliber and almost completely blocking the opening of the duct. It is 
especially common in children and young adults, but may be met with at all 
ages in connection with acute or subacute indigestion or any of a large num- 
ber of diseases associated with a tendency to catarrhal inflammation of the 
upper intestinal tract. It sometimes is epidemic and due to acute infection | Epidemic 
and in such cases may reach such high grades as to demand and receive special 
description (see "Weil's Disease"). 

A suppurative form also occurs in connection with the severer infections, 
affecting the gall-bladder and gastrointestinal tract. 

Save for the evidence of jaundice (color, light pasty stools, etc.) it may jaundice 
be wholly symptomless or be accompanied by symptoms of indigestion with | E 
vomiting or early and more or less persistent nausea. The loss of appetite 
is often absolute for several days. The liver is usually slightly enlarged, 
but the spleen rarely tumefies. The duration is from two to twelve 
weeks. 

Chronic catarrhal jaundice is merely an expression of chronic obstruc- 
tion, due to any one of many causes. It may be complete or incomplete, 
persistent or intermittent, and will be discussed further under " Cholecystitis" 
and "Cholelithiasis." (See also "Hypertrophic Biliary Cirrhosis.") 

ACUTE CHOLECYSTITIS.— In from 15 to 20 per cent, of the cases a 
cholecystitis exists without gall-stones. The flora of the disease is extensive 



type. 



976 



MEDICAL DIAGNOSIS 



Jaundice 

usually absent. 



Typhoid 

fever. 

Duodenal 

cultures 



and includes the pyogenic staphylococcus, streptococcus, pneumococcus, 
bacillus aerogenes capsulatus. colon, and typhoid bacillus. 

Symptoms in the Typical Case. — It should be stated emphatically thai 
jaundice is usually absent (90 per cent, and that the pain maximum may be 
distinctly localized in the region of the tip of the ninth cartilage over the gall- 
bladder itself, or may first be referred to the epigastrium or even to the region of 
the appendix. Pain usually radiates to the right shoulder and the back, is parox- 

.:! in type and may be agonizing in its intensity. 

There are usually nausea, vomiting, rapid pulse, chit'. pros- 

tration, local tenderness, and a defer. --#>', which in most cases become 

definitely localized over a more or less enlarged gallbladder * 

In old cases of cholelithiasis associated with colic, defensive rigidity is 
so inconstant as to suggest, when present, a perforation. 

The urine may or may not show a toxic ^febrile"! albuminuria. The liver 

is rarely enlarged and the question of splenic enlargement depends upon the 

nature and virulence of the infectious agent. Recurrence is, of course, the 

rule in cases of cholelithiasis or those associated with chronic infections of 
..... 

the viscera m circuit. 

Acute cholecystitis may initiate, or follow, typhoid fever but in such 
of these cases as have been seen by the author the pain was not excessive. 

It would seem probable that an early diagnosis of typhoid fever in the 
cases of primary cholecystic localization might be made through the making 
of cultures from the duodenal contents. 

It is obvious that a mild but important inflammation may exist without 
any exudate sufficient even to cause distention, especially if some drainage 
possibilities are maintained. 

Atypical Cholecystitis. — A large proportion of the cases of acute cholecys- 
titis fail to give the striking clinical picture above outlined. 

This is particularly true of cases complicating other diseases, but applies 
also to the exacerbations of chronic cholecystitis, with or without actual 
cholelithiasis. 

Pain may be slight or represented by mere distress or discomfort in the 
region of the gallbladder. 

Tenderness may be demonstrated only by special maneuvers which combine 
deep thumb pressure over the gallbladder with deep respirator)- movements. 

Localized defensive rigidity is present at times when other signs fail. 

Fever may be wholly submerged in that of any primary disease present, 
or. in the absence of such primary ailment, be only slight and evanescent. 

Vomiting may be wholly absent and even nausea only slight. 

Knowing the peculiar difference in the amount and character of the exu- 
date associated with infection by various pathogenic microorganisms, one 
cannot doubt that many cases yield no recognizable signs nor produce any 
overdistention of the gallbladder itself. 

Inasmuch as the minor cases may be of the utmost importance in diag- 
nosis, the student should not be led to assume that the striking classic 
* Such enlargement is usually associated with the presence of gall stones. 



CHOLECYSTITIS AND CHOLELITHIASIS 



977 



symptoms must exist. In typhoid especially the condition is very generally 
overlooked though the gallbladder is often distended and palpable. 

Distention of the Gallbladder. — This constitutes the most constant of 
the many expressions of cholecystitis and may be present when the others 
are slight or undemonstrable, save perhaps tenderness which in some degree 
is its almost invariable accompaniment. 

CHOLELITHIASIS. — Gall-stones may be single or present in hundreds 
or thousands (usually from 5 to 10 or 12).* They may vary in size from 
mere grains to stones measuring 6 inches or more in length, are polygonal with 
smooth facets, when multiple, more rarely single and smooth, ovoid or round. 
They have a nucleus, usually of bile pigment, and various bacteria are 
actively concerned in the inflammation or congestions, resulting stasis, de- 
composition, and cellular disintegration, initiating, and contributing to their 
formation. 

Section of these stones shows a laminated structure with radiations, and 
an analysis reveals biliary and fatty acids, magnesium and calcium salts 
and even traces of iron and copper. 

Cholesterin constitutes the bulk of the common type of gall-stones, the 
color is brown, yellow or even white and when just removed they are some- 
what soft, have a greasy feel and occasionally the surface of a solitary stone 
may be rough and mulberry-like. The mixed bilirubin-calcium stone (con- 
taining 25 per cent, cholestrin), the pure bilirubin-calcium stone and various 
other unusual forms may be found. It is probable that typhoid and colon 
bacilli^ are especially potent in relation to gall-stone formation, the strepto- 
coccus much less so. Autopsies show an astonishing large number of cases 
of gall-stones and prove that during life they have in many instances yielded 
no symptoms save, perhaps, "flatulent indigestion." 

Autopsies also demonstrate the frequent concurrence of gall stones and carcinoma of 
the gallbladder, the latter disease being seldom found without the former. This should 
not be misinterpreted as indicating that patients with cholelithiasis unoperated, are likely 
to die of primary carcinoma of the gall-bladder, a relatively rare condition. 

Frequency. — Autopsy records show that frequently in women of middle 
age and to a much less degree in males gall-stones are present. In women 
over sixty years of age the figures reach 25 per cent. 

It is wholly probable that of all cases of cholelithiasis 80 per cent, show 
gastric dyspeptic symptoms only and wholly lack the classical picture and. 
frank signs which depend almost wholly upon concurrent cholecystitis. 

All dyspepsias coming on in middle age after preceding immunity should 
especially suggest cardiovascular disease, gall-stones or carcinoma. 

Usually, their migration into the ducts give rise to biliary colic yet the 
passage of small stones may cause no pain whatever. f 

* 7802 were found by Otto in one case, Archiv fur Klinische Chirurgie, ci, 54, 1013. 

f Naunyn's statement that 90 per cent, of the women who suffer from lithiasis have 
borne children would lead one to ask what proportion of the female population from which 
the cases are derived represents spinsters or barren wives. Unless this is stated the figure 
is valueless for statistical purposes. 
62 



Distention 
and tender- 
ness 

Number. 

Size and form. 



Structure and 
constituents. 



97 8 



MEDICAL DIAGNOSIS 



Pain. 



Tenderness. 



Jaundice 
variable. 



Chief diag- 
nostic points. 



Misleading 
conditions. 



Women are far more susceptible than men to cholelithiasis, three, four, 
or five to one according to the (inevitably fallible) statistics and this is ascribed 
in part to tight clothing, deficient breathing and lack of exercise. It has been 
asserted that 40 per cent, of the women patients show the deeply grooved 
corset liver, an assertion to be taken cum grano salis, yet, doubtless, express- 
ing a general truth. 

The ailment is one usually discovered only in middle age and is a very 
common accidental autopsy or operative finding. 

Biliary Colic. — This is characterized by violent and abrupt pain in the right 
hypochondriac region or epigastrium, radiating to the shoulder-blade, with vomit- 
ing, sweating, circulatory depression and usually intermittent fever which may 
or may not be preceded by a sharp chill. 

The tenderness and defensive muscular rigidity tend after a time to become 
localized in the region of the tip of the ninth costal cartilage, the liver and spleen 
may or may not be enlarged, and the urine frequently contains albumin. 

If the stone be in the first or second portion of the cystic duct, there is no 
jaundice, or but a suggestion of it, indicating a complicating cholangitis. 

If the stone is in the common duct or the terminal segment of the cystic 
duct, jaundice may be present, either persistent and severe, or slight and 
transient. 

It is usually more intense and persistent if the terminal segment of the 
cystic duct is involved (pressure upon common or hepatic duct). 

These attacks may or may not be repeated at irregular intervals until 
the stone passes onward or backward or is removed by operation. Death 
rarely occurs during an attack, though phlegmon, necrosis, rupture and gen- 
eral peritonitis are dread possibilities. 

The location of the pain in the upper abdominal and lower thoracic seg- 
ment with localized tenderness (best elicited by deep pressure maintained 
both during full inspiration and expiration), and perhaps a history of previous 
attacks, are the chief distinguishing features. A case recently observed 
showed no tenderness over the liver or gallbladder even under forcible deep 
upward pressure in deep inspiration and expiration and the pain was invari- 
ably left-sided. 

The stools should be carefully examined for calculi during and immediately 
after a supposed attack. 

Gall-stones, cholecystitis or adhesions from any cause may alike give rise 
to recurrent attacks of more or less severe pain, and an old gastro-duodenal 
ulcer or even pylorospasm may, through the same cause, be associated with 
symptoms hardly distinguishable from those of gall-stone colic. 

Obstruction of the Common Duct. — Obstruction may be clinically abso- 
lute* with profound and persistent jaundice (pale stools, etc.), and be due to 
one or several stones, or it may be only partial with absent or only remittent 
jaundice. The so-called ball-valve stone is sometimes present producing 
paroxysmal chills with fever and sweating, persistent but variable jaundice 

* According to the reports of B. B. Cronin and others bile is seldom wholly absent from 
the duodenal contents in common duct block, unless the cause is carcinoma. 



CHOLELITHIASIS 



979 



(intensified during the paroxysm), hepatic pain and decided dyspeptic 
symptoms.* 

Suppuration may or may not complicate common duct stones, and 
empyema of the gallbladder and even hepatic abscess or perforation may 
occur. 

Cystic Duct. — Even in complete cystic obstruction jaundice may be slight 
or absent, the gallbladder is distended, unless the case is one of long standing 
and atrophy of the gallbladder has occurred, and it may attain an enormous 
size. Complicating cholecystitis is common and is occasionally of the sup- 
purative type with empyema of the gallbladder. Calcification of the walls 
and atrophy may occur and in some cases is so complete as to leave hardly a 
trace upon superficial examination. Fever is less often present than in 
stone of the common duct. 

General Comment. — The utmost diagnostic difficulties may be experienced 
in both acute and chronic forms of cholelithiasis or cholecystitis, and the greatest 
stress must be laid upon the location of the pain and the presence of localized 
tenderness, irrespective of jaundice which of course greatly assists the diagnosis 
when present. 

A palpable gallbladder usually moves with respiration, has its point of 
attachment in the region of the ninth costal cartilage and is movable only in 
a small segment of the circle whose center is its attachment. 

It should be noted that jaundice of marked degree is absent in complete 
obstruction of the cystic duct, and a distended gallbladder is rare in ob- 
struction of the common duct. 

The linguiform process of Riedel and Cruveilhier (Riedel's lobe) is espec- 
ially common in chronic disease of the gallbladder, though occasionally 
present in other abdominal ailments (Moynihan). It may lie to either side 
of, or overlay, the gallbladder, and is clinically a small freely movable but 
attached linguiform body, which lacks pendulum motion and has a sharp 
edge. 

Stone of long standing in the common duct is usually associated with a 
contracted gallbladder. The same condition may occur in old cystic duct 
cases, but the usual stage observed is one associated with distention. In 
malignant disease blocking the common duct, there is profound and per- 
sistent and progressive jaundice, slight or no localized pain, but progressive 
weakness and emaciation. Finally, all degrees of pain, fever and tenderness 
may be absent. 

* The combination of gall stone colic and chill almost always indicates a common duct 
stone. 



Septic angio- 
cholitis. 



Enlarged 
gallbladder. 



Atrophy. 



Often 
obscure. 



Chief symp- 
toms. 



Jaundice. 



| Riedel's 
lobe. 



Malignant 
cases. 



980 MEDICAL DIAGNOSIS 



Infection and Immunity 

A Brief Summary of Some of the Important Principles Underlying 

THE "WASSERMANN" REACTION AND CERTAIN OTHER 
TESTS INVOLVING COMPLEMENT-FIXATION, AGGLU- 
TINATION, PRECIPITATION AND ALLERGY 

Present Status of the Doctrine of Immunity. — The question of the mech- 
anism of immunity is in a state of flux. The ingenious and helpful, but 
complex theory of Ehrlich is somewhat severely shaken by the most recent 
developments in Serology and the entire theoretical groundwork is likely to 
undergo many radical changes in the near future. 

Its most vital phenomena, however, as embodied in its practical applica- 
tion, are relatively straightforward and lend themselves to simple descrip- 
tion. Many permit also their clinical use at the hands of any man who is 
educated along modern lines, even though not a serologist. 

The ll Wassermann Test" is not of that group. On the contrary, when it is 
in any but expert hands, the findings are not only untrustworthy but misleading 
and most calamitous in results with respect to errors of omission and commission 
alike. 

Nature of the Wassermann Test. — It is a test of the fixation or non- 
fixation of complement in the blood serum or spinal fluid of an individual 
suspected of syphilitic infection, past or present, and its intelligent discussion 
involves a brief review of both infection and immunity. 

Infection.— Reduced to its simplest terms " infection" means the invasion 
of the body by pathogenic parasites, animal or vegetable, under conditions 
which so favor or permit their lodgment, persistence, and reproduction, as to 
produce direct or indirect injury to their host. 

Arbitrary Divisions. — The line drawn between infection by bacteria or 
fission-fungi and that due to the parasitic worms or insects rests largely 
upon the greater size of the latter and their greater tendency to cause direct 
damage to their host, either of themselves or through their larvae. 

This line is not a clearly defined one inasmuch as mass-effects such as 
thrombi and emboli may be produced by microparasites, and most virulent 
tissue poisons by macroparasites. 

Bacterial Toxins. — The chief pathologic effects of pathogenic bacteria 
result from the action of soluble poisons, specific for the individual bacterial 
species, and representing either a secretion or excretion of the bacterium in- 
volved or a pathogenic element of its cytoplasm liberated at its death or 
elaborated during its gradual dissolution. 

Exotoxins and Endotoxins. — A distinction is drawn between "true" 
toxins ("Exotoxins") such as those of diphtheria, tetanus, B. botulinus and 
B. pyocyaneous, all products of cell metabolism, secretion or excretion, and 
"endotoxins" bound by the cell cytoplasm during its life and released only 
by its death and disintegration. 



INFECTION AND IMMUNITY 98 1 



"Exotoxins" are present in liquid culture media containing such of the 
pathogenic parasites as produce them, and alone give rise to powerful "anti- 
toxins" in infected individuals. 

The "endotoxins" can be obtained readily, if at al 1 , only after the 
death of the bacteria which contain them, and their effects are obtained 
by the use of such dead bacteria or to a less degree by extracts of such 
parasites. 

Leucocytosis and Chemotaxis. — Various substances stimulate the pro- 
duction of leucocytes and determine their localization and accumulation at 
the point of maximal tissue reaction, i.e., they are "chemotaxis-inducing 
substances" best exemplified in the case of the pus-producing (pyogenic) 
cocci but in some degree resident in all bacteria pathogenic or otherwise 
as well as in the products of cell disintegration whether of the tissues or of 
the leucocytes themselves. 

This phenomenon sometimes wholly fails (negative chemotaxis). 

Bacterial Hemolysis. — The growth and multiplication of many species of 
bacteria within the living tissues is associated with a marked destructive 
effect (hemolysis) upon the red-blood cells, these yielding up their hemo- 
globin to the blood plasma. 

Ptomains. — These bacterial products, toxic or non-toxic, and resembling 
alkaloids, are formed without the body, and depend for their production 
largely upon the nature of the culture medium and for their toxicity chiefly 
upon the oxygen supply. 

Any one of several bacterial species may produce the same ptomain. 
Their chief importance lies in the clinical domain of food poisoning (meat, 
milk, etc.). 

Selective Affinities and Effects of Toxins. — Most astonishing selective 
localization and tissue affinities are demonstrable with relation to many bac- 
terial toxins, a notable example being afforded by that of tetanus which 
promptly seeks a locus in, and exerts its chief pathogenic effects upon, the 
central nervous system. 

IMMUNITY. — There are several forms of immunity; i.e., (a) that which 
is inherited, i.e., "natural" immunity; (b) that which results from poisoning 
or infection and toxemia, by substances or microorganisms capable of con- 
ferring immunity upon their host, i.e., "acquired" immunity: (1) that which 
is artificially induced by systematic inoculation with graduated doses of bac- 
teria or toxins, i.e., "active" immunity; (2) that which is produced by gradu- 
ated systematic doses of immune substances recovered from immunized ani- 
mals, i.e., "passive" immunity. 

Mechanism of its Production. — The vital factors in immunity are rela- 
tively simple; the complexities of their variants, enormous. 

The toxicity of specific bacterial poisons varies greatly with respect to 
the species and even the strain producing the toxin, and in most instances 
equally so with respect to the individual attacked, whether the bacteria carry 
endotoxins or exotoxins. "Dosage" and strain- virulence are also important 
factors, but even against such poisons as diphtheria-toxin and the virulent culti- 



982 MEDICAL DIAGNOSIS 



vable filtrable virus of acute infectious poliomyelitis ("infantile paralysis") 
many individuals possess a high degree of natural immunity. 

Requisites for Immunity. — Obviously immunity must depend upon (a) 
some peculiar characteristics of the tissues which make them inimical to bacterial 
growth; (b) the blocking of channels of entrance, or (c) the possession by the body 
cells and fluids of properties or qualities necessary to the prompt organization 
of an effective defensive mechanism. 

Antibodies. — It is wholly rational to assume such a defensive mechanism 
for body tissues and to assert that not only must bacteria be destroyed or 
rendered inert, but that their toxins must, in some degree, be neutralized or 
so " bound" as to be rendered harmless. 

We find these requirements met by the production of il bacteriolysins," 
" immune-op sonins " " agglutinins" " precipitins" " cytolysins" " antitoxins " 
and the like. 

When one attempts to formulate exact processes he at once enters the 
realm of speculation. All that we know positively is that certain phenomena 
occur, which are readily demonstrable and, in great part, easily reproduced 
in the test-tube {"in vitro"). 

Correlation of these phenomena permit certain general deductions of a 
-most helpful and constructive sort, but of the exact nature and form of the 
basic reactions we know little or nothing. 

Processes Producing Immunity. — Phagocytosis, the envelopment and 
destruction of bacteria by the leucocytes is a readily demonstrable process, 
but certainly not the chief and most effective one. 

Opsonins. — These will be discussed further on, but the readers will recall 
that their assumed function is to so affect the invading bacteria as to pre- 
pare them for, or to facilitate, their inclusion and digestion by the leucocytes. 

How great the part played in immunity by phagocytosis and opsonic 
substances, we do not know. 

In all forms of immunity, natural, acquired or artificial, it is wholly 
probable that the same factors are dominant in each. 

Antigens. — This term applies not alone to bacteria, animal parasites, or 
filtrable viruses, but to proteins, which act as poisons to the tissues, either 
directly, or through split products. To a large degree they cause speciOc 
defensive responses on the part of the organism attacked, in so far as these may 
be determined by the selective activity of the so-called antibodies produced. 

That these u specific" antibodies are not always specific with reference to 
the bacterium itself, but may react chiefly or only to substances liberated 
or elaborated as the result of a specific infection, is demonstrated by the later 
findings with reference to the Wassermann reaction, in which it is evident 
that the antigen best calculated to demonstrate the presence of syphilitic 
antibodies is obtainable from certain normal tissues (heart-spleen),* and 

* Noguchi's antigen is the acetone-insoluble heart-spleen residue obtained by extraction 
with alcohol, evaporation, solution in ether and precipitation by acetone. A portion 
redissolved in ether and shaken up in salt solution until fine suspension is attained, is ready 
for use. 



INFECTION AND IMMUNITY 



983 



consists largely of cholestrin, sodium oleate and lecithin. On the other hand 
it is found that the Treponema pallidum itself or an extract of it cannot 
successfully be employed. 

These disconcerting findings do not affect the fact that the Wassermann 
reaction seems clinically specific for syphilis.* 

Bacteriolysis. — A direct knowledge of the phenomena attendant upon the 
destruction of bacteria in specific immune serum arrived by successive steps 
of which Pfeiffer's reaction was the most clarifying. 

Bacteriolysis was first reported by Pfeiffer in 1894 who discovered that 
living cholera vibrios introduced into the peritoneal cavity of a guinea-pig 
previously rendered immune to cholera were rapidly destroyed after prelim- 
inary loss of motility, f ' 

From this it was evident that the serum of an animal rendered immune to 
any bacteria or their toxins may, under proper and known conditions, de- 
stroy such bacteria and dissolve them {bacteriolysis). 

It was shown further that exactly the same destructive process might be 
demonstrated in a test-tube ("in vitro"), containing living cholera-vibrios 
(or extracts of dead cultures), and the serum of a cholera-immune, provided 
that the serum had not been heated to 56°C. or more. Once so heated it 
was inert ("inactivated") and so remained until some fresh serum, immune 
or unimmune, was added when it immediately became "activated" and lethal 
for the specific microorganism. 

It was thus shown that immune serum contains substances lethal for the 
specific species of bacterium producing the immunity and that the antibacterial 
activity depends in great part upon a " thermolabile" and a " ther mo stabile" 
substance, both of which must be present in the serum. 

It also proved the specificity of the thermostabile (resistant to heat), sub- 
stance, and the lack of specificity in its thermolabile (non-resistant to heat) associate. 

Substance Sensibilatrice. — The " thermostabile " substance, "Substance 
Sensibilatrice" (Bordet), or "Amboceptor" (Ehrlich) is permanent when once 
formed for defense against the specific pathogenic microorganism, or its toxin. 

The "Alexin" or " Complement."— The "thermolabile" body (" Alexin," 
i.e., "Complement") exists in all fresh serum, but is relatively impermanent 
outside the living body. 

The conditions described might be represented thus, in relation, for 
example, to cholera vibrios. 

Fresh Normal "non-immune" serum ("complement" only) + cholera 
vibrios = No effect. 

Fresh "Immune" serum unhealed ("specific amboceptors" only) + 
vibrios = No effect. 

Fresh "Immune" serum unhealed ("complement" and "specific, ambocep- 
tors") + vibrios = Bacteriolysis. 

*The only exceptions now known being leprosy, sleeping sickness, scarlet fever 
and "yaws." 

tThe agglutinins were first thoroughly studied by Gruber and Durham in 1896, the 
"precipitins" by R. Kraus in 1897. The action of each was manifested in Pfeiffer's original 
procedure. 



984 MEDICAL DIAGNOSIS 



Fresh "Immune" serum heated ("specific amboceptors" only) -f- normal 
scrum ("complement") -f- vibrios = Bacteriolysis. 

It is evident that the specific antibodies cannot destroy the bacteria if 
complement (alexin) is lacking. Furthermore, we know that if the amount 
of complement added to an immune serum falls below a certain amount, or, 
if this complement is in part already bound by other immune bodies, bacterio- 
lysis is incomplete {"complement deviation"). 

COMPLEMENT ALEXIN FIXATION .—From the foregoing it is 
evident: (a) thai complete binding and destruction of the invading bacterium 
demands specif c amboceptors; (b) that these are helpless without complement; 
(c) that this substance itself becomes bound ["fixed") in the bacteriolytic process. 

Fundamental to Test. — It therefore follows that if any properly pro- 
portioned mixture, consisting of inactivated immune serum, its spi 
antigen, and fresh complement, were placed under conditions of time and 
temperature, most favorable to bacteriolysis, all complement would become 

ted" (bound) and. because of that fact, the serum could not afterward 
be used to supply complement for the "activation" of any other. 

If such an inactivated serum was not immune to the specific antigen 
employed the "complement"'' would not become fixed, when added, and the 
serum could supply it to. and thereby activate, any other serum. 

Thus, in the case of the reaction of freshly activated serum, from a patient 
suspected of a disease capable of conferring immunity, the behavior of its 
complement toward a known immune serum containing antigen and specific 
amboceptor, but no complement, determines the presence or absence of 
specific amboceptor in the patient's serum and the existence or non-existence, 
past or present, of the suspected ailment. 

The Hemolytic System. — In hemolysis, the counterpart of bacteriolysis, 
the substance brought into solution is the hemoglobin of the red blood cell 
"laking of the blood "). 

Positive Test for Hemolysis. — Rabbits may be immunized against the 
erythrocytes of the sheep, which, ordinarily, would produce hemolysis, and 
their immune serum will destroy washed sheep's erythrocytes and indicate 
the solution of their hemoglobin by assuming a red coloration. 

Negative Test for Hemolysis. — If such immune serum is robbed of its 
complement by heating ''inactivated), before the washed sheep's cells (anti- 
gen) are added, no hemolysis occurs and the mixture shows only a red sedi- 
ment and translucent upper stratum. 

These phenomena of hemolysis become extremely useful in connection 
with the complement fixation tests, as a means of determining the question of 
free or bound complement in suspected sera through a striking color change. 

Application to Syphilis. — If to a heated 1 inactivated) serum taken from 
a patient suspected of syphilis, we add the correct amount of fresh complement 
guinea-pig serum) and a carefully proportioned amount of the proper antigen, 
and incubate the mixture to promote the activity of any specific amboceptors 
which it may contain, we know that the complement will become wholly 
bound if the patient is a syphilitic. 



INJECTION AND IMMUNITY 



9»S 



If one has some of the serum of a rabbit immune to sheep's blood, heats 
it to destroy its complement, and treats it with washed sheep's corpuscles 
(antigen), all of the elements of an hemolytic system are present, save one, 
and it will produce hemolysis so soon as "complement" shall be supplied, 
and not before. 

If, therefore, this is added to the foregoing incubated mixture and hem- 
olysis occurs, it proves that the serum of the syphilis suspect was free from 
syphilitic antibodies, contained unfixed complement, and through it, was able 
to complete the hemolytic system, necessary to hemolysis. 

If hemolysis does not occur in such an instance, syphilis is proven by the 
fact, thus established, that binding (" fixation") of the complement of the 
suspected human serum must previously have taken place and rendered the 
syphilitic serum incapable of activating any other. 

All this sounds simple, but in reality involves a maze of complexities and 
opportunities for damaging error. The commoner methods of actual applica- 
tion of the test, as described by Zinsser* in his admirable book, are quoted here: 

THE WASSERMANN REACTION 

Titration of Hemolytic Amboceptor or Sensitizer 

Titrations of both sensitizer and alexin should be made. For practical 
purposes it is quite enough to titrate the hemolytic sensitizer every few weeks 
and use a stated amount in successive reactions. The alexin or complement 
can then be titrated individually for each set of reactions. Examples of such 
preliminary titrations follow: 

Rabbit injected 3 times at 5-day intervals with washed sheep corpuscles 
. . . .,3,4, and 5 c.c, and bled 10 days after the last injection, f 

This serum is inactivated at 56°C. for 20 minutes. 



Washed sheep corpuscles 

5 per cent, emulsion 

in salt solution 


Sensitizer 


Fresh 
guinea-pig 
serum 


Hemolysis 


I I C.C. . 


O.OI 

0.005 
0.003 

O.OOI 

. . 0005 
. 0002 


O. I 
O.I 
O. I 
O. I 
O. I 
O. I 


+ + + 


2 1 I C.C 


+ + + 
+ + + 
+ + + 
+ + 
± 


2 I C.C 


4 I C.C 


c 1 c.C "..... 


6 1 c.c 



I c.c. 
I c.c. 



salt sol. 



* "Infection and Resistance." Hans Zinsser, The Macmillan Co., New York, 1914. 

t In immunizing animals with blood cells for this or any other purpose it is necessary 
to wash the cells very carefully in salt solution. Unless this is done blood serum or plasma 
will be injected with them and the treated animal will respond by the formation not only of 
hemolysin but of precipitins for the serum proteins as well. When a subsequent hemolytic 
test is carried out, a precipitin reaction between the precipitin in the antiserum and serum 
adhering to the corpuscles will follow, and this, as we have seen, will fix alexin, obscuring 
other reactions which may be under observation. 



986 



MEDICAL DIAGNOSIS 



In this case o.ooi c.c. still causes complete hemolysis of i c.c. of a 5 per 
cent, emulsion of sheep cells (volumetric measurement of cells sedimented 
in the centrifuge), and this amount (J'1000 C - C -) is called the " hemolytic 
unit" of sensitizer; two units are then used in the reactions. 

Against these cells alexin can, in each case, be titrated as follows: 

Alexin Titration: 

Fresh Guinea-pig Serum Pipetted from Clot 





Red cells 
S per cent, emulsion 


Sensitizer 

as above 

determined 


Guinea-pig 
serum 


Hemolysis 


I 

2 

3 

4 


I C.C. 

I c.c. 
1 c.c. 
I c.c. 


2 units (0.002) 
2 units (0.002) 
2 units (0.002) 
2 units (0.002 


O.I c.c. 
0.05 c.c. 
0.025 c.c. 
O.OI c.c. 


+ + + 
+ + + 
± 



The smallest amount of alexin which completely hemolyzes the red cells 
(0.05 in this case) is the amount used. Since it is easier to measure larger 
volumes with accuracy, the alexin is diluted 1 to 10 in salt solution before use. 
A typical Wassermann reaction can then be carried out as follows : 

Scheme for Wassermann Test 
adapted to original wassermann system after scheme of noguchi 





Test with 


Test with known 


Test with known 


Test without serum 




positive syphilitic 


negative normal 


to control efficiency 






serum 


serum 


of hemolytic system 


5 
o-fi 


Serum 2 c.c. 


Serum 0.2 c.c. 


Serum 0.2 c.c. 




2 § 


+ 


+ 


+ 




co 2 


Complement 


M _ Complement 


Complement 


Complement 




0. 1 c.c. 


g 0.1 c.c. 


0.1 c.c. 


0. 1 c.c. 


ps 


+ 


1 + 


+ 


+ 




Salt sol. 


- Salt sol. 


Salt sol. 


Salt sol. 




3 c.c. 


3 c.c. 
4- 


3 cc. 


3 c.c. 




2. 


6. 


8. 




Serum 0.2 c.c. 


Serum 0. 2 c.c. 


Serum 0. 2 c.c. 






+ 


+ . 


+ 






Complement 


Complement 


O Complement 


Complement 




0. 1 c.c. 


6 O.I C.C. 


0. 1 c.c. 


0.1 c.c. 


^ 8. 


+ 


» + 


+ 


+ 


O M 


Antigen 


5 Antigen 


Antigen 


Antigen 


e8 

O _ 


(required amount 


jj 








in 1 c.c. salt sol.) 


> 






& 


+ 


^ 


+ 


4- 




Salt sol. 


H Salt sol. 


Salt sol. 


Salt sol. 




2 c.c. 


2 c.c. 


2 c.c. 


2 c.c. 




1. 


3- 


5* 


7- 



O = Test-tube. 



INFECTION AND IMMUNITY 987 



Place in water bath at 40° C. for one hour, then add to all tubes washed red blood cells (of 
sheep) and hemolytic amboceptor. These are previously mixed so that 2 c.c. contains the 
equivalents of 1 c.c. of a 5 per cent', emulsion of sheep corpuscles and 2 units of amboceptor. 
Again expose to 40° C. 

If the serum tested is positive, tubes 1 and 3 should show no hemolysis, all the other 
tubes showing complete hemolysis in one hour. 

Since many human sera normally contain small amounts of antisheep sensitizer, it is the 
habit of many workers to add the sheep corpuscles, without the sensitizer or amboceptor, 
and incubate for a half -hour. If. at the end of this time, no hemolysis has occurred either in 
the front or the back row, then amboceptor may be added. This technic avoids the pos- 
sible error introduced by an excess of amboceptor, a condition which easily occurs when 
anv large amount is normally present in the serum and in addition to this 2 units are added 
as in the test described above. 



The foregoing represents the typical '"Wassermann" as at present carried 
out in most laboratories. It may be carried out just as well and with greater 
economy of material by using one-half the amounts throughout. It is 
evident that the performance of the reaction calls for experience of serum 
technic. and knowledge of such reactions, so that fortuitous irregularities 
may be intelligently controlled. It is our opinion that the performance of 
routine Wassermann tests by workers without a thorough knowledge of the 
fundamental facts of serum phenomena is worse than useless in that insuffi- 
cient attention to special conditions and to details may easily result in a posi- 
tive reaction when syphilis" is not present, and vice versa. 

Many modifications of the Wassermann test have been suggested. Prob- 
ably the most important is that of Xoguchi. The chief justification for this 
modification is the fact that many normal human sera contain hemolysins for 
sheep corpuscles. For this reason many workers carry out the ordinary Was- 
sermann technic without adding antisheep sensitizer or amboceptor until 
they have hrst observed whether or not the tested serum (in the •"'back row." 
without antigen i will not hemolyze the corpuscles without such an addition, 
adding the sensitizer only when this does not take place. This is advisable 
since the presence of any considerable amount of normal antisheep sensitizer 
in the human serum which is being examined (if added to the amount used in 
the ordinary reaction, 2 units), may so increase the total quantity that 
hemolysis will result even after most of the alexin has been fixed. Xoguchi 
excludes this uncertainty by avoiding the use of the " sheep-cell-antisheep 
sensitizer" system entirely, substituting a hemolytic complex consisting of 
human cells and antihuman sensitizer, produced by injecting washed human 
corpuscles into rabbits. 

His technic may be best illustrated in the following tabulation: 

Reagents 

1. Sensitizer prepared by injecting washed human blood corpuscles into rabbits. 

2. 1 per cent, emulsion of washed human blood cells. 

3. Alexin — fresh guinea-pig serum diluted with one and one-half volumes of salt solu- 
tion, 40 per cent 



988 



MEDICAL DIAGNOSIS 



The reaction is performed in the following way: 
Noguchi's Method of Complement Fixation for the Serum Diagnosis of Syphilis 





Set for diagnosis 


Positive control set 


Negative control set 










Test with the serum 


Test with a positive 


Test with a normal 










in question 


syphilitic serum 


serum 










a. Unknown serum, 


a. 'Positive sypb. 


a. "Normal serum, 






iT 


* 


i drop* 


serum, i drop* 


i drop* 




u 


a 




b. Complement, 


b. Complement, 


b. Complement, 




O 


jo 


a 

Pi 


2 units 


2 units 


2 units 


3 




H 

3 


c. Corpuscle 


O c. Corpuscle 


c. Corpuscle 


J3 




Xt 




susp., I c.c. 


susp., I c.c. 


susp., I c.c. 


5 


03 

a 

cS 

id 


u 03 
o a> 




a. Unknown serum, 


a. 'Positive syph. 


a. "Normal serum, 




i drop* 


serum, i drop* 


i drop* 


CO 


'-3 3 

a* 3 


"s 


* 


b. Complement, 


b. Complement, 


b. Complement, 


a 


•s' 3 






2 units 


2 units 


2 units 


o 


cS 


04J 

+3 «* 


C 
o 


c. Corpuscle 


c. Corpuscle 


c. Corpuscle 








Pm 


susp., I c.c. 


susp., I C.C. 


susp., I c.c. 


o 

a 


T3 G 


§5 

a 




+ Antigen 


+ Antigen 


+ Antigen 






i— i 



Since the reaction is not a specific antigen-antibody union but depends 
on some substance liberated or produced by reason of the syphilitic infection, 
it is not out of question that other infections may give rise to a "positive 
Wassermann," and this, indeed, is the case. It was claimed for a time that 
a positive reaction may be obtained in tuberculosis, but this has been refuted 
by subsequent experience, and the earlier positive results probably depended 
upon faulty technic. There can be little doubt, however, that occasional 
positive reactions are obtained in cases of leprosy, scarlet fever, malaria, and 
trypanosoma infections. 

The spinal fluid may be used instead of the blood serum in cases of syphilis 
of the central nervous system, but even here, as Citron f has shown, the 
results with blood serum are more frequently positive than those done with the 
spinal fluid itself. In isolated cases positive reactions have been obtained 
with ascitic fluids, pleural and pericardial exudates. 

Controls. — In the first procedure it will be noted that tubes i and 3 con- 
tain a complete lytic system, i.e., activated' human serum, the one that of a 
known syphilitic; the other that of the suspect. No. 5 contains a serum 
known to be non-syphilitic. No. 7 contains no serum. Nos. 2, 4,6, 8, con- 
tain no antigen. All receive fresh complement (fresh, normal guinea-pig 
serum). 

All are incubated, merely, for an hour. This incubation furnishes the ideal 
temperature, and adequate time, for the complete fixation of fresh comple- 
ment in any syphilitic serum. 

* When working with inactivated serum 4 drops (0.08 c.c.) should be employed. 
With cerebrospinal fluid 0.2 c.c. (not inactivated) is used. 

(Taken from Noguchi's "Serum Diagnosis of Syphilis," Lippincott, 1910, p. 57). 
t Citron. Deut. med. Woch., 1907, No. 29, p. 1165. 



INFECTION AND IMMUNITY 989 



Addition of Hemolytic System. — Adding the washed red-blood cells of the 
sheep and the serum of rabbits immunized against them, but no complement, 
must result in hemolysis in all tubes containing previously unfixed comple- 
ment. This we know is true of all save tubes 1 and 3, and certainly not 
true of 3, which contains known syphilitic serum. It is evident that com- 
plement remains unbound certainly in every tube save 1 and 3; must be bound 
in both of these if syphilis is present in the suspect or remain free in i if the 
reaction is negative for syphilis. 

From what has gone before it is obvious that the following events will 
ensue: (,See page 907.) 

Tube 1 (Suspect) may or may not fix the added complement. Tube 3 
must fix complement for the source of the serum is a known syphilitic. No 
change in color. 

Tubes 5 and 7 will not affect complement; the former being from a known 
normal, the latter lacking serum altogether. 

Tubes 2, 4, 6, 8 contain no Antigen, the last also, no serum, hence comple- 
ment remains unaffected. 

The entire test depends directly upon the behavior of Xo. 1 containing the 
suspected serum. 

If, together with all the tubes save No. 3, it shows the diffused red 
of the extracted and dissolved hemoglobin, it is not a syphilitic serum. 

If it remains actually unchanged, or but slightly so, it is positive. 

Results Obtainable with the Wassermann Test. — It is negative in at 
least 50 per cent, of syphilitics of the first stage (four to six weeks). 

In tertiary cases at least 20 per cent, escape, although this figure is bet- 
tered if the so-called provocative treatment with an ti- syphilitic remedies is 
first used. 

In secondary syphilis the positives should run nearly 100 per cent., if no 
treatment has been had, or, if a period of four weeks, at least, has elapsed 
since its discontinuance. 

Even imperfect treatment may abolish it, while not affecting the luetin 
test. 

As stated previously, one should not accept negative findings in the fact 
of positive clinical evidence, or grounds for strong presumption. 

The mere statement of the patient that a Wassermann has been made 
and was negative, should not be accepted in most instances until directly 
verified and never, if the test has been performed by anyone other than a 
serologic expert. 

In cerebrospinal lues the Wassermann may fail occasionally in the blood 
serum and be positive in the spinal fluid, and vice versa. 

The principle of the complement fixation test is now clinically applicable 
to the following conditions: (a) Gonococcus infections of at least four or five 
weeks' duration, (b) Echinococcus invasion* (c) Glanders, {d) Typhus 
fever, according to Olitzky's latest reports, (e) Tuberculosis. (/) Typhoid 
fever (Garbot's method with polyvalent antigens.) 

* Probably a group reaction applicable to various tenia. 



99° MEDICAL DIAGNOSIS 



Antitoxins. — The name aptly expresses the character of these substances 
and in instance of natural immunity they may be shown to play a large part. 
So far as known, they occur primarily only as the result of Exotoxin activity. 
The production of antitoxin and its therapeutic application are too well 
known to require description here. 

SCHICK'S TEST OF DIPHTHERIA IMMUNITY.— This test depends 
upon the results of the intradermic (not hypodermic) injection of diphtheria 
toxin in an amount representing one-fiftieth (J^o) of the minimum lethal dose 
for a 250 gram guinea-pig, as determined previously by proper laboratory tests. 

The required dose may be so diluted as to represent a convenient bulk 
for injection (0.2 c.c.) and introduced by pinching up a fold of skin, intro- 
ducing a very fine needle, with the barrel of the hypodermic syringe lower 
than the needle point, until the point of the needle is visible just under the 
epidermis, but not protruding. The test solution is then forced out and forms 
a bleb upon the surface. In most instances a typical inflammatory skin 
reaction develops by the end of thirty-six hours, but may be delayed until 
the lapse of seventy-two, and very rarely ninety-six hours. 

True Reaction. — The best test of the true reaction is apparently a decided 
tenderness to pressure associated with decided reactive inflammation. 

Induration is likely to be present and is best detected and estimated by 
pinching up the area involved. 

Doubtful reactions and pseudo-reactions are common and demand that 
the individual exhibiting them be given a prophylactic dose of diphtheria 
antitoxin, unless the observer has had a wide experience Vith the test. 

Recent reports attest the genuine value of the procedure, both in relation to 
preventing the disease and checking epidemics, and in sparing suspects from the 
unnecessary injection of prophylactic doses. 

Dr. A. Zingher has devised a simple outfit for the distribution of toxin 
for the Schick test,* and this provides for the simultaneous application of a 
control test which eliminates almost wholly the danger of misinterpretation 
of the pseudo-reactions, which are caused by protein content of the test 
serum, not by the toxin itself. This outfit, as previously described by him, 
"consists of a capillary tube which contains a little over one minimum lethal 
dose of a ripened diphtheria toxin, a small rubber bulb for expelling the 
toxin, and a 10 c.c. bottle of normal saline solution for diluting the toxin. 
Every 0.2 c.c. of the dilution represents one-fiftieth minimum lethal dose, 
the amount used in the Schick test. 

"The outfit for controlling the positive, pseudo and combined reactions 
is similar to the Schick test outfit, but the toxin in the capillary tube has been 
heated to 75 C. (167 F.) for five minutes. Heating the toxin at this tem- 
perature destroys the soluble diphtheria toxin, but does not, appreciably 
affect the protein of the diphtheria bacillus." 

Precipitin Test for Human Blood. — This is an extremely .important, 
wonderfully delicate, and accurate, forensic test and has been used exten- 
sively also to determine species relationships in animals (Nuttall). 

* Jour. A.M.A., Vol. 66. 



INFECTION AND IMMUNITY 99 1 



Technic— One uses the serum of a rabbit so immunized as to yield pre- 
cipitation in dilutions up to 1 to 10,000 under proper titration against human 
serum. With 1 to 1000, clouding should occur in three minutes at room 
temperature, and be very distinct in eight. 

This constitutes the " Antiserum." Five tubes are used as indicated 
below : 

Test.— 

Tube i. Unknown human serum 1 to 1,000. .1.0 c.c. + Antiserum 0.2 c.c. 

Tube 2. Unknown solution to be tested 1.0 c.c. + Antiserum 0.2 c.c. 

Tube 3. Unknown solution to be tested 1.0 c.c. + Normal rabbit serum. .0.2 c.c. 

Tube 4. Salt solution 1.0 c.c. + Antiserum 0.2 c.c. 

Tube 5. Unknown solution 1 .0 c.c. -f- Salt solution 0.2 c.c. 

(Fornet and Miiller). 

In each case the antiserum is first introduced and the solution to be 
tested is allowed to flow gently and slowly down the side of the inclined tube 
upon the surface of the underlying fluid. 

At the junction of the two a fine white ring will appear in tubes 1 and 2 
if the test is positive, the others remaining unchanged. The reaction may 
be positive for human blood in stains many years old, if these have been con- 
tinuously dry and in the dark.* 

Meningococcus Test. — (Vincent-Bellot.) To 3-6 c.c. of centrifugated 
cerebrospinal fluid, add one drop of meningococcus serum. Set the test 
liquid aside for 8 to 12 hours at a temperature of 50 to 53 °C. 

These investigators claim that in meningococcus infections a precipitate 
is demonstrable even though the specific microorganism is not to be found. 

Agglutination. — The most important of the agglutination reactions are 
discussed elsewhere. 

It should be remembered that they are specific when dilutions of not less 
than 1-40 to 1-60 are used and are as readily demonstrable with dead bac- 
teria as with the living organisms. 

In dilutions under 1-20 the normal agglutinins of the serum may prove 
deceptive factors. 

As stated elsewhere, dead bacteria, living ones taken from solid cultures, 
or those grown in bouillon, may be used, but the latter should not be too 
young. 

Though more or less devitalized, bacteria are not killed by the process 
of agglutination alone. 

Agglutination Reaction. — Our present understanding of the phenomena 
constituting the so-called agglutination reaction which has proven so valu- 
able in the diagnosis of certain obscure diseases depends upon the known 
fact that injected erythrocytes or other cells, not those of the animal into 
whose blood they have been introduced, or, bacteria similarly injected, 
produce in the blood serum of the animal so treated, the peculiar quality of 
agglutinating and precipitating, in vitro, these foreign elements, and even of 

* Extracts of the muscles of the neck and leg of a mummy of the first Egyptian Empire 
yielded a faint reaction according to Meyer, Munch. Med. Wochen., 1904, Vol. 51, No. XV. 



992 MEDICAL DIAGNOSIS 



producing agglutinins and precipitins specific for a given microorganism. 
This involves the assumption of agglutinins, and precipitins as products 
evolved during adaptation or immunization. The clinical application of this 
process has proven of value in a number of cases and is best illustrated by 
typhoid fever in which disease is found its first clinical use through the work 
of Widal based upon the previous investigations of Pfeiff er and Gruber and 
Durham, who worked along purely bacteriological lines seeking to apply the 
phenomena to the identification of bacteria. 

The agglutination reaction of typhoid, paratyphoid, colon infections, dysen- 
tery, cholera, plague, Malta fever and to a much less degree of pneumonia and 
tuberculosis have proven valuable. 

An early and definite reaction is chiefly marked in typhoid, paratyphoid, 
Malta fever and cholera. In paratyphoid one is sometimes embarrassed 
because of the fact that the paratyphoid bacilli of different epidemics may 
not react. In dysentery there are three types of bacilli to be dealt with, 
viz.: those of Flexner, Shiga and Hiss, while in plague the reaction is not 
constant and occurs too late to be of use, and the same objection of incon- 
stancy applies to tuberculosis and pneumonia. (For Widal Test see Typhoid 
Fever.) 

Anaphylaxis ("Hy 'pet susceptibility," "Allergy"). — This phenomenon, 
which may be found to constitute the very foundation of immunity, was 
reported fully first by Hericourt and Richet in 1902. 

Isolated observations were made by Magendie (1839) and S. Flexner 
(1894) clearly stated the basic phenomena. 

Their discovery first established the fact that the production of increased 
tolerance and resistance to antigens of any nature attained through the 
usual methods employed in the production of artificial immunity, have 
decided limitations and demand a close adherence to the terms imposed by 
certain conditions. 

This subject is so beset with contradictory opinions and conflicting ob- 
servations at the present time as to make an intelligent discussion impossible 
in a book of this kind. 

Speaking broadly, the most important phenomena are those of abnormal 
sensitization and excessive response of body tissues to foreign proteins, from 
whatever source, reaching the blood or lymph in an unaltered state. 

A specific sensitization may be inherited, may result from inunction, sur- 
face applications, inhalation, ingestion, irrigations, enemata, or any other 
method related to the taking of food or the administration of medicament. 

The most striking clinical analogies at once suggested are : idiosyncrasies 
with relation to foods, drugs, odors, and the like, hay-fever and spasmodic 
asthma. 

It is proven experimentally that specific sensitization may pass from 
mother to child, or be passed on from one directly and artificially sensitized 
animal ("active anaphylaxis") to another ("passive anaphylaxis"). 

The amounts of foreign protein necessary to produce specific sensitization 
are incredibly small. 



INFECTION AND IMMUNITY 993 



of a grain of crystallized egg albumin can produce demon- 

100,000,000 ° 

strable sensitization in a guinea-pig (H. G. Wells). 

The chief phenomena are: (1) Excessive reaction. (2) Decreased duration 
of symptoms. (3) A shortened incubation period. (4) A fleeting period of 
immunity to subsequent injections of the same foreign protein (anti-anaphylaxis) . 
(5) Absence of complement from the blood of the animal affected. (6) Dimin- 
ished blood-coagulability . (7) Leukopenia. 

SERUM DISEASE. — The first clinical observations on anaphylaxis were 
made by von Pirquet in a case of diphtheria. We now know that any foreign 
protein in solution, when injected into the living tissues, may so sensitize the 
individual to the particular protein employed, as to produce pathologic 
systemic or localized reactions of a character wholly foreign to any symptoms 
originally produced or an exaggerated response within a greatly shortened 
period. 

The same statement holds with respect to many substances regardless 
of the method or route of their introduction, and it now appears that hyper- 
susceptibility may also represent maternal inheritance or result from the 
direct transfer of serum from a sensitized to an unsensitized animal. Fur- 
thermore the hypersusceptibility may last for years in certain instances. 

Symptoms of Serum Disease. — The chief manifestations of serum disease 
are (a) Urticaria, (b) Swelling of lymph nodes, (c) Edema, which may be 
shifting and transitory and in some instances seriously threatens life by 
invasion of the larynx, (d) Joint pains, (e) Fever. (/") Albuminuria and 
casts. 

It is true also that it is the amount of serum, from the same class of animals, 
and not the antitoxin content which is the determining factor. When second 
injections of diphtheria antitoxin are demanded, after a lapse of one week 
or more, the use of the concentrated sera, and, if possible, of antitoxin 
prepared from animals other than the horse, are elements which make for 
safety. 

Death may, but very rarely does, occur from the therapeutic use of sera, 
and in such instances seems to result from the same condition which deter- 
mines exitus in the anaphylactic shock of the guinea-pig, viz. acute bronchial 
spasm, resulting acute distention of the lungs, and asphyxia. The suggestive 
resemblance of such a critical and lethal phenomenon to the attack of ordinary 
bronchial asthma is striking and led to the suggestion of anaphylaxis as the 
basic cause in 1910. 



63 



994 



MEDICAL DIAGNOSIS 



OPSONIC THEORY* 

It is not strange that the earlier enthusiasm regarding the opsonic diag- 
nosis and therapy has been followed by disappointment in certain directions, 
for the results so far obtained have riot yielded a reward commensurate 
with the tedious, delicate and elaborate technic required, nor is this technic 




Fig. 475- 



-Record curve of patient with large furuncle on back of neck. 
(Courtesy of F. M. Houghton.) 



free from serious faults, especially as regards the preparation and, more 
especially, the use of vaccines, but the procedure may yet prove to be the 
key to a larger knowledge and more accurate diagnosis, prognosis and therapy. 
All medical progress seems to partake of the nature of a persistently length- 
ening ascending spiral. 




Collecting blood for serum. 



Metchnikoff described phagocytosis; Denys and Leclef, the increased 
activity of the phagocytes in the presence of blood serum. Leishman de- 
veloped a method for measuring phagocytic activity and Wright and Doug- 
las formulated a new application of the doctrine of phagocytosis which is 
of sufficient scientific and historic interest to justify the retention of its 

* For the illustrations, with one exception, the author is indebted to the courtesyof 
Dr. E. C. L. Miller. 



INFECTION AND IMMUNITY 



995 



description in this edition even though it has already fallen into disuse both 
on the diagnostic and therapeutic side. 

These experimenters have found that the blood contains a limited 

amount of certain bodies necessary to prepare germs for destruction by the 

phagocytes of the body. It appears that if white blood corpuscles are 

thoroughly and repeatedly washed in normal salt solution until every trace 

of blood plasma is removed and then brought into contact with 

certain germs, the result is almost negative as regards 

phagocytosis. If, however, a little blood serum be added, the 

germs are at once acted upon by the white cells, and, further- 

m more, if the microbes brought into contact with the washed 

cells without blood serum have been previously incubated 

with such serum, they fall easy victims to the phagocytic 

cells, unless the serum has been previously heated to 65°C, 

in which case no phagocytic action appears. 

It thus becomes evident that normal blood contains a 
certain substance ("opsonin") destroyed by heating, but 
otherwise capable of rendering the bacteria vulnerable to the 
attack of the phagocytes or fit for phagocytic digestion. 
It is evident, moreover, that the action of the phagocytes is dependent 
not upon any quality inherent in these cells, but upon the amount of an extra- 
cellular opsonic substance contained in the serum of a given blood. Certain 
bacilli, e.g., those of diphtheria, are immune to opsonic action, but may be 
taken up to some extent by washed leucocytes (spontaneous phagocytosis). 



Fig. 477- 

Pipette with 

blood. 




Fig. 478. — Grinding bacteria. 

Further experiments establish the fact that in relation to different 
varieties of germs it is possible to establish a normal index of phagocytic 
activity, this index being represented by the number of germs of a given sort 
taken up by a definite number of washed leucocytes obtained from the blood 
of any individual, normal or abnormal, but treated with normal serum, 
and that in such cases the index is practically constant, whereas, in persons 
suffering from diseases caused by the different germs, the opsonic index 
is variable both as to individuals and as to the time or stage of the disease 



996 



MEDICAL DIAGNOSIS 



at which the estimation is made. Yet again it is found that if a given indi- 
vidual suffering from a certain disease, such as tuberculosis, receives a fixed 
dose of dead bacilli, said injection is followed by a change in the opsonic index. 
The first effect is to depress the phagocytic power of the patient's blood 





Fig. 479. — Emulsifying bacteria. 

(negative phase); on successive days, however, the opsonic index rises 
above normal (phase of flow and reflow) and finally reaches a maximum 
(high tide) at last reaching the stage of recession (the ebb phase) . From 
the negative phase to that of high tide several days may be consumed, 
then follows for two or three days the gradual 
return to the normal level. If at this period a 
second inoculation be made the same phenomena 
are observed with a shortened and lessened negative 
phase and higher flow. 

While subject to many inaccuracies and not 
adapted to general diagnostic use, the presence of 
these phenomena is of some diagnostic, prognostic, 
and therapeutic interest, and furnishes an interest- 
ing sidelight upon relative individual susceptibility 
to the infectious diseases. 

Technic. — Some blood of a normal individual, or, 
better the "pooled" blood of several, and a cor- 
responding amount of that of the patient or suspect 
is drawn by gravity and capillary action into 
separate tubes (Wright's tubes) with capillary ex- 
tremities and a curved shorter limb. The upper 

limb is then heated and sealed in the flame and the blood is drawn by the 
resulting condensation of the rarefied air into the body of the tube which 
is inverted and centrifuged to bring it into the longer arm, then allowed 
to rest until the clot begins to separate, and again centrifuged. Finally, 



Fig. 480. Fig. 481. 
Blood and citrate solu- 
tion before and after 
centrifugalizing. (Plain 
tubes.) 



INFECTION AND IMMUNITY 



997 



the capsule is cut across above the fluid level and the serum forming the 
upper stratum is removed with a pipette. A bacterial emulsion is then 

H prepared from cultures of the required germ (bacillus 

tuberculosis, gonococci, staphylococci, etc., sterilized 
by heat) by grinding the germs in an agate mortar 
with a sterilized 0.85 per cent, solution of sodium 
chloride until an apparently uniform mixture is 
obtained. After sedimentation and removal of the 
upper layer, this coarse emulsion is drawn into 
Wright's capillary tubes as described above, centri- 
fuged several minutes to remove clumps, and the 
opalescent supernatant layer then constitutes the 
test emulsion. 

To procure the washed leucocytes, a few (10-15) 
drops of blood (from either the patient or another 
person) are drawn into a centrifuge tube contain- 
ing sterile salt solution plus 1 per cent, of sodium 
citrate. After thoroughly mixing, the liquid is cen- 
trifuged, and, after the clear upper layer is pipetted 
off, again centrifuged, after which the upper surface 
of the precipitate will be found to consist largely of 
leucocytes which may be removed with a pipette 
and used for testing. 

The four test solutions have now been obtained, 
viz.: (1) normal serum, (2) suspected serum, (3) bac- 
terial emulsion, (4) washed leucocytes. Into a marked 
or otherwise graduated sterile nipple pipette with a 
long capillary extremity one draws equal parts of 
the washed leucocytes, suspect serum, and bacterial 
emulsion, separating the three portions by aspirated 
air bubbles; these equal portions are thoroughly 
mixed by alternating expulsion and respiration, and 
finally sealed in the capillary pipette by heat and 
placed in the incubator for fifteen minutes at a 
temperature of 37 to 4o°C. A control tube is pre- 
pared in the same manner, using normal serum. 
Finally films are made in the same manner, stained 
in the usual way and examined with an oil immer- 
sion J^2 l ens - The number of bacteria contained 
in 50 leucocytes is counted for both the test and 
control films, and the bacterial count per leucocyte 
in the patient divided by the average number con- 
tained in the leucocytes of the control film ; i.e. , if the normal serum shows 5 and 

2. z 
that of the patient 2.5 per leucocyte, the index is represented by - : =0.5. 

The normal index is but slightly variable, the minimum for the tubercle 



Fig. 482. Fig. 483. 

Fig. 482. — Opsonizing 
pipette, showing the 
equal parts of blood 
serum, bacterial emul- 
sion and leucocytes. 

Fig. 483. — Mixture 
ready for incubation. 



99 8 



MEDICAL DIAGNOSIS 



bacilli being fixed at 0.8 and the maximum at 1.2. In most chronic infections, 
such as lupus, furunculosis and tuberculosis, and- acute infections of the type 
of septicemia or Malta fever the index is uniformly and persistently low 




Fig. 484. — Mixing test solutions. 




Fig. 485. — Drop ready to spread. 




Fig. 486. — Making smear. 

(0.4 or less). In the former one deals with a localized or "shut-off" process, 
in the latter with a blood-stream infection. 

In cases where the infection is but imperfectly or intermittently shut 
off, as in certain cases of advancing pulmonary tuberculosis or tuberculous 



INFECTION AND IMMUNITY 



999 



joints, the index may show marked variations. For diagnostic purposes 
the T. R. is used in the usual manner in the case of tuberculosis and the 
resulting phases as previously described give to some extent, diagnostic, 
prognostic, and therapeutic indications. 

Measuring the Dose of the Vaccines. — As it is necessary to use an exact 
or approximately correct dosage of any given germ, various procedures 
have been devised. One of the simplest consists in preparing an emulsion 




Fig. 487. — Smear. 

of the germs with salt solution and making a mixture consisting of 1 part 
of the germ solution, 1 part normal blood and 3 parts of salt solution. A 
count will determine the number of corpuscles and the proportion of germs 
to blood corpuscles and hence the number of germs per cubic millimeter. 
From 100,000,000 to five or ten times that quantity may be required to main- 
tain the highest and most sustained positive phase, together with the 
minimum extent and duration of negative phase which is the therapeutic 
optimum. 



IOOO 



MEDICAL DIAGNOSIS 



Endemic. 



Seasonal 
incidence. 



Character- 
istics. 



Eberth's 
bacillus. 



Fulfills Koch' 
law. 



Vitality of 
germ. 

Water and ice 



Soil 



Modes of 
conveyance. 



Chronic 
carriers. 



Green salads. 



Oyster beds. 



The urine a 
menace. 



THE INFECTIOUS DISEASES 
TYPHOID FEVER {Enteric Fever, Typhus Abdominalis) 

Definition. — This acute general infection is endemic rather than epidemic, is 
especially frequent in the late summer and early autumn, rarely affects babes, is 
most prevalent between the ages of ten and twenty-five, rare in persons above sixty 
and especially affects the adult male. 

It is caused by the bacillus typhosus and characterized by continued fever, 
enlargement of the spleen, a peculiar exanthem, diarrhea or constipation, tympan- 
ites, abdominal tenderness, marked nervous symptoms, the diazo -reaction in the 
urine, the presence of the causative organism in the blood during the early days 
of illness at least, and the agglutination reaction of Widal. 

Etiology. — The bacillus typhosus of Eberth (1880) is a small motile rod, 
flagellated, Gram-negative, staining readily, constantly present, easily re- 
covered and grown in pure culture and capable of producing the disease in 
certain apes, thus fulfilling Koch's law; 

Its development in the body results in the formation of agglutinins and pre- 
cipitins responsible for the almost pathognomonic test of Widal. 

Outside the body it resists cold and moderate dry heat, but fortunately, 
direct sunlight destroys it in a few hours and it is readily killed by the ordinary 
antiseptics. In water it lives but a few days if saprophytic organisms are pres- 
ent and in ice rarely longer than ten days or two weeks, though in rare instances 
Living germs have been recovered from surface ice after a period of nearly 
Ave months. 

In superficial soil and in the feces they may live for months unless exposed to 
direct sunlight or other unfavorable conditions, and this applies to dust and 
filter sand as well as ordinary earth. 

In milk, sweet or sour, in butter or in cheese, they may persist for months, 
and infection arises ordinarily through germs cast off in the feces or urine and 
indirectly conveyed to the water or food supply of the individual. 

Though possible, direct contagion, under ordinary precautions, is rare, but 
the germs may be conveyed by food, clothing, soiled fingers, house flies, and even 
by dust. 

Certain individuals may become chronic carriers of virulent organisms 
and living centers of infection. One polluted spring may poison a whole city, 
and milkmen using water from infected wells for cleansing utensils or with 
less innocent purpose, frequently convey contagion to their patrons. Salads 
may be dangerous when their components are grown on soil fertilized by 
infected material, and even oysters bedded along lines of sewage flow may 
become active sources of infection. 

Distribution of the Germs in the Body. — The infection is a general one, 
and almost any body fluid, secretion or excretion, may contain them. The 
urine is a peculiarly dangerous source of infection, containing germs in at 
least one-third of all cases, and oftentimes for long periods after apparent 
recovery. The organism is constantly present in the feces during the active 



PLATE IV. 




Typhoid Ulceration. 
( From "Infectious Diseases," C. B. Ker.) 



THE INFECTIOUS DISEASES 



1001 



stages of the disease and spleen, blood, and rose spot cultures yield positive 
results in the majority of instances. It may be found in the bile and even 
in sweat, sputum, serous exudates or foci of suppuration.* 

Modes of Entrance. — It is probable that all infections occur through the 
gastrointestinal tract and in the vast majority of cases it is the intestine 
and its associated structures that show the most marked lesions. 

Incubation Period. — The incubation period ordinarily is from 10 to 14 
days, but great variations are encountered. 

In certain instances where the time of the ingestion of infected food 
has been definitely known, certain prodromal symptoms have appeared 
within seventy-two hours, whereas in other rarer instances the onset of the 
disease has been postponed for thirty or even forty days. 

Varieties. — Following Osier, we may group cases as follows: (1) Typhoid 
fever with marked enteric lesions. (2) Those of slight enteric lesions. (3) 
Cases with no discoverable intestinal lesions. (4) Mixed infection. (5) Pseudo- 
typhoid cases or those due to the so-called paratyphoid groups. 

The first group comprises the vast majority of all cases. Groups two and 
three represent extremely rare findings. Group four should be confined to 
those cases in which the secondary infection is caused by germs which favor 
the growth and intensify the action of the original germ. Such are the ordi- 
nary pyogenic cocci, the pneumococci, and the colon bacilli. 

The fifth group comprises those cases denominated paratyphoid. In 
regard to these it may be said that they are due to the so-called paratyphoid 
bacillus of Achard and Bensaud (1896), and the disease cannot be differentiated 
by its clinical manifestations, which may be identical with those of true typhoid 
fever. The absence of the Widal reaction with the Eberth bacillus in a case 
clearly typhoidal in type is the best diagnostic evidence if paratyphoid cul- 
tures are unobtainable. If such can be had a specific diagnosis may be read- 
ily made by the methods of Widal or Pfeiffer. 

Clinical typhoid fever may in fact be due to either the bacillus typhosus, 
bacillus paratyphosus A., or bacillus paratyphosus B., but the paratyphoid Mild types. 
fevers usually are milder, of shorter duration and more rapid and acute onset. 
Hemorrhages are rare and perforation does not occur, but the anatomic lesions 
differ only in intensity from those of true typhoid fever. f 

In the Serbian army the failure to secure protection by the usual routine 
vaccinations led to the identification of a paratyphoid "C" which proved 
efficient. 

There are certain features which justify one in making a tentative 
diagnosis of paratyphoid infection pending laboratory reports. These 
diagnostic factors may be grouped as follows: 

* It is quite possible that in a considerable number of cases it may be recovered from 
the duodenal secretions very early. It has been so obtained by means of cultural methods 
long after convalescence. 

fL. D. Bristol in reporting on paratyphoid "A," emphasizes the importance of apply- 
ing agglutination tests with that strain as well as with "B " in doubtful cases. He reminds 
us also that demonstrable splenic tumefaction is often lacking in the paratyphoid "A" cases. 



1002 



MEDICAL DIAGNOSIS 



Typhoid vs. 
Tuberculous 
ulcers 



Usual sites. 



In paratyphoid the gastrointestinal symptoms usually are more severe 
than in true typhoid; the onset is more likely to be abrupt or rapid and an 
initial chill is reported in many cases; the temperature rise and termination 
are more rapid in paratyphoid, though cases of crisis have been reported. 
Herpetic eruptions of the facial or buccal type are relatively common in 
paratyphoid and very rare in true typhoid. (See also page 933.) 

The adoption of protective vaccination has robbed typhoid fever of its 
terrors as an army disease. In the American forces during the Great War 
just closed a triple vaccine was used and as a result there were but 297 cases 
in the entire army on June 30, 19 18. 

PATHOLOGIC ANATOMY.— The germ may be recovered from the 
blood, mesenteric glands, spleen, bone marrow, and intestinal lymph struc- 
tures and readily cultivated. The essential and almost constant lesions are 
those found in the agminate glands known as Peyer's patches, and the solitary 
follicles of Lieberkuhn in the ileum and jejunum, the process being one of 
medullary infiltration. The simple follicles of Lieberkuhn are found in both 
the large and small intestine; Peyer's patches, throughout the ileum and the 
lower jejunum. The follicles are at first grayish white and prominent and 
the inflammation increases during a week or ten days, then terminating by 
fatty degeneration and absorption, or more often in necrosis and ulcer forma- 
tion involving the follicles alone, or exposing the submucosa and muscularis 
at the base of oval or round ulcers, which, unlike those of tuberculosis, tend 
to parallel the long axis of the bowel and lie opposite the mesenteric attach- 
ment. This process results in deep and extensive sloughing, the neighbor- 
hood of the ileo-cecal valve being usually the point of maximum change. The 
ulcer border may be undermined, the edge regular or irregular, and the stage 
of actual necrosis ordinarily represents the third and fourth weeks of the 
disease. (See Plate.) 

Hemorrhages, trivial or serious, may occur at any time, from the begin- 
ning of the ulcerative process to the completion of that of healing, but death 
from hemorrhage after cicatrization is a rare event. 

Perforation with septic peritonitis occurs in about 5 per cent, of 
all cases and the danger of excessive tympanites during the later weeks 
of typhoid is evident. The perforation is ordinarily found in the ileum, 
rarely in the cecum or adjacent portion of the colon or vermiform appendix. 
The spleen is enlarged and extremely soft, rupture may rarely occur, 
either with or without traumatism, abscess is rare, infarction not unusual. 
The liver is hyperemic and shows signs of parenchymatous degeneration, 
rarely abscess, and the gall bladder not infrequently contains the germs 
and may be the seat of a cholecystitis. Kidneys. An acute nephritis or 
suppuration is rare, cloudy swelling and glandular degeneration more fre- 
quent. Heart lesions. Endocarditis and pericarditis are extremely rare. 
Granular and fatty degeneration of the myocardium is common, but is 
seldom a cause of death. The arteries and veins. Emboli and thrombi 
are not uncommon, venous thrombosis being the rule and having its most 
frequent seat in the femoral veins. Such a thrombosis constitutes one of the 



TYPHOID FEVER 



IOO3 



complications of later typhoid. Respiratory organs. Splenization and 
hypostatic congestion are extremely common, infarction occurs in about 
5 per cent, of all cases, but abscess, gangrene, and pleurisy are extremely 
rare.* Nervous system. A specific meningitis in typhoid is extremely rare, 
severe headaches and delirium common. Mesenteric glands. Their marked 
involvement is constant. 

SYMPTOMS AND DIAGNOSIS.—/;;, the absence of the laboratory aids, no 
disease is at times more difficult to diagnose in its earliest stages, none save influ- 
enza or syphilis more interesting and protein in its forms, none more difficult to 
forecast and few more exacting in their demands upon the therapeutic resources 
and good sense of the clinician. 

Many cases are remarkably clear in their development and run an un- 
eventful course, but the practitioner must recognize the atypical and beware 
of hasty conclusions in those apparently straightforward. The work of the 
last decade has greatly simplified the diagnosis of typhoid for those who 
have at hand the aid of the clinical laboratory or the simple means to be 
described, and clinical and microscopic tests have added enormously to our 
positive knowledge of the character and frequency of variations in type. 

Major Symptoms. — {a) An insidious onset, (b) A continuous and some- 
what characteristic temperature, (c) Enlargement of the spleen, (d) Rose 
spots, (e) A lowered pulse-temperature ratio. (/) A low leucocyte count, (g) 
Ehrlich's diazo-reaction. (h) Agglutination test of Widal. (i) The positive 
blood culture during the first days of illness, (j) The recovery of typhoid 
bacilli from the stools, duodenal contents, or urine. 

Minor Symptoms. — Of the more or less inconstant minor symptoms, one 
may mention nose-bleed, gurgling, and tenderness in the right iliac fossa, the so- 
called typhoid tongue with its V-shaped red tip and brilliant edges, the pea- 
soup stools, becoming a brilliant ochre in the later stages, headache and delirium. 

Complications. — The two most important are hemorrhage from the 
bowel and perforation of the intestines. The former is characterized by 
symptoms of concealed hemorrhage; the latter by profound shock. 

Two chief symptoms often signalize a large hemorrhage, even in the profound 
stuporous toxic patient, and should be carefully watched for and promptly 
noted by the nurse. They are (1) a sudden drop in temperature; (2) coldness 
or even clamminess of the body surface. 

A sudden drop in blood pressure {below 90 mm. Hg. systolic) and tempera- 
ture, abrupt severe abdominal pain,\ and profound pallor are suggestive of per- 
foration and the pain may be sharply localized with tenderness and defensive 
rigidity of the abdominal muscles and in some cases is gradual in onset. An 
insidious onset is relatively rare, yet cases come to autopsy which have pre- 
viously yielded no definite signs of perforation or hemorrhage. + 

* Ulceration of the larynx has been reported, but has never been observed by the 
author. 

f Pain may be absent or undetected in 10 or 12 per cent, of such cases. Tenderness is 
demonstrable in about three-fourths of the cases. 

+ The profoundly toxic state of many of these patients is sufficient in many instances 
to suppress pain and tenderness alike. 



Protean. 



Obscure cases. 



Simplified 
diagnosis. 



Classic 
symptoms. 



Inconstant 
phenomena^ 



Hemorrhage. 



Symptoms of 
perforation. 



Variants. 



ioo4 



MEDICAL DIAGNOSIS 



Shallow breathing induced primarily by the pain and tenderness and later 
by abdominal distention if that be present, is usually observed. 

The remaining symptoms of later development are those of the ensuing 
peritonitis. One should seek for tactile crepitation over the xiphoid tip and 
costal arch areas, obliteration of splenic and hepatic dulness, movable dulness 
in the flanks, and audible friction on auscultation over the liver, spleen and 
intestinal coils. The systolic blood pressure is said to fall sharply in hemor- 
rhage and rise abruptly in perforation, but according to the author's observa- 
tions is likely to show a decided primary drop in both conditions. 

In perforation the primary drop is followed by a somewhat deliberate 
secondary ascent of 20 to 60 mm. of Hg. (Norris), occupying from two to six 
hours, and succeeded by a return to low figures. 

Norris finds that the average systolic blood pressure in this disease runs 
as follows: First week, 115 mm.; secon,d week, 106 mm.;»third week, 102 
mm.; fourth week, 96 mm.; fifth week, 98 mm. (auscultatory readings). 

In somewhat more than half the cases of perforation a leucocytosis occurs. 

The sudden drop in the fever and acceleration of the pulse usually present 
may be misleadingly absent. 

Successful treatment by surgical means demands prompt recognition 
and the early diagnosis is often extremely difficult. 

In both hemorrhage and perforation the mental condition may suddenly 
become clear and, occurring abruptly in such conditions, this should always 
excite suspicion and cause a thorough search for other phenomena of these 
complications. 

If hemorrhage be suspected the bowel should be cleared by enemata in 
order that early demonstration of the blood may be made. 

The sudden appearance of abdominal distention is also a suspicious 
circumstance. 

Proper care of the mouth has greatly reduced the frequency of otitis 
media, a condition readily overlooked when present in dull or stuporous 
patients, and bandaging of the lower extremities when the patient begins 
to sit up or walk usually prevents a saphenous phlebitis. 

The Typical Case {Seen rarely nowadays in its complete form).* — There is 
first a period of general malaise (lassitude, aching head and limbs, loss of 
appetite, etc.), during which (or later) nose-bleed may occur with diarrhea 
or constipation, more generally the latter. 

This condition progressively increases, slight fever is apparent and the 
patient takes to his bed. The fever rises each night higher than the night 
preceding, receding each morning about one degree below the temperature of the 
preceding evening. The face becomes flushed, the tongue is heavily ' coated, 
save the tips and margin, which may remain a bright angry red. An antece- 
dent diarrhea may now increase or replace constipation, or the latter condi- 
tion may persist. Mental hebetude is marked, and the pulse, heretofore 
somewhat slow and soft, becomes weaker and tends toward dicrotism. At the 

* Before the days of refined diagnostic methods a case had to be reasonably typical to be 
recognized as typhoid fever. 



TYPHOID FEVER 



IOO5 



end of a week or ten days pale red points, like flea bites, easily blanched by 
pressure, appear over the abdomen and lower chest usually in small numbers, 
and the spleen may be readily palpable. Tympanites may be a prominent 
and distressing symptom. By the end of the second week the fastigium is 
reached and all symptoms are intensified. Headache and hebetude are 
replaced by a low muttering delirium, and the pulse grows more rapid and 
dicrotic. The heart sounds are weaker, there is a tendency to congestion 
of the lung bases, the tongue grows dry and hard and sordes tend to accumulate 
upon the patient's lips and gums necessitating the most scrupulous cleanliness, 
the attitude of the patient indicates profound weakness, he sinks down in bed, 
lies constantly in one position, which must frequently be changed by the 
efforts of the nurses or ward attendants. If diarrhea is present, the pea-soup 
stool of the earlier period is replaced by the light ochre stool of the latter typhoid. 
Tympanites is likely to be excessive and increases the danger of perforation. 

During two weeks the temperature is practically continuous, all symptoms 
are intensified, hemorrhage or perforation may occur and tendency to hy- 
postatic pneumonia increases. In the fourth week there is a recession of 
symptoms, fever gradually subsides, the mind clears, the spleen shrinks under 
the ribs, tympanites lessens and the heart sounds and pulse are of better 
quality. Such a case offers no difficulty in diagnosis, but one must consider 
the common variations. 

Occasional Sudden Onset. — Our experience during the Spanish- American 
war has shown how frequently there may be a sudden onset with chill and high 
fever. 

Period of General Malaise. — Nose-bleed is frequent but neither con- 
stant nor limited to typhoid fever. Gurgling and tenderness in the right 
iliac fossa. This much overrated symptom may be found in any diarrheal 
condition, and any extreme early tenderness is more suggestive of an appendicitis 
than of typhoid fever; moreover, in many cases of typhoid these symptoms are 
altogether lacking. 

The Typhoid Tongue. — Such a tongue is strongly suggestive of typhoid, 
but is not always present, and may occur in other conditions associated 
with high temperature and gastrointestinal disturbances. 

Fever. — "Step-ladder" temperature is somewhat rare in its typical form, 
and the use of cold baths has robbed it of much of its symmetry; moreover, 
as before stated, fever may occasionally rise rapidly with or without an 
initial chill, instead of gradually as in a typical case, and terminate either by 
crisis or by lysis in a few days or after several weeks. 

The So-called Abortive Typhoid. — The abortive typhoids are much more 
common than was formerly supposed, and still more extraordinary are those 
extremely rare cases lacking temperature, which have been verified by the 
most modern and exacting clinical tests. 

Diarrhea. — This symptom is present only in a minority of the cases on a 
modern dietary, regular movements or moderate constipation being the rule.* 

Rose Spots. — These, when present, are valuable diagnostic aids and a 

* Speaking from personal observation. 



'Rose spots." 



Mental state. 



Decubitus. 



Stools. 



Period of 
recession. 



Often atypical. 



Inconstant 
symptoms. 



Afebrile 
typhoid. 



The exception. 



Present in 

two-thirds. 



ioc6 



MEDICAL DIAGNOSIS 



Often 
obscured. 



Seldom 
necessary. 



Mental state. 



Sudorous. 

Septic, 

Pulmonary. 

Scarlatinal. 
Renal. 



Value of 

clinical 

picture. 



Valuation 
of single 
symptoms. 



great source of comfort to the practitioner groping for a clew. They are 
present in about two-thirds of all cases, ordinarily few. scattered, and limited 
to the lower chest and abdomen, they may be profuse and widely distributed, 
but unfortunately, are not limited to typhoid.* 

Enlargement of the Spleen. — In association with the general symptoms 
of typhoid this sign is of great value but often an existing tympanites 
makes its determination impossible, and. moreover, it may be found in para- 
typhoid, acute miliary tuberculosis., malaria, septicemia and some of the 
tropical fevers. The spleen is often only just palpable. 

Disturbed Pulse Temperature Ratio. — A low pulse rate associated with 
high fever is a valuable confirmatory sign of typhoid infection though by no 
means limited to this disease. 77 is, furthermore, a valuable prognostic sign 
indicating light infection or good resisting power. It should be remembered 
that pneumonia otters the same symptom, and in either disease one may be 
misled in elderly persons, in whom a slow pulse may be the result of an ob- 
structive aortic lesion or arteriosclerosis. 

Recovery of the Bacillus from the Stools, Blood, or Urine. — The intro- 
duction of the Widal test and the simplification of the blood culture has made 
the first (difficult and unsatisfactory" 1 method of investigation of little use to 
the practitioner. Spleen puncture will often yield a pure culture, but is neither 
necessary nor justifiable save in the rarest instances. Blood from the rose 
spots affords an easy method of cultural .::.:. i many instances. 

Nervous Symptoms. — These are essentially those of the "typhoid s: 
and may be seen in any disease associated with overwhelming toxemia. The 
low muttering delirium of the typical typhoid, and less often the mental 
hebetude torpor may be entirely absent, or. in rare instances, replaced by 
an acute maniacal delirium, which constitutes a most serious complication. f 

Misleading Variants. — Of the many curious variations in the general form 
of this disease may be mentioned {a) that associated with profuse and 
hausting sweats which strongly suggest septicemia, pyemia, certain forms of 
malaria or ulcerative endocarditis: (b) those in which the onset is so distinctly 
pulmonary in its type as to lead to a diagnosis of pneumonia alone without 
regard to the underlying infection; (c) the tonsillo-typhoid form, often accom- 
panied by erythema and simulating scarlatina; (ifl the renal form in which 
symptoms of nephritis are prominent and misleading, and (e) the many 
variations due to complicating abscess and necrosis. 

The Important Factors in Accurate Diagnosis. — The essential thinz 
proper appreciation of the lesser value of individual symptoms, and the greater 
one of the grouped signs. 

Aside from the Widal test or the blood culture, no single clinical symptom 
suffices for a diagnosis of typhoid, but »;.: ::ned reduce error to a mini- 



* A case coming under the author's observation a short time ago presented the typical 
rose spots, but failed to react to the Widal test, and proved to be a case of miliary tubercu- 
losis. Several such have been observed. 

" Nowadays a considerable number of true typhoids pass through the whole course of 
their illness without anv marked mental disturbance. 



TYPHOID FEVER : Z Z ~ 



:•::-:; 



mum. and of those mentioned nearly all are important in combination, but of 
slight significance if isolated. 

Four symptoms hart been reserved for separate discussion because of their didum 
great individual value. These are law leucocyte count; second, Ehrlich's 

diazo-r eaction; third, the agglutination test of Widal; fourth, the blood' 
culture. 

It has been amply proven that nine-tenths of all cases of typhoid, unless 
complicated by a secondary infection, yield a subnormal or low normal 
leucocyte count, which tends to progressively decrease as the disease increases in 
sever 

The exceptions represent, chiefly, blood concentration from vomiting, 
diarrhea, or cold baths. A count of 15,000 may be regarded as the maxi- 
mum thus produced, and, on the other hand, even in complications counts 
as low as 1000 have been reported. Absence of a high count in the relation to 
a suspected complication does not furnish absolute proof of its non-existence, 
but the presence of a high count with no profuse diarrhea or vomiting is good 
proof of one. A moderate secondary anemia is practically invariable in all 



Recent investigations by BBmmelheber show that the lowest count 
coincides with the maximum of toxemia and that the leucocyte reduction 
first affects the neutrophiles, and later, the lymphocytes. The latter then 
increase, and by the end of the second week a relative ljTnphocytosis may be 
present. The " coagulation time " of the blood is increased during the height 
of the fever (favoring hemorrhage), and shortened during convalescence (in- 
vi:ir.z :b::~:b : sis . 

Ehrlich's Diaz -re action. — This much maligned, nusonderstood, and vaiueia 
faultily applied test is one of genuine value in the exclusion of typhoid, but 
:-7.:\;-. be usei save vrirb. a :h:r:ugb 'zzz.izziz^.z.zizzz :: :_e ::^ii:i:^s under 
which it appears, its limitations and the true :yphoid reaction color. The 
test recommended is that of Ehrlich as modified by C . E . Simon and the 
author (see under " Urinalysis") - 

Limitations of the Diazo -reaction. — It cannot be too emphatically stated 
that the presence of a true typhoid diazo-r eaction does not prove the disease to be 
typhoid; with equal emphasis it may be said that absence of reaction in a 
supposed case, provided the test be made at a proper stage of the disease, amounts 
to almost positive proof that typhoid is not present. This statement, iterated 
and reiterated by the author ten years ago, has, in the las: few years, been 
abundantly confirmed by other observers using it in connection with the 
agglutination test, It may appear as early as the fourth day of a typhoid and 
is almost invariably present by the end of the first week or ten days. It becomes 
intensified as the disease progresses, but rapidly fades as soon as the acm< 

.Hon is passed. This latter fact is an extremely important one, and a 
failure to recognize it has led to many errors. The reaction is present in 
many of the acute exanthematous diseases, but if made with the author's 
higher dilution, as described elsewhere, will be found absent in malaria, most 
cases of appendicitis, pneumonia, and the earlier stages of acute miliary tuber- 



ioo8 



MEDICAL DIAGNOSIS 



Practically 
pathogno- 
monic. 



Rapid rough 
method. 



culosis. Indeed, its late appearance in the last disease is of considerable 
diagnostic value in that connection.* 

The Agglutination Test ofWidal. — Aside from the blood culture this is by 
far the most important and positive test of typhoid fever. It was first announced 
to the medical profession by Widal in 1896.! This test really depended 
upon an earlier discovery by Pfeiffer (May, 1893), wno found that cholera 
vibrios mixed with the serum of an immune animal and injected into the 
peritoneal cavity of a guinea pig lost their motility and changed their form, 
and later on, finding that the typhoid germ reacted in a like manner with 
the blood serum of typhoid patients, he applied the test to the identification 
of the germ. Widal reversed the process and applied it to the diagnosis of 
the disease. The test is as nearly pathognomonic as any in the range of medi- 
cine, and in its simplest form may now be applied by any practising physician. % 

The method originally employed by the author, though rough, was 
surprisingly definite in its results and required merely 
an agar-agar {i.e., solid) culture of typhoid bacilli, a 
medicine dropper, a platinum loop, and distilled water. 
The loop being made of fine wire was so constructed 
as to leave a central opening of not more than ^{q 
inch. The tests were made either with the fresh blood 
or the dry film, the latter being treated with a drop of 
distilled water before testing. Instead of the "hanging- 
drop" method, the ordinary flat preparation was used 
with equally good results. It was only necessary to 
place a drop of distilled water upon each of two clean 
microscope slides, take a small particle of the culture 
with a sterilized platinum loop, stir it into the drop of water, sterilize the 
loop, and from a drop of blood obtained from the suspect allow the tiny 
loop to fill and stir this film into one of the drops containing the bacilli. A 
cover-glass was then dropped upon it, it was rimmed with vaseline, placed 




Fig. 488.— Typhoid 
agglutination test. 
(Widal.) Upper seg- 
ment shows the freely 
moving germs. The 
lower the typical 
"clumping." 



* The present neglect of the reaction is due in part to the availability of the crucial 
bacteriologic and serologic tests and in part to the fundamental difficulty inherent in any 
test depending upon color interpretation. It is extremely simple if instructions are fol- 
lowed absolutely. 

f Bulletin Medicale, 1896, p. 618. The papers of Wyatt Johnston (New York Medical 
Journal, Oct. 31, 1896) and of the author (Medical Record, Nov. 14, 1896, and Dec. 6, 
1896), being the first reports published in this country. 

% At the present time one may obtain the so-called typhoid agglutometer (Parke, Davis 
& Co.), by means of which the test may be applied without the use of the microscope. 
The agglutometer comprises three tubes containing: (a) A sterile permanent suspension of 
typhoid bacilli, (b) A control tube of the same nature for the comparison of reactions. 

(c) A dilution tube containing fluid for properly diluting the serum previous to testing. 

(d) Tube for the collection of the blood to be investigated, (e) A pipette for the with- 
drawal of the serum. (/") A puncture needle. The test is made by adding 2 drops of the 
serum to the fluid in the diluting tube and this diluted serum is distributed in specific 
quantities in three tubes of suspended material. If the reaction is positive floccules appear 
in one or more of the tubes in one or two hours, the reaction being readily determined by a 
comparison of the treated tubes with the control. 



TYPHOID FEVER 



IOO9 



A macroscopic 
test. 



As early as the 
fourth day. 



under the microscope and a reaction was indicated by loss of motility, and 
grouping of the germs, half an hour being the time set for a positive reac- 
tion, reference being made to the control slide for error due to pseudo-reac- 
tions or preformed clumps. 

The methods now in general use quite properly provide for exact dilution 
and the use of bouillon cultures,* and require laboratory facilities. 

During this early period in tests thus made the author found that if a 
relatively large amount of the solid culture material was used a positive reaction 
could be determined in the same time and by the same method, without a micro- 
scope, through the gradual appearance of a dust-like film or haziness, due to 
agglutination, which became visible when the surface of the cover-slip was viewed 
tan gent i ally against the light. This was easily proven by the microscope to 
represent the agglutination reaction. 

It may be added that oil-immersion lenses are not absolutely necessary 
to the performance of the test, those of moderately high power being quite 
sufficient. 

Slides and cover-glasses should be washed in pure water before using, to 
remove any powerful antiseptics. Blood should never be taken upon paper 
or cardboard, but rather upon glass, porcelain or tinfoil, f 

Time of Appearance.— If the fresh whole blood be used, the reaction 
may be found as early as the fourth day of the disease. It is persistent 
throughout the illness and in some cases for a year or more, but its exact 
duration has not been determined. Cases of delayed or even absent reaction 
have been reported, but the author has found few which have been delayed '■ Period of 
beyond the first ten days of the illness. A single negative test should never unknown, 
be considered sufficient. 

Value of the Test. — Even when working with dried blood, competent 
observers report positive results in at least 95 per cent, of the cases tested. 
It corrects innumerable errors of observation and must be given not only first 
place among readily available measures in the diagnosis of typhoid, but a 
value more than equal to that of all other symptoms combined. It should 
by now be universally invoked by city and country practioners alike, and its 
teachings accepted in a proper spirit of humility. 

The Blood Culture. — Unlike all other tests, this is of greatest value and 
constancy during the first week of the disease and of diminishing importance as 
the local changes increase.% 

It is almost invariably positive during the first week and present in from Constancy 
80 to 90 per cent, of cases .early in the second week. 

Test. — The technic itself is extremely simple. The blood may be taken 
from the lobe of the ear or the finger-tip, exactly as in the case of the ordinary 

* Young bouillon cultures are not dependable. 

t To the city practitioner who may send his patient's blood to the laboratory of his city 
or state, and obtain a prompt report, these statements may seem of slight importance, but 
it is sometimes most comforting to the country practitioner to anticipate by several days 
the report of a distant laboratory. The same statement applies to the diazo-reaction. 

+ It is quite uncertain after the tenth day of established clinical typhoid fever. 
64 



Its use 
imperative. 



An early test. 



IOIO 



MEDICAL DIAGNOSIS 



Decisive test. 



blood count, from 30 to 40 drops being milked into a test-tube containing 
bile medium (inspissated ox bile, 30.0; peptone, 2.5; water, 250 ex.). A 
better method consists in the use of a sterilized hypodermic syringe and the 
direct withdrawal of blood from a superficial vein. 

A report can be made in from twelve to twenty-four hours, motile Gram- 
negative bacilli being often demonstrated in the original solution after twelve 
hours of incubation. If not then present, a solid agar culture receives a 
few drops of the original bile medium and suspected blood and is incubated 
for twelve hours. For absolute accuracy, tests should be applied for colon 
and paratyphoid. 




^^ 



Fig. 489. — The usual method of obtaining blood for blood cultures. {After Todd.) 

In view of the value of blood cultures in the diagnosis of obscure infec- 
tions a brief reference to the simple method of securing blood and culture 
medium made available to all practitioners by the Keidel vacuum tube may 
be desirable. 

Keidel Vacuum Tube. — Directions for Use. — Cleanse the patient's arm 
at the bend of the elbow with soap and water, and with alcohol and ether, 
in the usual manner. Place a constricting band around the arm above the 
elbow and after removing the connecting cap and stylet from the needle, 
introduce the needle into any prominent vein that may present itself. 
When the needle has been satisfactorily introduced into the vein, break off 
the sealed point of the vacuum tube (of 50 c.c. capacity), containing the 
culture medium within the rubber tubing, holding this tubing between the 
ringers and thumbs of both hands. As soon as the blood begins to flow, 
remove the constricting band and allow 5 c.c. of blood to enter the tube, then 
quickly withdraw the needle, replace the protecting tube and thus reassemble 
the outfit, which may then be carried to the laboratory. If it is necessary 
to mail the tube, remove, the rubber tubing under aseptic precautions, and 
carefully seal the broken end of the tube, that contains the culture medium 
and specimen, in a Bunsen or alcohol flame. (See Fig. 490.) 

DIFFERENTIAL DIAGNOSIS OF TYPHOID FEVER.— Widal's reac- 
tion or the blood culture when practicable will almost invariably eliminate 



TYPHOID FEVER 



lOII 



any doubt that arises, but in its absence one must depend upon the grouping 
of symptoms. 

Acute Miliary Tuberculosis. — This differs from typhoid in its irregular 
temperature, the fever being often of the inverse type; its chills and sweats, 
more rapid emaciation, the fact that rose spots are usually absent, the late 
appearance of the diazo-reaction and splenic tumor, the failure of the Widal 
test and sometimes in the discovery of definite pulmonary symptoms. 

The family history, past health record, or known exposure to infection is 
often suggestive, but it must be remembered that typhoid and acute miliary 
tuberculosis may co-exist and that in both diseases there is a tendency to abnor- 
mally low leucocyte counts and low blood pressure. 

A peculiar bilateral, universal, thoracic hyperresonance has been present in 
nearly every case of general miliary tuberculosis observed by the author. 





Fig. 



B D 

490. — Keidel's tubes. Simple sterilized tubes, carrying a needle and containing cul- 
ture medium are now readily procurable at a small cost. 



Septicemia. — As this disease is usually characterized by a distinctly 
"typhoid state" the focus of suppuration must be sought, and the irregular 
temperature, with possibly chills and sweats, and a marked leucocytosis may 
point to a true diagnosis. It gives the diazo-reaction exactly as does typhoid, 
but does not yield a Widal or the typhoid bacillus in the blood. 

Blood cultures may be decisive and reveal the dominant microorganism. 

Ulcerative Endocarditis. — These present much the same features with the 
added help of localized symptoms, yet under superficial methods, most cases of 
malignant endocarditis of the acute type are mistaken primarily for typhoid, 
and many of those of endocarditis lenta for typhoid, tuberculosis or malaria. 



Sepsis and 
local signs. 



IOI2 



MEDICAL DIAGNOSIS 



The symptoms of chronic recurrent ulcerative endocarditis are, however, 
more distinctly septic, cardiac lesions, almost invariably, are pronounced, 
and precordial oppression and dyspnea are rarely absent. Cutaneous pe- 
techia? are especially common on the extremities, and in the chronic recurrent 
type due to the streptococcus viridans, the painful, tender, transient, cutane- 
ous nodules are almost pathognomonic. Leucocytosis is usually marked. 

Blood cultures if positive will lack the typhoid bacillus and show the causa- 
tive organism which is usually a streptococcus. 

Salpingitis. — Salpingitis is of course to be thought of in all obscure 
infections. 

Cholecystitis. — As a complication of typhoid this condition is not un- 
common and though usually occurring during the second week it may be 
encountered in the early days of illness. Perforation of the gallbladder has 
occurred and should always be kept in mind as a rare possibility. 

Appendicitis. — This constitutes a not infrequent source of error, opera- 
tions for appendicitis being made without justification and cases of appendi- 
citis being treated as typhoid. Ordinarily, the localized symptoms and sud- 
den onset with perhaps a previous history of similar attacks serve to make the 
diagnosis clear. Early localized tenderness in the appendiceal region and a 
leucocytosis are rare in typhoid and in appendicitis the early colicky pain is 
almost invariable and blood cultures and the Widal test are negative. 

Meningitis. — This is sometimes to be distinguished from the cerebral 
form of typhoid only by the absence of the diazo-reaction, the failure of the 
blood cultures and Widal test, but ordinarily no confusion of the two diseases 
is possible. Lumbar puncture and the examination of the spinal fluid is now 
a ready means of differentiation. 

Simple Continued Fever. — This can never be positively differentiated 
from the early stages of typhoid fever unless the two crucial tests are applied. 
As a matter of fact, we may reasonably assume that no such thing as simple 
continued fever exists. It merely represents an unsolved problem in 
infection and, nowadays, may usually be placed under its proper specific 
designation. 

Pneumonia. — This is a frequent complication of typhoid, but as an inde- 
pendent disease may be recognized by its sudden onset, marked localizing 
pulmonary symptoms, high leucocyte count, absence of true diazo-reaction in 
high dilution (i-ioo), negative blood cultures and Widal test. 

Psittacosis. — An epidemic chronic enteritis of parrots which when trans- 
mitted to man presents a clinical picture of typhoid complicated by atypical 
pneumonia. Inasmuch as the germ may be agglutinated by typhoid serum, 
though in lower dilutions, and strongly resembles it in cultural character- 
istics, the observer's opinion is likely to be based upon the past handling and 
feeding of infected parrots and the occurrence of house epidemics.* 

Malaria. — The remittent form can at times be differentiated only by 

* As a matter of fact the bacteriologic findings are extremely varied and reports are 
contradictory. It is probable that in most instances the disease in man would lack the 
agglutination test. 



TYPHOID FEVER 



IOI3 



finding the plasmodium in the blood, the absence of a diazo-reaction and a 
negative blood culture and Widal test. In any malarial country a mistake 
in diagnosis is extremely frequent if clinical symptoms alone are considered. 

Influenza. — This protean disease may sometimes closely simulate typhoid 
but lacks the rose spots, enlarged spleen, diazo-reaction, positive blood 
culture and Widal. 

Trichinosis. — The early stage of trichinosis and typhoid are similar, but 
edema of the face, muscle tenderness, and eosinophilia in the former and 
lack of the cardinal tests of typhoid, soon permit accurate differentiation. 

Tubercular Peritonitis. — This may closely simulate typhoid fever but 
lacks the cardinal features of developed typhoid. 

Brill's Disease. — This, a mild form of typhus fever, lacks the chief 
symptoms of typhoid and can hardly cause confusion. 

Paratyphoid. — As before stated, this disease exactly simulates typhoid 
and can only be differentiated positively by cultural methods and the 
agglutination tests. It unquestionably furnishes an explanation of the 
cases in which a failure of the Widal test has been reported in the face of 
a group of symptoms convincingly typhoidal in type and such failures can 
scarcely be proven without cultural or paratyphoid-agglutination tests. 

It is only during the past few years that the frequency of paratyphoid 
infections has been recognized. 

As stated previously, the disease ordinarily is milder and its mortality 
much less than is the case with typhoid fever of the classical type. It is 
true, nevertheless, that certain epidemics have been reported in which the 
symptoms were extremely severe and the mortality great. (See also page 922.) 

Conclusion. — It is evident that, both in direct and differential diagnosis, 
in certain cases the agglutination test, the blood culture, and the negative 
diazo may be the only determining factors. 

PROGNOSIS. — The mortality of typhoid varies greatly according to the 
age of the patient, his condition at the time of its onset and the character of 
the epidemic, if such exists. It varies in private practice from 5 to 1 5 per cent. , 
in public hospital practice it may reach 20 per cent. Much depends upon the public.' 
character of the hospital population and methods of treatment employed. 
The mortality of different epidemics varies widely in the presence of virulent 
infection, a picked body of men such as would be represented by a newly 
mustered volunteer regiment furnishing a low death rate. On the other 
hand, the same regiment after a long campaign is likely to furnish an extreme 
mortality.* The female furnishes a higher mortality than the male, and sex 
the so-called walking typhoid, i.e., the ambulatory form, presents, as might 
be expected, an excessive death rate. 

* This is well illustrated by a comparison between the light death rates of such of our 
own volunteer regiments as remained in camp, but out of service during the Spanish- 
American war, and the British regiments in South Africa among whom the death rate was 
nearly trebled in cases occurring during or after the active campaign. 

The frightful incidence of typhoid in armies has been overcome to a gratifying ex- 
tent by the present method of prophylactic immunization. 



Private vs. 



Varying 
mortality. 



ioi4 



MEDICAL DIAGNOSIS 



The temperature curve seems not to figure greatly, but pronounced nervous 
symptoms, high pulse rate, and excessive meteorism are of bad portent, and such 
complications as hemorrhage and perforation threaten life, the latter being almost 
invariably fatal even if prompt surgical measures are instituted. 

Hemorrhage occurs in about 5 per cent., and perforation in about 3 per 
cent, of the cases. There is a marked tendency to relapse, especially if improper 
feeding be permitted during the period of convalescence, and it is seldom wise 
to depart from the modernized routine fever diet until the temperature has been 
normal for a week, though it sometimes requires the finest judgment to decide 
whether fever is due to an obscure complication or the persistence of the in- 
fection and intestinal changes. 

The best guide is the condition of the abdomen; freedom from tenderness and 
rigidity {general or localized) being the safest indication for an increased dietary. 

COLON BACILLUS INFECTIONS 

However much of a factor the colon bacillus may be in infections of the 
gallbladder, urinary bladder, and the peritoneum, when it suddenly gains 
access to that tissue under conditions reducing greatly its resistance, it seems 
wholly probable that its attacks are usually limited to more or less devitalized 
tissues. 

It is certain that the more critical analysis, associated with the modern- 
izing of methods, is greatly reducing the number of ailments formerly accred- 
ited to this normal and usually benevolent inhabitant of the intestinal tract. 

One may admit the following activities: 

(a) Terminal infection, i.e., producing toxemic symptoms in moribund or 
near-moribund patients. 

(b) Peritonitis in some instances of perforation, strangulation of a hernial 
sac content and the like. 

(c) Cholecystitis. 

(d) Cystitis and pyelitis. 

(e) Occasionally an enteritis in conditions of impaired vitality. 

(f) Pseudo-typhoid. 

It is probable that its role as an etiologic factor will undergo further 
shrinkage with the passage of time. 



INFLUENZA 



1015 



INFLUENZA 

("La Grippe" "La Cocotte" "La Follette" "The Pleasant Acquaintance" 

"The Jolly Rant" "The Knock-me-down Fever " "Catarrhal Fever" 

"Epidemic Catarrhal Fever") 

Historic Note. — Influenza has been recognized as a clinical entity for 
over 2000 years, having been reported first by Hippocrates in 426 B.C., 
who recognized its epidemic type and described the chief outstanding 
symptoms of the disease. 

Influenza appeared in the Greek army at the siege of Syracuse and 
destroyed thousands of soldiers. In 1728 it drove the Imperial Court of 
Russia from the city of Moscow. In 1782 it so crippled the fleet of Admiral 
Kempenfeldt as to drive it back to port. 

The epidemic of 19 18-19, occurring during that critical period when 
the cantonments of the United States Army contained the very flower of 
the youth of our country, brought home to our people as never before a 
realization of its fearful destructiveness. 

The author's duties in War service took him at this time from hospital to 
hospital and from camp to camp, and the Fall of 19 18 held for him more of 
tragedy than any other period in his life. The extraordinary morbidity and 
the terrific mortality, affecting as it did chiefly the choicest and best of 
American youth, was appalling and unutterably depressing. 

Epidemic Variants. — The epidemic and pandemic nature of the disease 
has long been demonstrated but this epidemic showed also the peculiar 
tendency of the disease to vary in virulence in different countries and even 
in the various centers of infection in the same country. This variability 
was manifested both with respect to the incidence and the mortality. Cur- 
iously enough the Expeditionary Forces seemed to have suffered far less than 
did those undergoing training in the United States. 

It is now known that there is a fairly definite cycle of recurrence with 
respect to this disease which occurs in periods of from 28 to 30 years, and 
it is also certain that the type remains essentially the same, though wide 
variations exist as to its severity. The epidemic of 1918 was much more 
virulent in type than that of the early 90's. It is believed that over 500,000 
deaths resulted from the former, whereas the probable mortality of the 
latter epidemic was comparatively small, though considerable. 

General Comment. — Like cholera, influenza seems to follow lines of com- 
merce in its spread and one can hardly escape the belief that, while essentially 
it is epidemic, it nevertheless is always present in some form throughout a 
large portion of the world. Furthermore, there is a definite tendency to 
the recurrence of the individual epidemics themselves after a period varying 
from six months to a year, and during such recurrences the type of the 
disease may be markedly modified. This certainly was true in the recur- 
rences of the epidemic of the early 90's according to the recollection of the 



Its misnomers. 



Ancient 
epidemics. 



Epidemic of 
1918. 



Geographic 
distribution. 



Periodicity of 
epidemics. 



Recurrences. 



ioi6 



MEDICAL DIAGNOSIS 



Older theories 
as to cause. 



Pfeiffer's 
bacillus. 



Specificity 
unproven. 



Many strains. 



author. In the case of that of 191S this country was fortunate in escaping 
any severe repetition of the original infection. 

Etiology. — The cause of influenza remained a mystery until very recent 
times. Hippocrates ascribed it to "Divine wrath." and Sydenham to some 
"occult and inexplicable changes wrought in the bowels of the earth.*' 
Weber spoke of a "negative state of electricity." whatever that may have 
meant, and recommended the wearing of socks lined with non-conductors. 
The prevalence of fogs of an extraordinary character, the appearance of 
comets, earthquakes, and various other disturbances, were held by many 
to be concerned in its causation, yet more than two and a hah centuries ago 
there were advocates of the " con-tagium vivum.'' 

The Influenza Bacillus. — In 1S92 Pfeiffer described small, non-motile 
bacilli, recoverable from the secretions of those suffering from influenza and 
staining readily with concentrated alkalin methylene blue and carbol- 
fuchsin. These took the dye so deeply at the ends as to resemble diplococci. 
They proved to be Gram-negative, were cultivable with difficulty on blood 
agar, and in smears tended to form groups. He did not succeed, however, 
in absolutely establishing this organism as the cause of the disease nor can 
it be said even at this time that we know positively that, unassociated with 
other organisms. Bacillus influenzae is capable of producing true influenza. 

Nevertheless the evidence in its favor has been strengthened greatly by 
observations made by competent observers during the epidemic of 191 8. 
In general there was a tremendous amount of variability in the reports 
submitted even from the Army hospitals, some failing to rind Pfeiffer's 
bacillus at all and others reporting it only in a limited number of cases. 
On the other hand it is significant that observers of undoubted trustworthi- 
ness were able to recover the organism in nearly all cases coming under their 
observation, some reporting as high as 95 per cent, positive findings. (Still- 
man and Pritchet:. 

So far. the specificity of this organism has not been proven for man. but 
Blake and Cecil have shown recently that when cultures, whose patho- 
genicity has been heightened by animal transmission, are introduced into 
the trachea and bronchi of monkeys there is produced in these animals a 
disease closely resembling or identical with true influenza, the parallelism 
extending even to the production in some instances of the peculiar hemor- 
rhagic pneumonitis which constituted the chief cause of mortality in the 
recent epidemic. 

One of the interesting developments of the recent studies of Bacillus 
influenzae is the discover}* that many strains are obtainable varying con- 
siderably in their pathogenicity. This has been held as being against the 
specificity of the organism but such an assumption would seem to be far- 
fetched. On the other hand such variation reasonably may be associated 
with the peculiar variability in the symptomatology of influenza in different 
epidemics and especially in the recurrences following them. It is worthy of 
note that during epidemics Pfeiffer's bacillus is present in a large number of 
normal " individ uals . 



I Ml UENZA 



IOI7 



Contagiosity. — The disease is highly contagious and, with respect to Highly conta- 

. . . . gious. 

virulence and transmissibility of its pathogenic organism, it may be said 
that it is probable that the height of virulence and the maximum of con- 
tagiosity is attained at the very beginning of an attack. If this be true, 
as seeems probable, it goes far to explain both the rapid spread of the disease 
early in epidemics and the extreme difficulties attending the prevention of its 
spread. 

After the experience of 1918 it would seem that no measures however 
radical would be unjustified in the presence of an epidemic. The wearing Prevention of 
of face masks, the prevention of all public meetings so far as humanly possible, 
and the isolation of the individual patient, all countribute to the limitation 
of the spread of the disease. 

Under such conditions as have prevailed heretofore, in all probability 
practically every person who did not possess individual immunity acquired 
influenza. 

Immunity. — With respect to the production of immunity in those having 
the disease, little can be said positively. It is probable that for a limited 
period such immunity may be acquired. With respect to the production of \ immunity, 
immunity by artificial means through the use of sera, dead cultures, or 
what not, it can only be said that the value of these various procedures 
remains unproven. 

Age and Sex. — This disease affects the male and female about equally 
and attacks with especial severity and frequency young adults. Those 
individuals under 16 and over 40 years of age are less frequently subject 
to attacks, or, at least to its severer manifestations. Pregnant women, if i 
far advanced, showed a fearful mortality in the epidemic of 19 18. 

Incubation. — Hitherto the period of incubation has been unknown, but 
observations made during the recent epidemic show that in a large majority 
of the cases it is of forty-eight hours' duration. In a larger number of 
instances it may occupy three days; in a still smaller number of instances 
one day; and possibly the period may be extended to a week or ten days in 
rare instances. 

Types of the Disease. — In general, one may speak of "true epidemic, 
influenza" and of "endemic-epidemic influenza." The former is by far chief types, 
the more serious and fatal type but, aside from the severity of its symptoms 
and complications, is practically identical with the second form. From a 
purely clinical standpoint we speak of " simple influenza" in which only the 
basic characteristics of the disease are present, the duration being short, 
and of "influenza with complications" 

. In 1918 especially, the dominant complication was a peculiar hemorrhagic 
type of pneumonia, these cases furnishing almost the sum total of the exces- 
sive mortality experienced. 

Moreover, while possessing certain well-defined peculiarities, influenza 
is one of the most protean of acute diseases if we consider the differences Protean, 
to be noted in its various epidemics and especially the variance associated 
with its recurrences. 



ioi8 



MEDICAL DIAGNOSIS 



Common type. 



It would appear that the epidemics of different years assume certain 
predominating features. Some are especially catarrhal, coryza and bron- 
chitis being the prominent features, and pneumonia a frequent complication. 
In others, nervous and even cerebral manifestations play a considerable 
part; and in yet others gastrointestinal symptoms are unduly prominent. 
Furthermore, while distinctly a febrile disease, it often presents an afebrile 
form or one in which the fever is so slight as to lead to an under -estimation of the 
importance of the attack. 

Such variants are especially common in the endemic-epidemic form 
and to a less degree in the definite recurrences. 

Its diagnosis in the absence of a definite epidemic and even in the presence 
of one is rendered obscure oftentimes by its simulation of a multitude of diseases 
as a result either of certain selective points of attack or the peculiarity of Us 
complications. 

Among these confusing conditions may be mentioned cerebral and 
cerebrospinal meningitis, cerebritis with hemiplegia or paraplegia, intract- 
able neuralgia, pleurisy, pneumonia of the ordinary type, jaundice, excessive 
vomiting, diarrhea, dysentery, nephritis, suppurative or non-suppurative 
otitis media, endo- or pericarditis, thrombosis, embolism, psychasthenia, 
melancholia, or mania. 

In the epidemic of 191 8 there was little opportunity for error along any 
of these lines and it is probable that in the past some of the confusing com- 
plications just mentioned were due to conditions now much more readily 
and certainly recognized, such, for example, as sinusitis, the most frequent 
cause of so-called intractable neuralgias and violent, long-persisting 
headache. 

In view of these complicating conditions there is but one safe ground for 
the clinician to occupy, and that is to recognize and act upon the fact that in the 
absence of an epidemic, influenza may sometimes be recognizable only through 
the recovery of the bacillus and the abrupt appearance of a degree of exhaustion 
entirely out of accord with the other symptoms of acute infection presented. 

Mistakes in diagnosis must inevitably be common, excusable, and 
fortunately in most instances without serious results, inasmuch as the treat- 
ment of most complications is essentially that of the disease which they 
simulate. 

Unfortunately this statement did not hold true in the terrible epidemic of 
1918 for it was necessary to treat even suspects with extraordinary care in 
order that the excessively common and fatal complication, hemorrhagic 
pneumonia, might be avoided. 

SYMPTOMATOLOGY.— Simple Influenza.— Onset.— One of the most 
characteristic symptoms of influenza in all of its forms is the astonishing 
abruptness of its onset. In many instances a person in perfect health 
becomes in a few moments a sick patient; in others there may be during a 
period of several hours certain prodromal symptoms, usually a sense of weak- 
ness in the legs and back, often in the joints, and in a certain proportion of 
cases associated with headache more or less severe. 



INFLUENZA 



IOI9 



Pain. — The pains described may be very severe; the pain in the back, for 
example, in cases of the severer type may equal that of the prodromal pain 
of smallpox. The headache is usually frontal, but may be occipital, general, 
or even hemiparietal. 

The pains are frequently associated with a considerable degree of 
hyperalgesia. 

Fever. — Fever comes on promptly and attains its maximum early, endur- 
ing in simple cases from three to five or six days and subsiding ordinarily by 
lysis. In preceding epidemics the ending of the fever seemed usually to 
terminate the attack save for the exhaustion and weakness remaining. In 
the epidemic of 1918, however, this was not true and it was found to be 
unsafe to assume that the ending of the febrile period might permit the 
patient to resume his physical activity. In a host of instances the failure to 
recognize this fact led apparently to the oncoming of the most dreaded and 
fatal complication, namely, pneumonia. Indeed, it seemed to be proven 
beyond contradiction that the only safeguard against this extremely fatal 
pulmonary complication lay in a prompt recognition of the initial symptoms 
of the disease, the immediate putting of the patient in bed, and insistence 
upon his remaining there for several days after all active symptoms seemed 
to have disappeared. 

Coryza and Bronchitis. — The degree to which coryza, tonsillitis and 
bronchitis dominate the clinical picture in influenza varies widely in different 
epidemics. In the epidemic of the early 90' s coryza was a very prominent 
feature, and to a less degree this statement is true of the epidemic of 1918. 
Tonsillitis in some epidemics has been a prominent feature. In the last 
one it was only occasional. On the other hand, bronchitis is one of the 
relatively fixed features of influenzal attacks and in the last epidemic was 
very prominent. An harrassing cough with substernal pain or distress 
developed early, and it is significant when taken into consideration with 
the frequency of pneumonic complications and the type of pneumonia pres- 
ent, that the degree of substernal pain was great in so large a proportion 
of the cases. In no other respect than this last did the bronchitis differ 
from the simple influenzal form. The sputum was not characteristic, 
though claimed to be so by some observers, but followed the usual changes, 
being mucoid, mucopurulent, and sometimes streaked with blood. 

Prostration. — The degree of prostration present in simple influenzae 
is always marked and oftentimes excessive. In any event it is wholly out 
of proper relation to the fever and other symptoms present in the given 
case. Oftentimes it is peculiarly persistent and it has seemed to the author 
that in the older epidemics this was the case in a great many of the relatively 
or almost wholly afebrile cases. 

Circulatory System. — Nearly all writers unite in stating that cardiac 
complications are rare in influenza though some describe a cardiac type of 
this disease. Such assertions are perhaps dangerously misleading. It 
may be granted that endocarditis and pericarditis are rare, but on the 
other hand it has seemed to the author that myocardial toxemia is marked 



Hyperalgesia. 



Dangerous 
over-sight. 



Coiyza. 



Tonsillitis. 
Bronchitis. 



Cough and 
pain. 



Sputum. 



Prostratio 
marked or 
extreme. 



Heart. 



Myocardial 
toxemia. 



1020 



MEDICAL DIAGNOSIS 



Of cardinal 
importance. 



Important 
factor. 



Leucocyte 
count. 



Albuminuria. 



"Abdominal 
influenza." 



Erythema. 



Macular 
eruption. 



even in cases of moderate severity and profound in those of the severer 
type, especially when pneumonic complications supervene. 

Undoubtedly the greater number of cases of definite toxic myocarditis 
are overlooked and this statement is more or less justified by the author's 
experience following his return from Army service and the resumption of a 
practice devoted almost exclusively to cardiovascular disease. An astonish- 
ingly large proportion of the cases reporting for diagnosis and treatment 
at that period dated their symptoms of decompensation from an influenzal 
attack. 

Cyanosis. — One of the characteristic features of the severer types of 
influenza in the 191 8-19 epidemic was the cyanosis present and by some 
observers this seems to have been regarded as one of the symptoms of un- 
complicated cases. This assumption no doubt is erroneous, and any marked 
degree of cyanosis must be considered as indicating the presence of a com- 
plicating pneumonia or profound cardiac weakness. 

The Pulse. — The pulse rate in influenzal cases is not accelerated usually 
to a degree conforming to the physiological rule of pulse and temperature 
ratio and even though a complicating pneumonia ensues the same statement 
holds true. Indeed pulse acceleration is one of the important factors suggest- 
ing the onset of a pneumonia or other complication, and if this rate exceeds 
120, other causes being eliminated, and pneumonia is present it adds greatly 
to the gravity of the prognosis. 

The Blood. — The low leucocyte count in influenza cases is a somewhat 
striking symptom and may reach low figures, 2000 or less per cubic milli- 
meter. Even when a pneumonic complication occurs the rise in the count 
is slow and the total seldom exceeds 15,000 or 20,000 leucocytes per cubic 
millimeter of blood. The average leucocyte count in uncomplicated cases 
is about 6000 per cubic millimeter. 

~ Genito-urinary Tract. — Practically all severe cases of influenza will show 
febrile albuminuria with hyaline and finely granular casts in the urine. On 
the other hand, nephritis as a complication is extremely rare. 

Gastrointestinal Symptoms. — These usually are not pronounced in mild 
cases, though in certain epidemics or recurrences after epidemics they may 
be so pronounced as to justify the use of the term " abdominal influenza." 

In the epidemic of 19 18 they were often present in the pneumonia cases, 
taking the form most frequently of absolute anorexia, nausea and tympanites. 
In many instances vomiting was severe and, in some, an exhausting diarrhea 
occurred. In many of the cases with severe tympanites, an extremely acute 
abdominal pain occurred which misleadingly suggests a surgical condition. 

Cutaneous Manifestations. — Many observers writing of the epidemic of 
191 8 report the frequent occurrence of an erythema affecting chiefly the 
face, the chest, or the back to a greater or lesser degree. In some instances 
this seems to have been so decided as to resemble scarlet fever. Instances 
of the appearance of a macular eruption resembling measles have been 
reported and in a few cases disseminated papular eruptions have been 
described. 



INFLUENZA 



I02I 



Respiration. — The respiratory rate is not markedly increased and this is 
true to an extraordinary degree even in the presence of a complicating 
pneumonia so that any decided increase in the respiratory rate is of importance 
as suggesting the onset of pneumonia and a high respiratory rate in an estab- 
lished pneumonia is of ill omen prognostically. 

It may be said in this connection also that during the epidemic of 191 8 
the pneumonia cases were free to an extraordinary degree from actual 
dyspnea or complaint of respiratory distress, though occasionally a feeling 
of suffocation was experienced and was very troublesome and harrassing. 

Cough. — Even in simple influenza the cough may be and usually is 
extremely harrassing and not infrequently paroxysmal. This was par- 
ticularly true of the epidemic of 19 18 and in many of the pneumonia cases it 
constituted a most serious and exhausting favtor. 

It has seemed to the author that since the original epidemic of 191 8 
there has been a tendency to the occurrence of paroxysmal cough following 
what seemed to be ordinary "" colds." These may or may not represent 
residual endemic influenzal manifestations. In some instances they are 
extremely persistent, enduring over long periods, the cough being most 
troublesome at night, and oftentimes leading to emesis before relief is 
obtained. 

Nose-bleed. — Epis taxis was a frequent occurrence in the epidemic of 1918. 

Comment. — // is important to remember, first, that pneumonia is the most 
frequent and deadly complication of influenza; second, that in the form occur- 
ring so commonly in the 19 18 epidemic it was not recognizable by auscultation 
and percussion in its earliest stages; and third, that in a large proportion of 
such cases it was never positively diagnosticated. 

It is necessary, therefore, to remember primarily that uncomplicated simple 
influenza endures but a few days and in most instances after the third day is 
on the decline. If then, the symptoms continue actively beyond this period, 
the temperature persisting or rising again after reaching low figures or the 
normal, the signs of prostration increase rather than diminish, the rate of the 
pulse and respiration is accelerated, and particularly if cyanosis develops in 
the patient, pneumonia is present in all probability whatever may be the physical 
signs elicited in the chest. 

ACUTE HEMORRHAGIC PNEUMONITIS.— The influenza epidemic 
of 1 9 18 owed its mortality almost wholly to the complicating broncho- 
pneumonia of a peculiar type and to the profound toxic effect exerted upon 
the heart. This form of pneumonia possessed characteristics which were so 
nearly constant as to suggest a distinct influenzal form. 

Pathology. — In the first stage, the lungs were moist, greatly engorged 
and bloody, subpleural extravasations of blood being manifest. The picture 
was one of acute inflammatory hemorrhagic edema rather than a true pneu- 
monia of the usual type, and a large number of the cases escaped diagnosis 
on account of the curious divergences from the usual symptomatology 
together with a suppression of the commoner physical signs of pulmonary 
consolidation. 



Onset of pneu- 
monia. 



Dyspnea. 



Recurrent 
coughs. 



'Colds. 



Emesis. 



Epistaxis. 



Cardinal 
points. 



Peculiar 
broncho- 
pneumonia. 



Hemorrhagic 
edema. 



1022 



MEDICAL DIAGNOSIS 



Tracheal 
engorgement. 



Cyanosis. 



Cell destruc- 
tion. 



Cardinal 
points- 



Selective 
site. 



The bronchial and tracheal mucous membranes were unduly engorged 
at the outset and with the progress of the disease from the hilus outward 
the lungs became more voluminous and more intensely hemorrhagic. 

The peculiar deep cyanosis which was one of the characteristic features 
of these cases was attributable apparently in part to the condition of the 
lung but also to the profound toxic influence exerted upon the heart. 

As demonstrated by Selby, the lung apices and the peripheral portion 
of the bases remained unaffected. 

On section the lung yielded much fluid, thin and bloody. The tissue 
was quite friable in the later stage and areas of hemorrhage were frequent. 

One of the peculiar developments in connection with the pneumonia 
cases of this type occurring at the beginning or during the height of the epi- 
demic in 1918 was the absence of decided pleural exudate and even of any 
considerable amount of fibrin on the pleural surfaces. Histologically, in 
the earlier stages the alveoli were filled with exudate, serous or hemorrhagic ; 
polymorphonuclear leucocytes were relatively scarce, and the dominant 
cell was the mononuclear. 

A striking feature of the disease in its later stages was the apparent 
tendency to disintegration of cells, in the capillaries and alveoli alike, and 
often a necrosis of the alveolar walls. 

Other features of importance were the occurrence of interstitial emphy- 
sema and acute bronchiectasis in many cases. Desquamation of bronchial 
epithelium was marked and there occurred oftentimes an hyaline deposit 
along the alveolar and bronchiolitic walls. 

Changes in the Skeletal Muscles. — Not infrequently marked degenera- 
tion of the skeletal muscles was observed in the fatal cases of influenza 
in 1918. 

Symptoms of Influenzal Pneumonia. — The greatest stress should be laid 
upon the importance of persisting fever, renewal of fever after primary sub- 
sidence, the appearance of cyanosis, an increased respiratory rate even though 
this be only moderate, an increased pulse rate, and a leucocyte count above 
normal, as symptoms indicating the onset of a pneumonia. It is especially 
necessary to stress these points as the physical signs of the condition are so slight, 
misleading, inconstant and slow in their development. 

Most observers unite in reporting that the earliest signs appeared in the 
region of the lower angle of the scapula and consisted of simple crepitant 
rales or small consonant rales which might be only temporary in their appear- 
ance, coming and going at varying intervals. 

Signs of consolidation, if present at all, seldom appeared until twenty- 
four hours or more later. The clinical signs of consolidation were relatively 
infrequent. As shown in Selby's article, which is quoted freely in this 
section the pneumonia began in a large proportion of the cases in the left lung. 
Resolution, when it appeared, was usually relatively slow, termination by 
crisis being the exception rather than the rule. 

Roentgenographic Findings. — As an interesting incident of his War 
service the author was privileged to see a portion of the radiographic work 



INFLUENZA 



I02 



done by Major John Hunter Selby, Chief of the Roentgen Ray Section, 
Walter Reed Hospital, in cases of influenzal hemorrhagic pneumonitis. 

The X-ray pictures were so clarifying with respect to the beginnings and 
extension of the pneumonic process and so great a degree of accuracy in 
prognosis was shown by Major Selby that he feels that a brief consideration 
of this investigator's findings should be included in this article. 

In all 470 patients were referred and of these 386 were found to be suffer- 
ing from hemorrhagic pneumonitis. So far as possible all cases were sub- 
mitted daily to radiographic examination by means of the ward unit made 
available in army hospitals. 




Fig. 491. — The initial film reveals the presence of hemorrhagic pneumonitis in the 
adjacent portions of the upper and lower left lobes and also in the adjacent portions of the 
lower and middle right lobes. Note that the density is most intense at the hilum and 
fades out toward the periphery. Note the clearness of the costophrenic angles on the 
right and left sides. 

The following quotation is taken from Selby's article in the American 
Journal of Roentgenology.* 

"Mode of Onset. — Hemorrhagic pneumonitis usually began coincidently 
with, or soon after, the incidence of a secondary rise in temperature,! occur- 
ring from one to five days after the patient had run what was apparently a 
typical influenza course. Less frequently it appeared on the fourth or fifth 

* American Journal of Roentgenology, 1919, Vol. 6, page 211. 

t This observation was noted early in the epidemic by Lieut. J. Harkavy and 
personally communicated to me. This enabled us to detect a larger number of early 
cases than otherwise would have been possible. 



Time of onset. 



1024 



MEDICAL DIAGNOSIS 



Interesting 
observations. 



day after the initial onset of influenza, where the temperature curve was 
atypical, in that the characteristic fall did not occur. In a few instances, it 
was detected the day after the patient went to bed. 

" Characteristic Roentgen Ray Appearance. — In the earliest stage demon- 
strable by the roentgenogram hemorrhagic pneumonitis is recognized as a 
faint filmy haze opposite the level of the lower angle of the scapula. The 
mesial portion of haze is partially obscured by the outer portion of the 
normal hilum shadow. This hazy area enlarges in all directions and fre- 
quently it is observed that the adjacent portions of the upper and lower 
lobe are involved simultaneously. The process may advance so rapidly as 




Fig. 492. — Compare with Fig. 491 and note the extent of spread in 48 hours. 

to include the greater portion of all lobes in the same side of the chest within 
forty-eight hours. In fulminating cases all five lobes may become blood- 
logged and death ensue within forty-eight hours. Hemorrhagic pneu- 
monitis invariably began as a unilateral process, and in 82 per cent, of our 
cases the left lung was primarily involved. It was never seen to begin in 
any peripheral portion of a lobe, but invariably appeared in the region of the 
lung roots. It was also noted that the involvement never began simultane- 
ously in two or more widely separated areas, but it was found to spread from 
the original site. Later it may develop around the roots of a lobe on the 
opposite side. The peripheral portions were the last to fill with blood. 
The true apex and the lower borders of the lower lobes were never involved. 
We discovered this characteristic absence of apical costophrenic involvement 
early in the epidemic and requested a check by autopsy. The autopsy con- 



INFLUENZA 



IO25 



firmed this, so that we were enabled to utilize the sign in detecting pleuritic 
involvement. 1 In other words, we found that in every case where the roent- 
genogram showed a haziness or a total density over the apex or costophrenic 
angle, it was indicative of a pleuritic complication or lobar pneumonia. 
In the vast majority of cases we found pleural effusion responsible. 

"Course.-^- The hemorrhage showed a tendency to disappear within three 
davs where the area of involvement did not reach a greater diameter than a 
silver dollar. In moderately advanced cases, e.g., where the invasion was 
arrested when the involvement included no more than the lower proximal 
half of the upper left lobe and the adjacent proximal portion of the lower left 




Fig. 493- 



-The patient was too ill to hold his breath and died within 24 hours after this 
examination. 



lobe, the condition would slowly but progressively fade away, usually dis- 
appearing by the twelfth day unless complicated by some other intrathoracic 
condition. If in such a case there had been a progressive clearing demon- 
strated over a period of several days followed by an interruption, a compli- 
cation usually appeared soon thereafter, the most frequent one being a 
pleural effusion. This often changed into empyema. 

"During the height of the epidemic the cases which showed extensive 
involvement of all five lobes usually proved fatal regardless of whether the 
involvement developed slowly or rapidly. Later in the epidemic, the 
virulence diminished and the percentage of fatalities in extensive involve- 
ments became conspicuously less. In some cases the process of absorption 
65 



Course. 



Compoete 
bilateral cases. 



102 6 



MEDICAL DIAGNOSIS 



of the hemorrhage was noted in one lobe while a complication would develop 
in the region of another lobe. 

''Prognosis. — Soon after these daily roentgen ray observations were 
instituted it was found that the cases presented certain definite character- 
istics by which a prognosis could be offered with much accuracy. The 
second or third film usually sufficed to base our predictions on. Our prog- 
nosis was made utterly regardless of the clinical data. We based it upon 
the rate, direction and extent of the spread, interpreted in the experience 
furnished by the earlier cases. 



24 HOURS BEFORE DEMH 



Remarkable 
prognoses. 



Fig. 494. — Another case showing extensive involvement of lower and middle right 
lobes, lower portion of upper right and adjacent portions of upper and lower left lobes. 
The patient was too ill to hold his breath but this figure illustrates clearness of costophrenic 
angles and true apex. The patient died 24 hours after this was taken. 

"The rapidity with which the hemorrhage spread to include the lobes 
opposite the original hemorrhage bore a direct relation to the gravity of 
the case. We did not observe a fatal case in which the hemorrhage remained a 
unilateral condition, even though all lobes on the affected side became extensively 
involved. 

u Ordinarily if the patient survived seven days after the onset of the hemor- 
rhagic pneumonitis, the prognosis was favorable. However, the convalescence 
in many cases was interrupted by one or more of the previously enumerated 
intrathoracic complications. Empyema was the most frequent to occur 
after the seventh day in hemorrhagic pneumonitis. 

"In our series, where the roentgen ray observations were possible early 
in the course of the disease, w r e erred in two cases w r here a grave prognosis 



INFLUENZA 



IO27 



had been rendered. In one, all five lobes were involved and a bilateral 
empyema developed subsequently. This case was interesting in that an 
entirely different organism was recovered from the right pleura than from the 
left. In the other case, the convalescence was complicated and prolonged. 

" Theory of Invasion. — The serial radiographic studies upon the trachea, 
bronchi, bronchioles, alveoli and their capillaries, interpreted in the light 
of the autopsy findings, support the conception that the causative organism, 
whatever it be, gains access through the respiratory tract. It lodges and 
proliferates in the lower portion of the trachea or in a main bronchus, whence 




Fig. 495 — Another case showing extensive hemorrhagic pneumonitis in lower right lobe, 
lower left lobe, and adjacent portions of upper left lobe. 

the organisms are distributed by contiguity, reaching first the bronchi and 
alveoli in the immediate vicinity. These individual colonies elaborate the 
toxin which produces local destructive change in the cells lining the bronchi, 
the alveoli, and also the capillary walls, the result being a frank pernicious 
hemorrhage. The spread is perhaps augmented by the flow or inhalation 
of the infected bloody exudate into other portions of the respiratory tract. 
The process seems to develop by spread in contiguity from the original focus 
in the main bronchus to the alveoli. 

"The serial radiographs proved that the hemorrhage invariably com- 
menced in the central portion of a lobe nearest the hilum. Later it spread 
in all directions simultaneously. It is plausible to assume that when the 
hemorrhage becomes extensive enough all approaches to the peripheral 
portions of the lobe are likely to be blocked off by the presence of the rapidly 



Mode of 
extension. 



Primarily 
"central." 



1028 



MEDICAL DIAGNOSIS 



Curious 
immunity. 



accumulated blood in the distributing bronchi. If this is true, the air 
circulation is retarded and the organisms cannot be transported either by 
air or by the flow of exuded blood into the more distant alveoli. Autopsy 
| consistently confirmed the conspicuous absence of hemorrhagic pneumonitis 
in the true apex and in the costophrenic borders of the lower lobes. It was 
also noted that the alveoli situated nearest the pleura are relatively free 
from hemorrhage. 

"This absence of hemorrhage at the apex and in the costophrenic borders, 
together with the delayed involvement of the peripheral portions of the 




Fig. 496. — Compare with Fig. 495 and note extent of spread in 24 hours. Both costo- 
phrenic angles remain clear. 

lobes, strengthened the theory that the hemorrhage is due to the toxins 
elaborated locally. It is also obvious that the hemorrhage cannot be 
explained on the assumption of a state of hypostatic congestion because the 
autopsy findings failed to confirm hypostasis in the most dependent portions 
of the low T er lobes. Thus it is obvious that the condition is in no way a 
septicemia. 

"We found it advisable to divide our 470 cases into the following groups: 

(a) Hemorrhagic pneumonitis uncomplicated. These presented the 
typical hazy spreading shadow produced by the increased condensation. 
Xo discrete mottling was present, nor was there any conspicuous enlarge- 
ment of the mediastinal glands. No pleuritic complications were present. 

(b) Hemorrhagic pneumonitis associated with a conspicuous enlarge- 
ment of the mediastinal glands, but without discrete mottling. 



INFLUENZA 102 0, 



Hemorrhagic pneumonitis associated with discrete mottling, but 
without conspicuous enlargement of the mediastinal glands. 

Hemorrhagic pneumonitis associated with conspicuous enlargement 
of the mediastinal glands and with a definite discrete mottling over the 
pulmonary area. 

(e) Hemorrhagic pneumonitis complicated by some form of pleural 
involvement, pericardial involvement and mediastinal empyema. 

(f) Adenitis unassociated with hemorrhagic pneumonitis, discrete mot- 
tling, or any other form of pulmonary or pleural pathology discernible by 
roentgen ray. 

(g) Adenitis and fibrosis unassociated with other intrathoracic pathology 
discernible by roentgen ray. 

Adenitis without hemorrhagic pneumonitis or discrete mottling but 
associated with some other intrathoracic pathology. 

Discrete mottling of the pulmonary area uncomplicated by hemor- 
rhagic pneumonitis, enlargement of the mediastinal glands, or any other 
intrathoracic pathology discernible by roentgen ray. 

(J) Discrete mottling associated with conspicuous enlargement of the 
mediastinal glands unassociated with any other intrathoracic pathology 
discernible by roentgen ray. 

(k) Mottling unassociated with hemorrhagic pneumonitis and enlarge- 
ment of the mediastinal glands, but associated with some other intrathoracic 
pathology. 

Hemorrhagic pneumonitis associated with pulmonary tuberculosis. 

(tw) Hemorrhagic pneumonitis associated with lobar pneumonia. 

(n) Lobar pneumonia uncomplicated by hemorrhagic pneumonitis. 

(0) Cases in which there was definite clinical evidence of pulmonary 
pathology but in which the serial roentgenographs failed to confirm the 
presence of a pulmonary lesion. 

' "Naturally the cases presenting a discrete mottling offered the greatest 
difficulty in interpretation, for we did not have prehminary plates by which 
an estimate might have been made of the previously existing chronic lesions; 
such as peribronchial adenitis, chronic parenchymatous, tubercular changes, 
etc. However, we were soon enabled to identify the mottling by autopsy. 
It was found to be due to the discrete interstitial lesions, commonly held 
to be streptococcic in origin. In our cases the sum total of mottled types 
was so small as to be conspicuous. 

"The total number of patients studied roentgenographically was 47c. 
Of these 82 per cent., or 386. presented hemorrhagic pneumonitis compli- 
cated or uncomplicated by one or more of the intrathoracic conditions already 
noted. Of the remaining 84 patients. $3 failed to show any lung pathology 
by the roentgenogram, although clinically there was evidence of so-called 
bronchopneumonia. 7 were Group (g) (mediastinal adenitis 1. 13 were Group 
iscrete mottling uncomplicated): the remaining 31 could not be classi- 
fied, as the presence of fluid completely obscured the original pathology. 

'"Of the cases which came under roentgen ray observation early enough, 



1030 



MEDICAL DIAGNOSIS 



the hemorrhagic process was found to appear primarily in the left lung in 
82 per cent. This is a striking fact, but no less remarkable than the observa- 
tion that in our 91 cases in which there was unmistakable evidence, the 
initial invasion appeared in the lower left lobe eighty-five times to six in the 
upper left lobe. 

"Group (a) includes a few cases where autopsy revealed a small amount 
of pleural fluid, which roentgenographically was not present twenty-four 
hours before death. Presumably this developed as a terminal process. The 
importance of serial roentgenograms in influenza has been amply proven 
in this clinic, chiefly in detecting and identifying pulmonary complications 
in the early stages. 

"We had no deaths from Group (/) or (g) and so far we have not seen 
a single instance of fatal influenza unassociated with an intrathoracic 
complication." 

Prognosis in Influenza. — As has been said, influenza is a disease of enor- 
mous actual but low relative mortality; that is to say that, considering the 
universality of an epidemic and the enormous numbers of individuals 
attacked, the death ratio is small, yet the total number of deaths is enormous 
and the indirect mortality adds greatly to the figure. The enormous 
mortality, the fact that it kills the adult by preference, and especially those 
engaged in active productive work, has opened the eyes of sanitary author- 
ities to the necessity for quarantine regulations, both as applied to the 
State and X& the household. 

As to the prognosis of simple uncomplicated influenza, one may say that 
there is only a small mortality save in individuals suffering from chronic 
disease, greatly debilitated, or of an advanced age. 

The onset of pneumonia at once converts the case into one of extreme 
danger. 

Pregnant women suffer very greatly, usually abort especially if the preg- 
nancy is advanced, and show a mortality which in certain instances has been 
reported as reaching 60 per cent. 

In the epidemic of 191 8 it was found that those individuals who survived 
for a week or ten days after the onset of pneumonia usually recovered. 
Furthermore, as has been stated by Selby quoted in this article, those cases 
which showed only a unilateral pneumonic involvement yielded a relatively 
slight mortality. . 

As stated previously, the heart suffers seriously from the toxemia of this 
disease and those who carry a chronic heart lesion are more greatly endan- 
gered during the attack and are prone to show its effects for long periods 
thereafter. A failure to appreciate this fact results very seriously for an 
enormous number of cardiopaths and every physician should watch the 
heart carefully during convalescence and prolong this so far as is necessary 
to secure for the patient the best possible reestablishment of his myocardial 
reserve. 



ASIATIC CHOLERA 



103 I 




ASIATIC CHOLERA 

("The Death Blow") 

Definition. — An acute infection caused by the comma bacillus of Koch and 

characterized by profuse rice-water diarrhea, violent muscle cramps and collapse. 

Historic Note. — It is one of the most ancient of diseases in the East, but 

of comparatively recent development in the United States, the first epidemic 

having occurred in 1832. 

Etiology. — Koch reported his discovery of the comma 

bacillus in 1884. The germ retains its vitality for a 

week or more on foodstuffs, such as butter, milk, and 

meat, lives but a day or two in oysters, but finds sewage 

a good culture medium. Water is a great conveyor and 

flies also carry it, but it travels no faster than man, 

following the trade channels, whether these be railways, 

canals, rivers, or steamship lines, tending to spread from 

India, where it is endemic, to all parts of the civilized 

world. The great pilgrimages, fairs, and festivals serve 

to disseminate it widely; filth, overcrowding, and infected 

water and food being part and parcel of such gatherings.* 

The disease is readily conveyed by fomites, but is 

essentially water-borne. The city of Hamburg in 

1892-93 had 18,000 cases with a mortality of over 40 

per cent., whereas Altona, a suburb, had but 516 cases. 

Both cities drank the same water, but Altona filtered hers. One convalescent 

workman from Marseilles once infected the water of a large reservoir, and 

through it a large district of the city of Paris. 

Cholera is a hot weather and low altitude disease, the germ is readily 
destroyed by sunlight, but vast quantities of bacteria are discharged in the 
stools and many objects may serve as indirect carriers. It is not highly 
contagious and scrupulous care in regard to the dejecta permits nurses and 
physicians to perform their duties without fear of infection. Age and sex 
seem to cut no figure as regards disease incidence, and neither absolute nor 
relative immunity is well proven. 

Morbid Anatomy. — Rigor mortis is extraordinarily rapid, producing 
horrible post-mortem movements of the extremities, lower jaw and even 
the eyes. The tissues are dry and shrunken, the blood is thick and tarry, 
and there is an intense congestion of the stomach and intestines and cloudy 
swelling and parenchymatous degeneration of the viscera. 

Incubation Period. — The incubation period is from two to five days. 

* The British have found the utmost difficulty in checking its development and dis- 
semination. Native visitors to holy shrines bathe in holy wells and drink of the precious 
water which contains the washings of many bodies. Sick and well are crowded together. 
dirt abounds, ventilation is deficient, and in event of an epidemic the care of the sick and 
the proper disposition of the dead are alike neglected. 



Fig. 497.— Chol- 
era Bacillus (comma 
bacillus or spirillum 
cholerae of Koch). 
Non-s porogenous, 
flagellate, motile, 
parasitic, saprophy- 
tic non-chromogenic 
aerobic and facul- 
tative anaerobic, 
liquefying, spirillum, 
readily stained but 
Gram negative. 



An ancient 
scourge. 



Readily 
conveyed. 



Difficult to 
control. 



1032 



MEDICAL DIAGNOSIS 



Typical attack. 



Profound 
toxemia. 



"Rice-water 
stools." 



Preliminary Stage. — When present, this lasts but a few hours and presents 
malaise, marked mental depression, headache, diarrhea, nausea, vomiting and 
colicky pains. In most instances the onset is abrupt. 

Stage of Purging and Collapse. — This is characterized by profuse and 
almost constant serous discharges from the bowel, accompanied by tenesmus, 
intense thirst, and excruciating muscle cramps especially affecting the abdomen 
and calves of the legs. Vomiting is almost incessant, acidosis profound, the 
countenance Hippocratic, cyanosed and shriveled, the skin wrinkled, moist and 
cold, the superficial temperature greatly subnormal, though the rectal temperature 
may reach 103 to io5°F., the blood pressure minimal (60-75). 

The hemoglobin percentage is high and the blood is obtained with difficulty. 
The pulse soon becomes excessively rapid, weak, flickering, or even absent at the 
wrist, the albuminous urine scanty or suppressed, the tongue and throat dry, 
yet the patient sweats profusely. The stools are of the characteristic u rice-water " 
type and the patient becomes comatose or passes into the third stage. The 
duration of this stage of collapse is from a few hours to two days. 

Third Stage {Reaction). — All symptoms gradually subside and a tedious 
convalescence ensues. Various late eruptions may occur. 

The Blood. — There are both polycythemia and leucocytosis in the algid 
stage, the red cells varying from 6,000,000 to 8,000 000 and the leuco- 
cytes from 14,000 to 60,000 per cubic centimeter. 

Acetonemia and uremia must be guarded against even in this stage. 

Prognosis. — The mortality varies from 25 to 75 per cent, in different 
epidemics, death may occur in relapse, in cholera typhoid, when the delirium 
is marked, and coma rapidly supervenes, or the patient may die even before 
the rice-water stools appear {cholera sicca) . 

Diagnosis. — In the absence of an epidemic, cases of poisoning by certain 
minerals, ptomains, or mushrooms may cause difficulty. 

The so-called cholerine is a very mild form of the disease, accompanying 
certain epidemics, and isolated cases offer great difficulties in diagnosis. 

Cholera nostras (cholera morbus) in its severer forms exactly simulates 
true cholera, but is usually a paratyphoid infection. 

Positive Differential Symptoms. — The germ must be recovered and culti- 
vated from the stools, and the diagnosis thus absolutely established. 

In the presence of an epidemic a tentative diagnosis may be made in a 
majority of the cases from the appearance of the vibrios in a smear from 
fecal mucus and the "scintillating motility of the organisms" as viewed in 
.the hanging-drop. 

Expert handling is absolutely necessary to positive diagnosis which 
involves the application of the agglutination test with known immune sera, 
the use of Pfeiffer's method, and the nitroso-indol reaction. 

BUBONIC PLAGUE 

{"Black Death;' "Pest," Malignant Adenitis) 
Definition. — A virulent epidemic disease, highly infectious but not mark- 
edly contagious, caused by the bacillus pestis of Yersin, and characterized 



BUBONIC PLAGUE 



I033 



"The 
Killer. 




by high fever, great prostration, the formation of buboes, a tendency to hemor- 
rhage, both subcutaneous and from mucous membranes, and a remarkably 
high leucocyte count. 

Historic Data. — It is as old as the Pyramids. After the sixth century it 
repeatedly visited Europe and Great Britain, killing during less than one 
centurvin London alone, 161,344 people; indeed, the epidemic of 1665 caused 
68,000 deaths, the total population of London being at that time under 
500,000. The Indian plague of 1889 is said to have been responsible for at 
least 250,000 deaths and in the fourteenth century it is said to have carried 
off not less than one-fourth of the total population of 
Europe. It is endemic in China and India, and a fre- 
quent visitor to the Philippines. 

Etiology. — 77 is distinctly a rat disease, and its 
development and spread occurs under conditions favor- 
ing the development and multiplication of these animals. 
The germ is an encapsulated, short, round microorgan- 
ism, discovered in 1894 by Yersin and Kitasato working 
independently. It lives long and thrives in urine, 
sputum and fecal matter. 

The disease is communicable, chiefly through drop- 
let infection in pneumonic cases, but it is probable 
that only a small proportion (3 per cent.) of the cases 
are so contracted. 

So far as the human being is concerned, nearly all 
cases acquire the disease through the fleas infesting in- 
fected rats, the chief carrier being the Epimys norwegicus. 
In California, ground squirrels have been proven to 
be carriers. 

Morbid Anatomy. — That of an acute infection with profound toxemia. 
The lymph vessels are chiefly affected, the glands being enlarged, edematous, 
and hemorrhagic, or showing suppuration and external ulceration. The 
bacilli are generally distributed, the kidneys and spleen are hyperemic and 
the lungs may show pneumonia and infarction. Primary and secondary 
carbuncles, ecchymoses and dermatitis may be present and the viscera 
generally show fatty and parenchymatous degeneration with marked 
hyperemia. 

PESTIS MAJOR. — Symptoms. — Incubation period two to ten days. Pro- 
dromal period from twenty-four to forty-eight hours. Pallor, vertigo, and pro- 
found muscular weakness are associated with nausea, vomiting, and diarrhea. 
Nose-bleed is frequently present and mental depression marked. The fever 
rises steadily until just before the active stage. 

Active Stage. — This is characterized by chill, high fever (104 to io6°F.), 
and rapid pulse (120 to 200). The expression is anxious, countenance livid, 
conjunctival congested, the skin dry and hot. After three or four days buboes Buboes 
appear in from 70 to 80 per cent, of the cases. The inguinal and femoral glands 
are affected primarily in 60 per cent, of the cases. Suppuration is a favorable 



Fig. 49S. — Bacil- 
lus of Bubonic 
plague (bacillus 
pestis of Yersin). 
Minute, non-motile, 
n, o n - s p o rogenous, 
non-ch romogenic, 
pleomorphous, aero- 
bic and facultative 
anaerobic organism, 
easily cultivated 
and stained, but 
Gram negative. 



1034 



MEDICAL DIAGNOSIS 



Plague spots. 



High counts 
Virulent types. 



Misleading 
form. 



Cardinal 
points. 



Usually easy. 



Prognosis. 



A mosquito 
host. 



sign, but gangrene may supervene. Petechial or extensive ecchymoses may 
appear {plague spots), as may other skin eruptions of various types. Any 
mucous membrane may be the seat of hemorrhage. 

The Blood. — The leucocytes average more than 90,000 to the cubic 
centimeter, and there is marked polycythemia, the average count of red cells 
being about 7,000,000 per cubic centimeter. 

Varieties of Pestis Major. — (a) Septicemic plague. In this form buboes 
do not appear, the organism is overwhelmed and death occurs in a few days 
or hours, (b) Pneumonic plague. In this the lesions are chiefly and ordi- 
narily those of broncho-pneumonia, the sputum is loaded with germs and 
about 90 per cent, of the cases die. 

Pestis Minor. — This mild form has slight fever of short duration, glandular 
swelling with or without suppuration, and may easily be misdiagnosed. Such 
cases, unfortunately, are the usual forerunners of epidemics. 

The Diagnosis. — Lacking an epidemic, the diagnosis must sometimes 
depend upon the recovery of the germ, as the agglutination reaction, though 
often obtainable, is not absolute and occurs late in the disease. Reliance 
is to be placed chiefly upon : (a) Prevalence of an epidemic, (b) Profound ex- 
haustion, (c) Anxious countenance and mental depression, (d) Buboes 
which are characteristically edematous, (e) Petechice. (/") Hemorrhage, (g) 
Leucocyte count. 

Pathognomonic Sign. — There is but one, viz., the recovery of the bacillus 
from the blood, urine,' sputum, or feces and its positive identification. 

Differential Diagnosis. — Tuberculous adenitis. Fever absent or inter- 
mittent, development slow and comparatively painless; this could hardly be 
confounded even with pestis minor. Syphilis presents initial lesion or cica- 
trices, sore throat, characteristic eruption of mucous patches and its buboes 
do not suppurate. Chancroid, initial lesion, strict localization of bubo. 
Hodgkirfs disease and gonorrheal bubo should not be confusing, but neverthe- 
less are sources of disastrous error. 

The mortality is always large and even in those inoculated with antiplague 
serum it is said to be 14 per cent. In some epidemics it runs from 50 to 95 
per cent. 

DENGUE (deng-ga) 

{''Break Bone" or "Dandy" Fever) 

Definition. — A mosquito-borne tropical and subtropical disease of unknown 
origin, low mortality, high infectivity, and slight contagiousness, characterized 
by its sudden onset, severe muscular and joint pains, irregular rashes, double 
febrile paroxysm, and tendency to relapse. 

Etiology.— It is probably due to an ultramicroscopic organism as Ashburn 
and Craig found blood highly infective, even though passed through a porce- 
lain filter and as reported by H. Graham, of Beyrout, Syria, in 1903, the 
Stegomyia fasciata is probably the intermediary host and source of infection. 
Ashburn and Craig failed to find the parasite reported by Graham though 



DENGUE AND YELLOW 1T\ Ik 



I035 



confirming his report that the mosquito acts as a carrier of the specific 
filtrable virus. 

Incubation Period. — Three to six days, no prodromata. 

Symptoms. — The onset is extremely abrupt with chill, high fever, and rapid 
pulse, headache, muscular, joint and deep-seated bone pain associated with 
extreme tenderness. Both large and small joints may be swollen. Red and 
enlarged lymph glands are frequent and, often, long persistent vomiting may 
occur, the face is deeply congested, and a rash of short duration, irregularly 
distributed, and variable in character is often present. Initial symptoms 
usually include extreme pain in the eyes* and a blotchy facial erythema. 

On the second, third, or fourth day a crisis occurs with the usual phenomena, 
and is followed by a period of remission of all symptoms, lasting from twelve 
hours to three days; then follows a reinvasion less severe than the first, terminat- 
ing in a second crisis after three or four days or even a few hours, and during this 
stage a somewhat characteristic rubeolar eruption may appear, first on the hands 
then over the body, but always most markedly over the hands, wrists, elbows, and 
knees, occasionally forming a diffuse red rash by coalescence. Desquamation 
follows and is usually furfur aceous. 

A second remission and third paroxysm may occur, or the first remission 
may terminate the disease. In more severe cases, jaundice, black vomit, 
marked albuminuria and hematuria may occur and suggest "yellow jack." 
A decided leucopenia is observed in this disease. 

Differential Diagnosis. — (See Yellow Fever.) 

Prognosis. — There is practically no mortality. 

YELLOW FEVER 

("Yellow Jack," "Bronze John") 

Definition. — A virulent infectious but non-contagious disease, charac- 
terized by sudden onset, high fever, jaundice, black vomit, and slow pulse. 

Etiology. — At the present time it is believed that the Leptospira icteroides 
of Xoguchi may be the specific casual factor. A commission, headed by the 
later Walter Reed, U. S. A., in 1900-01 proved the intermediary host and 
transmitter of the filtrable virus to be the mosquito known as the Stegomyia 
calopus fasciata. This commission furnished one of the most brilliant 
examples of scientific acumen and heroic self-sacrifice in the history of 
medicine. Dr. Lazear became infected and died. Xon-immune volun- 
teers slept for twenty days in the stained sheets taken from the beds of yellow 
fever patients, their heads wrapped in soiled, bloody cloths, yet all these, being 
protected from mosquitoes, escaped the disease. Those isolated for long 
periods and then exposed to multiple inoculation by mosquitoes that had 
fed upon yellow fever patients, in nearly every instance developed the disease, j 
It was found that mosquitoes required twelve days to develop virulence, and j 
retained their infectivity for eight weeks or more. A subcutaneous injection 
of yellow fever blood produced the disease even though the blood were 
defibrinated and passed through a porcelain filter. 
* This may also be marked in yellow fever. 



Filtrable virus. 



Abrupt onset. 



Arthritic onset. 



Remission. 



Initial and 

tsrminal 

erythemas. 



Severe forms. 



Major Reed's 
great work. 



Heroism of 
volunteers. 



Period of 
virulence. 



Blood 
infective. 



1036 



MEDICAL DIAGNOSIS 



Simple pre- 
ventive 
measures. 



Substantial 
proof. 



"A bolt from 
the blue." 



Early jaundice. 



Black vomit. 



Remission. 



Character- 
istic facies. 



The experiments proved that the only quarantine measures necessary were 
those calculated to destroy mosquito life in houses or on shipboard, and that the 
disease is not conveyed by fomites; further, that to control an epidemic it is only 
necessary to screen the sick and the houses of the well, destroy all resident mosqui- 
toes, and to treat marshes, stagnant pools, water barrels, and other breeding places 
with petroleum which destroys the surface-breathing larvce. 

Through such measures, Santiago, Havana, and other towns were ren- 
dered free from yellow fever by the government medical authorities after the 
Spanish-American war. 

Seasonal Influences. — All that was previously written regarding these 
matters now resolves itself into a discussion of mosquito life and propagation, 
and it has always been recognized as a summer and early autumn disease, 
killed by frost. Race. The whites are chiefly affected, though negroes are 
not wholly immune and visitors contract the disease more readily than those 
acclimated. Sex. There is equality of susceptibility, though on account of 
greater exposure males chiefly predominate. Age. It resembles typhoid in 
its preference for the young adult. Old people and infants ordinarily escape, 
the latter probably from minimum exposure. Immunity. One severe at- 
tack protects for life. 

Morbid Anatomy. — Diffuse nephritis, gastric hyperemia with hemor- 
rhagic stomach contents, hemoglobinemia, general glandular enlargement, 
cutaneous hemorrhages, and deep jaundice are the usual findings. 

Symptoms. — The first stage strikes u like lightning from a clear sky," with 
chill and high fever (103 to io6°F.) accompanying a singularly slow pulse 
(80 to a temperature of io4°F.) ; there is excruciating pain in the loin and in 
the leg muscles, profound muscular weakness, violent headache, sore throat and 
vomiting, and the mental depression is often marked. A slight jaundice com- 
mencing in the eyes and extending to the chest, arms, and body may appear even 
in this stage. 

Albuminuria may be marked as early as the second or third day. 

There is photophobia frequently associated with intense orbital headache; 
vomiting, increasing in intensity until black vomit may appear; the tongue is 
swollen and beefy or often small and pointed, and the gums are tumid. The 
pulse is not primarily slow, feeble, and compressible, but tends to decline even 
with rising temperature. 

Physiognomy. — The expression is thought by Guiteras to be quite character- 
istic. The cheeks and conjunctives are congested, the eyes staring, humid and 
ferrety, the general expression " anxious." 

Second Stage - (duration from a few hours to thirty-six hours). — On the 
third or fourth day all symptoms abate leaving the pulse slow (even 30 or 40) 
and compressible, the temperature may be normal and recovery follows in 
mild and favorable cases, though convalescence is often protracted and ac- 
companied by irregular fever. 

Third Stage. — In severe cases a stage of intensification of the initial 
symptoms and collapse follows a remission. Its duration is from one to 
three days. The temperature usually rises slowly to 102 or io4°F., or may 



YELLOW FEVER AND MALARIA 



IO37 



rise steadily until death, though the pulse may fall to 60 or even 30 beats per 
minute. The jaundice deepens, black vomit occurs, albuminuria is invariable, 
hematuria commences, total urinary suppression is not unusual, and hemorrhage 
may occur from the nose, gums, lips, rectum, or any other mucous membrane, the 
skin may be of a deep mahogany color, and various irregular eruptions may 
occur. The late Dr. West, of Galveston, of wide experience and a keen observer, 
always insisted that the renal symptoms overshadowed all others in severe cases. 
A "butcher-shop odor" is marked in this disease. 

Diagnosis. — Essential Data. — Mild cases ("acclimatation fever") may be 
unrecognizable, but in marked cases one especially notes: (a) Sudden onset 
without prodromata. (b) Presence of an epidemic or history of exposure, (c) 
Physiognomy, (d) Low initial pulse rate with high temperature, (e) Falling 
pulse rate and volume with rising temperature. (/) Excessive gastric irritability, 
(g) Early jaundice and later extreme pigmentation, (ji) Black vomit, epistaxis 
and bleeding gums, (i) Albuminuria with a tendency to suppression (pre- 
dominance of renal symptoms). (7) General tendency to hemorrhage, (k) 
The apparent slight loss of red cells per cubic centimeter is a marked feature 
in view of the hemorrhagic condition. 

Differential Diagnosis. — Dengue. — No mortality, joint symptoms usually 
more pronounced and persistent, yellow fever pulse- temperature ratio absent , 
jaundice seldom marked and rarely as early as the third day, black vomit 
usually absent, renal symptoms not so prominent or so early, rashes common 
and somewhat characteristic, and hemorrhages rare save hematuria. 

Malaria. — Plasmodium in the blood, sequence of phenomena usually 
widely different, enlarged spleen, response to quinin, renal symptoms less 
prominent, jaundice later, facies of yellow fever absent, albuminuria delayed 
and hemorrhage rare. Only the irregular forms of malaria can by any possi- 
bility be confounded with yellow fever. Acute yellow atrophy, Weil's disease 
and relapsing fever lack the chief symptoms of u yellow Jack." 

Prognosis. — It is largely determined by the height of the original fever. 
In Sternberg's analysis of 269 cases, of those characterized by an initial 
temperature of 105 to io6°F., 61 per cent, died; of 104 to io5°F., 30 per cent, 
died; of 103 to io4°F., 6 per cent, died; of 103 °F., none died. Recovery may 
ensue in any case, however severe, but convalescence is slow. 



MALARIA 

{Marsh Miasm) 

Definition. — An infectious disease caused by the hemameba or Plasmodium 
malaria and characterized in its common forms by periodic paroxysms, consist- 
ing of chill, fever, and sweating periods, and by its response to quinin. 

Historic Note. — One of the most ancient of diseases, malaria has been 
carefully studied in all ages, and when, in 1880, a French army surgeon, 
Laveran, described its special organism, and Patrick Manson and Ross, a 
little later, demonstrated the role of the mosquito as intermediary host, it 



Falling pulse. 
Hemorrhages. 



Renal 
symptoms. 



Faget's sign. 



Seldom offers 
real difficulty . 



Relation to 
fever. 



Mosquito 

intermediate 

host. 



io 3 8 



MEDICAL DIAGNOSIS 



Conditions 

governing 

incidence. 



Air breathing 
larvae. 



Easily 
destroyed. 



Dark colors 
attract. 



was found that little was needed to make all previously recorded and ac- 
cepted observations fit the newer theory. Everyone knew that the season 
of maximum prevalence of malaria was the spring, summer, and early fall, 
that it prevailed most extensively in the tropics, that it tended to follow water 
courses and haunted the neighborhood of stagnant pools and fresh, brack- 
ish marshes, that salt marshes were free from it, and that sandy-bottomed 
fishy pools might abound without malaria. Its curious horizontal spread, 
the fact that dwellers in upper stories might escape it, the danger of night 
exposure, its rapid extension with the drift of prevailing winds, its disap- 
pearance under drainage and cultivation of land, all these things were 
thoroughly understood, even by the ancients, and each and every one corre- 
sponds to the life history of the mosquito. The carrier is the female anophe- 
les, a mosquito never absent from malarial districts, although anopheles may 
be present in non-malarial districts, the organism being absent. The world- 
wide distribution of malaria makes it a disease of great importance, although, 
generally speaking, of low mortality. 

Fifteen thousand are said to die annually of malaria in Italy. It has 
been estimated that over 3,000,000 cases occur annually in Russia. Japan, 
India, China, and the Philippines suffer greatly, and the yellow races seem 
to have little or none of the immunity so evident in the Congo-black or pure 
negro, the Japanese, Chinese, and East Indian being readily infected. 

Characteristics of the Mosquito. — There are probably over 500 varieties, 
the general appearance and character being too well known to require de- 
scription. Like others of the order of diptera, they lay eggs from which 
come the larvae after two or three days of warm weather. These feed 
energetically on the water-borne organic matter and are air breathers, float- 
ing on the water, or possessing a respiratory funnel placed near the tail; 
hence they may be easily destroyed by the use of petroleum on the surface 
of their breeding places. The grown male insect is a vegetarian, the female 
seeks a mixed diet and sucks the blood, not alone of man, but of mammals 
generally, and, it is said, of birds, reptiles, and even of fishes. The time re- 
quired for full development is about thirty days in warm summer weather 
and the hatching process may be repeated several times during the season, 
one pair of insects producing millions of their kind. 

The Special Characteristics of the Anopheles. — Length of palpi and pro- 
boscis about equal, the former four-jointed in the female and three-jointed 
in the male. The straight filamentous palpi are held almost parallel with the 
proboscis, the wings are often spotted, the abdomen is pilose with no scales, the 
legs are long, ending in dentate claws, and the nucha has posterior scaly 
cornua. 

Color in Relation to the Mosquito. — Nuttall has reported some interest- 
ing observations in regard to the color preferences of mosquitoes. He found 
that of the various colors ranging from white to black, the former was the 
least, the latter the most attractive. The observations are of distinct value 
in relation to the proper colors for clothing for dwellers in mosquito- 
infested communities. 



MALARIA 



I039 



Classification of the Organism. — As will be seen from the plates illustrat- 
ing the cycle of development in the human body, the malarial organism is 






^ \? 








Fig. 499. — Culex (left) and anopheles (right) mosquitoes and larvae. In the above 
figure note the culicine egg raft, 45° angle position of siphonate larva, parallel attitude of 
resting mosquito, non bulbous palpi of male and short palpi of female as contrasted with 
the 'anopheline star or ribbon arrangement of eggs, horizontal attitude of asiphonate sur- 
face larva, brad-awl attitude of resting mosquito, spotted wings, bulbous palpi of male and 
long palpi of female mosquito. {From Jordan after Kolle and Hetsch. Stilt.) 

easily recognized and differentiated by blood examination and the expert 
observer can also closely predict the time of segmentation and recognize 
double or triple infections. 



1040 



MEDICAL DIAGNOSIS 



Double 
infections. 



The clinical divisions correspond to the old time relationships, based 
upon the frequency and regularity of the seizures. 

The tertian organism (p. vivax), requiring forty-eight hours for its develop- 
ment, brings about a paroxysm on each third day, the interval of apyrexia 
being one day. 



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leaving one day of apyrexia. If, as rarely happens, there be a triple quartan 



MALARIA 



IO41 



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65 




1042 



MEDICAL DIAGNOSIS 



Severe form. 



Quartan rare. 



infection, the disease assumes the quotidian or daily type, as in the case of 
the double tertian.* 

Estivo-autumnal Plasmodium (p. falciparum). — This is irregular in its 
development and manifestations and is the variety which causes the severer, 
more chronic, malignant, or pernicious types of the disease. In the United 
States the tertian organism is exceedingly common; the quartan rare. The 
accompanyng plates give a description of the various forms and show their 
progressive development at the expense of their erythrocyte host. 

Evolution of the Organism in the Mosquito. — Two days after the inges- 
tion of human blood containing sexual forms (gametocytes) small pigmented 




Fig. 502. — Malarial fever. Quartan form. Seventy-two hours is required by this 
form for the development of its cycle. Hence segmentation and the associated malarial 
paroxysm falls on each fourth day, the wholly free periods occupying two days. Double 
and even triple infections may reduce the apyretic interval to a single day or to zero. 
(Marchiafava and Bignami, modified.) 

granular bodies (zygotes) are formed which appear in the muscular coat of 
the mid-intestine of the mosquito host as ookinetes. These zygotes result 
from the conjunction of the spermatozoa-like, actively motile flagellar of the 
microgametes of the male bodies (microgametocytes) with the female cells 
(macrogametes) and represent, therefore, the fertilized female element trans- 
formed into a worm-like body (vermiculus or ookinete) which penetrates 
between the cells and develop the oocyst. 

Five days later striation appears representing the sporoblasts which con- 
tain and later set free the tiny sickle-shaped embryos {sporozoites) by the 
rupture of the parent oocyst. These enter the salivary glands, and thence 
pass by the venenosalivary duct to the pharynx of the mosquito and are thus 
passed into the blood of man. 

The sporozoites of the mosquito cycle and the spores of the human cycle 
(merozoites) are essentially like bodies and in the human host may pursue 
either a sexual or an asexual development. 

The human cycle is primarily and for several generations asexual or 

* Craig, Manson and others have reported a quotidian type of organism which they call 
Plasmodium falciparum. 



MALARIAL FEVER 



I043 



sterile, producing schizohts only, but later the sexual forms {gametes) are 
developed, the one male {micro gametocyte) , the other female {macrogame- 
tocyte). The former has a clearer protoplasm, stains less deeply blue, has less 




pigment, more chromatin and a more centrally placed "nucleus than the 
latter. (See Fig. 408.) 

Cultivation of the Parasites.— The first successful cultivation of the plas- 



io44 



MEDICAL DIAGNOSIS 



Sporulation 
Kelease of 
Mero7oits 




Fig. 504. — Developmental cycle of the malarial parasites. (1) Youngest form. (2, 3, 
4, 5) Stages of enlargement and pigment formation. (6) Sporulation. (7, 8, o) Female 
forms. (io> n) Female forms going on to sporulation within the human body and pro- 
ducing relapse. (12, 13, 14) Male forms, development terminating in a conjunction with 
female form of the sexual cycle within the body of the mosquito. (15) Flagella-like 
microgametes formed from male cell. (16) Conjunction of male and female elements. 
(17, 18, 19) Zygote (impregnated female form) passing under epithelial lining of mosquito 
stomach. (20) Development of sporoblasts and formation of oocyst. (21, 22) Rupture 
of mature oocyst and release of sporozoites which pass to salivary glands of mosquito (23), 
and thence to human blood by inoculation. (After Blanchard and Schilling, greatly mod- 
fiied.) 



MALARIAL FEVER 



I045 



modia was reported by Bass of New Orleans, using the upper layer of centri- 
fugated defibrinated blood taken from the human host, a trifling amount of 
glucose being added. 

Examination of the Blood for Malarial Organisms. — Fresh blood on a 
warm stage gives the most satisfactory results in these examinations, but it 
is quite possible to detect them in the dried and fixed specimens, stained as 
in ordinary blood examinations. If the old triple stain be used, or the better 
stain of Wright, already described elsewhere, the organism will be found to 
have taken the blue. The common mistake born of inexperience lies in the 
failure to search primarily for pigment in both red and white blood cells, and in 
the readiness with which the unpigmented form? are confounded with artefacts. 
In nearly all specimens taken at a proper time pigmented organisms may be 
found within the erythrocytes and pigment granules in the. leucocytes. 
In the tertian variety the pigmented forms appear from eight to sixteen hours 
after the preceding chill, and the large pigmented organism is best obtained 
eight hours before the paroxysm. It is useless to hunt for tertian or 
quartan forms if quinin has been taken for twenty-four hours or more. 

Stippling of the erythrocyte host may be visible in stained specimens 
(Giemsa's stain). This may take the form of brick red tiny dots in the 
tertian form. 

In the estivo-autumnal infections, specimens deeply stained with Maurer's 
modification of the "Romanowsky" may show dark red- violet spots of irreg- 
ular and variable form ("pernicious spots"). 

Immunity. — It would appear that natural complete immunity to the 
malarial organisms is very rare. 

Relative immunity is not uncommon and is especially marked in the 
negroes of malarial countries. 

Symptoms.— The tertian and quartan forms are manifested by typical 
paroxysms whatever the frequency of their occurrence, and the order of 
events is as follows: (a) The cold stage: after a rigor lasting from one-fourth 
to one and one-half hours and occurring usually in the mid-forenoon or early 
afternoon, the temperature, which rises with and during the chill, reaches 
a maximum (104 to io7°F.) and the cold stage is succeeded by (b) the hot stage, 
which presents all the symptoms of a sthenic fever which reaches its fastigium 
in an hour or two and declines to normal during the next six, eight or ten 
hours, its recession being marked by the coming of (c) the sweating stage during 
which all symptoms abate and the patient feels well. These attacks vary 
greatly in duration, those of the severe type lasting from eight to fourteen 
hours. The spleen enlarges if they are repeated on several days, and if 
they are long continued, tends to become permanently hypertrophied (ague 
cakej. In spite of the marked evidences of infection there is a normal leuco- 
cyte count or more frequently a leukopenia. Herpes labialis is a common 
manifestation. Albuminuria may be present during the attacks or persist if 
they are frequently repeated, and the gastrointestinal disturbances accom- 
panying the fever may be profound. 

The estivo-autumnal form, due to the organism of that name, may at 



Fresh blood 
best. 



Look for 
pigment. 



Best time to 
search. 



"Fever and 
ague." 



Cold stage. 



Hot stage. 



Sweating 
stage. 



"Ague cake.' 



Herpes and 
albuminuria. 



DESCRIPTION OF PLATE V 

Quartan, i, 2, 3, 4, 5, and 6, show the development from the hyaline 
form to the mature intracellular (6) and large extracellular (10) forms; n 
shows vacuolization of an extracellular form; 7, 8, 9, show segmentation 
stages; 12, the flagellate form (sexual cycle, microgametocyte). 

Note. — In the tertian and estivo-autumnal organisms the same phases 
are shown. 

Note. — 

A. Relative depth of color in the erythrocyte host, deepest in the quar- 

tan, lightest in the tertian, often brassy with cell deformity in the 
estivo-autumnal (tropical form). 

B. Comparatively coarse, scant, and dark granules of the quartan as 

compared with the tertian. 

C. Tendency to shrinkage in the erythrocyte host of quartan vs. large 

pale host of tertian. 

D. Peripheral arrangement of pigment in developmental stage of tertian 

and quartan followed by central grouping initiating segmentation. 
The pigment in the quartan may form an oblong band across the 
erythrocyte host. 

E. Note greater regularity in quartan as compared with tertian forms. 

F. Xote relative number of segments. 

G. Xote greater density and clearer outline of quartan forms. 

H. Star-like arrangement of pigment in early segmentation stage of 

quartan. 
I. Relatively small flagellate forms of quartan and estivo-autumnal. 
J. The peculiar ovals and crescents of the developed estivo-autumnal 

form, its scantily pigmented spherical form (35) and the ring 

bodies of the early stage. 



1046 



PLATE V. 



THE QUARTAN PARA5ITL 






itT 11 12. 






„••-•/£ 






THE TERTIAN PARASITE. 



13 \4- 15 16 






THE ESWO-AVTTJMNAL PARASITE 



25 


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i 13, 23. — Schizonts (youngest ring forms). 

8, 20, 29. — Sporulation. 

9, 21, 30. — Release of new merozoites. 

25, 26. — Double infection by young schizonts. 
32. Female gametocyte (macrogamete) . 
34. Male gametocyte (microgamete). 



1047 



1048 



MEDICAL DIAGNOSIS 



"Dumb ague' 
sequelae. 



Choleraic and 

comatose 

forms. 



Blackwater 
fever. 



Usually estivo- 
autumnal. 



Misleading 
symptoms. 



its onset be definitely periodic, usually like tertian but with longer paroxysms. 
Ordinarily, owing to the irregular development of the parasite crops, the 
fever tends to assume the remittent (bilious remittent) type, and in such cases 
the temperature curve may be lower than in the fastigium of the regular 
form. Jaundice is common, gastrointestinal symptoms and splenic enlarge- 
ment marked. Under this head the most diverse types of malaria must be 
included, representing on the one hand the larval types, or dumb agues, often 
manifesting themselves by persistent headache, neuralgia, general malaise, 
dyspepsia, anemia, etc., and, at the other pole, the pernicious form of the 
disease, encountered especially in the tropical and subtropical countries. 
These assume various types, are often limited to a certain small area and are 
peculiarly fatal to the unacclimated. 

Classification of Pernicious Forms. — (a) Choleraic. Symptoms, low or 
slightly elevated temperature, vomiting, choleraic diarrhea and stools, fre- 
quently a jaundice, cyanosis, feeble, rapid pulse, collapse and high mor- 
tality, (b) Comatose form. This is preceded usually by a typical malarial 
paroxysm which is succeeded by stupor, hyperpyrexia, Cheyne-Stokes breath- 
ing, and every symptom of collapse, stupor deepening into coma, (c) The 
hematuria or hemoglobinuric form. This is characterized by the predominance 
of renal symptoms, associated at times with bleeding from the mucous mem- 
branes and includes undoubtedly the so-called "black- water fever." It is 
very fatal. 

Comment. — These pernicious forms are usually though not invariably 
associated with the estivo-autumnal organism; in the choleraic type masses of 
organisms may be found in thrombi of the intestinal vessels; in the cerebral or 
comatose form, in the vessels of the brain. The strong resemblance to yellow 
fever presented by these cases will at once be noted (see "Yellow Fever"). 

Malaria in Infants. — Fusco has found malaria in many infants living in 
malarious districts and states that in such cases the symptoms may be most 
misleading. 

Fever may be brief, the chill absent, or replaced by convulsions, vomiting, 
mere pallor or cyanosis. , 

The spleen is almost invariably enlarged and in 85 per cent, of Fusco's 
cases the estivo-autumnal organism was present. 

Chronic Malaria (Malarial Cachexia). — The chief characteristics of this 
form are the enlarged spleen, anemia, sallow skin, and persistent malaise. 
In many instances there is a tendency to chronic diarrhea, dysentery, or 
marked chronic gastrointestinal disturbance of a vague and indeterminate 
type. In some cases there are accessions of fever, perhaps actual paroxysms 
occurring irregularly, and persistent and repeated examinations will usually 
reveal the estivo-autumnal organism. 

Complications. — Persistent neuralgias, often regularly or irregularly peri- 
odic, persistent anemia, gastrointestinal difficulties, and chronic nephritis 
are among the commoner complications and, more rarely, actual changes in 
the brain, spinal cord, or peripheral nerves may occur, producing paralysis, 
ataxia, or even symptoms of disseminated sclerosis. 



RELAPSING FEVER 



I049 



Diagnosis. — The recognition of the regularly periodic form is not difficult, 
but in general no accurate diagnosis can be made without an examination 
of the blood, the two elements of importance being the plasmodium and the 
leucopenia. Clinically dependence must be placed oftentimes upon the 
effect produced by quinin given in large doses and in solution. The differ- 
ential diagnosis as regards typhoid and yellow fever has been discussed under 
those diseases. 

RELAPSING FEVER 
("Famine Fever" " Seven-day Fever") 
Definition. — An acute contagious disease due to the spirocheta Obermeieri, 
(Spirocheta recurrentis) , and in different countries to spirochetae differing some- 
what in their characteristics (S. novyi, S. duttoni, in 
African tick fever; S. carteri in that of India). It is 
characterized by recurrent febrile paroxysms, each 
being of from five to seven days' duration and asso- 
ciated with an acute onset and critical termination. An 
attack does not confer immunity. 

Etiology. — The disease is one of filth and is highly 
contagious. The spirillum is unquestionably the cause 
of the disease but cannot be cultivated. 

Morbid Anatomy. — There are no special lesions. 
Enlargement of the fiver and spleen being common, 
together with catarrhal inflammation of the gastro- 
intestinal tract. 

Symptoms. — The symptomatology is summed up in 
the definition. It represents repeated attacks (usually 
two) of high fever of sudden onset terminating by crisis, 
alternating with afebrile periods. 




Fig. 505. — Spiril- 
lum of relapsing 
fever {spirocheta 
Obermeieri). Motile, 
flagellated, spirillum 
readily stained but 
not cultivated and 
Gram-negative. The 
organism is usually 
longer than is indi- 
cated in the illustra- 
tion. 



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Fig. 



506. — Clinical chart of relapsing fever showing the febrile movement upon the four- 
teenth day. — (From Wilcox's Fever Nursing.) 



Blood exam- 
ination and 
therapeutic 
test. 



DESCRIPTION OF PLATE VI 

Malarial organism of types shown in Plate III but treated with Wright's 
stain. 

Quartan Parasite. 

i. Non-pigmented form. 

2, 3, 4. Young organisms showing chromatin bodies (red) and pigment 
granules. 

5, 6. Full-grown parasites, the former intracellular, the latter extracellular. 

7, 8. Presegmentation forms. 

9. Segmentation. 

11. Normal blood cell. 

12. Flagellate body. 

Tertian Parasite. — The forms are self-explanatory in connection with 
the preceding description. 

Estivo-autumnal Form. Various ring forms are shown together with the 
characteristic crescents, Nos. 32, ^t,, 34 (Micro- and Macrogametocytes). 

(In both this and the preceding plate the drawings are almost entirely 
based upon personal observation, though certain forms have been adapted 
from Thayer's valuable monograph.) 



1050 



PLATE VI. 



THL QUARTAN PARASITE 



7 






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13 



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TYPHUS FEVER 



1051 



The diagnosis is at once established in most, but not all cases by an ex- 
amination of the blood which reveals the long spirilla which are in length 
about three times the breadth of the red cell. The usual complications of 
fever of this type may be present, i.e., pneumonia, nephritis, hyperpyrexia, 
jaundice, ophthalmia, and renal, gastric, or intestinal hemorrhage, yet in 
general the disease is uncomplicated, the prognosis favorable, the mortality 
low (2 per cent.)- 

The inoculation of susceptible animals is occasionally required if the or- 
ganism cannot be recovered either in the apyrexial or febrile period. 



TYPHUS FEVER 



("Spotted Fever," "Ship Fever," the 



Black Assize," 



"Jail Fever") 



Definition. — An acute self-limited infection, the specific cause of which is 
probably a microorganism known as Rickettsia prowazeki, its intermediary host 
the body louse, highly infectious and char- 
acterized by its sudden onset with high and 
continuous fever, its termination by crisis 
on or about the fourteenth day, and its 
association with a petechial eruption, a 
mottled skin and a characteristic odor and 
fades. 

Etiology. — Ricketts described in 19 10 
the occurrence of certain bacterium-like 
microorganisms in body lice and his 
observations were confirmed later by 
Hegler and von Prowazek. Studies 
were made later by Rocha-Lima, who 
named the organism rickettsia prowazeki. 
The Commission to study typhus oper- 
ating under the Red Cross Societies 
conducted a large amount of experi- 
mental work in 1920 which seems to 
have definitely established this organism 
as the causal factor of the disease 
although as yet it has been impossible to cultivate it. 

In smear preparations the organism is ovoid, occurs in pairs, filaments, 
or as bipolar staining rods. The organism is Gram-negative and can be 
satisfactorily demonstrated only with the Romanowsky stains, of which 
Giemsa's modification is most satisfactorv. 

A Valuable Test. — Anderson and Goldburger have introduced a valuable 
test for atypical cases. A guinea pig is injected with the blood of the suspect 
by the peritoneal route and will show the typical fever curve if typhus is 
present. 

Transmission. — Contrary to the belief formerly held up to the last few 
years, typhus fever is not readily, if at all, directly communicable from man 




Fig. 507. — Clinical chart of typhus 
fever ending in recovery. — {From Wil- 
cox's Fever Nursing.) 



Probable 
cause. 



10^2 



MEDICAL DIAGNOSIS 



A banished 
scourge. 



Easily 
preventable. 



to man and practically all cases are now known to be dependent upon the 
bite of infected body lice. 

The conditions under which it develops make it extremely difficult to 
avoid epidemic spread, but it is now known that in hospitals those actually 
attending typhus cases seldom acquire the disease unless they become infected 
with body lice from outside sources. On the other hand, those employees 
of the hospital who have to do with the reception and preparation of patients 
at the hospital run a very considerable risk of acquiring the disease. 

Seasonal Occurrence. — The disease is distinctly seasonal as well as 
epidemic in type, being most prevalent during the later winter months, 
diminishing as the spring advances and reaching its minimum of incidence 
during the summer. 

Historic Note. — This ancient disease, which owes its name to de Sau- 
vages (1760) and was first described by Frascatorious of Verona in the six- 
teenth century, was confounded with typhoid fever until the early part of 
the nineteenth century, and even the clear distinction made by Louis did 
not bring about its separation from typhoid until nearly half the century 
had passed. Once a common and fatal disease,* it has now become one of 
the rarest and, save in the mild forms known as "Brill's disease," is limited 
to insanitary, semicivilized and densely populated countries or communities. 
Overcrowding, bad air, and dirt have always been its chief promoters. It is 
highly infectious and conveyed usually by the body louse (P. vestimenti). 

The Great War brought about renewed interest in and extended study 
of typhus fever as a result of serious outbreaks in certain of the Eastern 
countries. Fortunately the Western war front was not affected at all. 
The first serious primary outbreak occurred in Serbia in 191 5. At this time 
the disease still exists in Poland and Russia. 

Morbid Anatomy. — There are no characteristic changes beyond those of 
an intense febrile infection. 

Incubation Period.- — The period of incubation varies from seven to 
fourteen days. 

Immunity. — Absolute immunity over a period of many years is conferred 
by a single attack and individual immunity probably occurs. Artificial 
immunity has not been established as yet. 

Symptoms. — The symptoms characteristic 0] typhus are — a strikingly 
abrupt onset of fever, often moderate at first, tending to advance daily and as- 
sume a continuous type, at the outset accompanied by chilling or actual chills 
with marked nausea or actual vomiting, headache, backache, profound prostra- 
tion, the rapid development of a typical u typhoid state," and the appearance 
of an eruption at the end of the fourth or fifth day. 

The eruption, at first like rose spots, soon becomes darker and fades to a 
brownish discoloration and is associated with a dim subcuticular mottling. 

The termination is usually but not invariably by decided remission or a 
sharp crisis. Relapse is rare and the complications are those attending any 
profound febrile infection with marked toxemia. 

* It is said to have killed 1,000,000 of the British people during the eighteenth century. 



Violent onset. 



Rapid 
prostration. 



Eruption. 



Crisis. 



MALTA FEVER 



105 s 



Variants. -As in so many other Infectious diseases, many atypical 
cases occur often of a most misleading character. Both the fever and the 
exam hem may be Lacking and many mild cases occur. Doubtless these 
facts lead to an exaggerated notion oi the extent of natural immunity. 

The stormy manifestations usually associated with its onset may be pre- 
ceded by several days oi fever and other prodromal symptoms. 

Physiognomy and Odor. — An odor often described as "mousy" or, by Ker, 
as that of "rotten straw" is quite constant even in well-kept patients, and the 
physiognomy is that of a "drunken rounder," the eyes being bleary and blood- 
shot, the face bloated and swollen. 

Diagnosis. — This must depend still upon the clinical symptoms inasmuch 
as cultural methods are too slow to be of use during the attack. 

Prognosis. — The mortality may reach 50 per cent, in old people, and 
varies from 10 to 20 per cent, in children and young adults. The heart 
suffers profoundly during the height of the illness and cyanosis and pulmonary 
hypostasis are almost invariable. 

BRILL'S DISEASE (Attenuated Typhus).— This is a form of sudden 
onset, profound prostration, severe general pain, violent headaches, and 
febrile movement, associated usually with an erythematous sometimes mis- 
leading!}', " rose-spot" like, maculopapular rash of wide distribution and 
variable profusion appearing on the fifth or sixth day, reaching its acme 
in twenty-four hours and persisting until the end of the illness which is at- 
tained either by crisis or rapid lysis in from twelve to fourteen days. 

The rise of temperature is abrupt and it terminates in a rapid descent 
covering but 24 to 36 hours. 

Anderson and Goldberger have apparently proven this to be a mild 
typhus of relatively slight transmissibility, identical wdth the typhus of 
Europe and Mexico.* 

MALTA FEVER 

(Mediterranean Fever, Undulant Fever, "Rock Fever" Neapolitan Fever, 

Gibraltar Fever). 

Definition. — An endemic tropical and subtropical septic infectious fever due 
to the "micrococcus melitensis" (Bruce) and characterized by long-continued 
undulatory pyrexial periods and repeated relapses. 

Etiology. — The micrococcus melitensis, discovered in 1887, is a small oval 
or round coccus (0.33/z), occurring singly or in pairs, staining readily though 
not by Gram's method, easily cultivated in faintly acid media at 37 to 38°C. 
It is of slow growth and show r s an agglutination reaction similar to that of 
typhoid fever. The milk of the Maltese goat has been proven the chief agent 
in the spread of disease in Malta and Gibraltar and resulting preventive 
methods have enormously reduced the incidence of the disease in its home. 
It is essentially a disease of summer, respects no age, is uninfluenced by sex 
and confers prolonged immunity. The disease has been almost wiped out 

* Dr. N. R. Brill has reported 225 cases with no mortality. 



Mild typhus. 



io54 



MEDICAL DIAGNOSIS 



in the garrison at Malta and in the Mediterranean fleet by stopping the use 
of raw goats' milk. Nearly 15 per cent, of these, the most numerous of the 
domestic animals of Malta, were found to carry the germ in their milk. 

The disease is also said to be endemic in certain regions of Texas where 
goats are extensively bred. 

Morbid Anatomy. — The pathological changes merely reflect the toxemia 
and high fever; splenic tumefaction and congested lung bases are constant 
factors. There is moderate anemia, and often a relative leucocytosis, the 
spleen contains the specific germ in quantities and shows an increase of 
lymphoid tissue. It may be found also in liver, kidney, urine, blood and in 
the lymphatic and salivary glands. 

History. — Unrecognized or undifferentiated, this disease has existed from 
time immemorial along the Mediterranean shore, and ancient writers are 
supposed to have referred to it under the head of malaria. It would seem 
to be widely distributed, cases having been reported from the Mediterranean 
Islands, Italy, Greece, Turkey, Arabia, Palestine, China, South America, 
the Philippines, East and West Indies, Central America, and even in this 
country in isolated instances.* 

The period of incubation is about fourteen days. 

Symptoms. — The onset closely resembles typhoid, the fever running in 
waves of three weeks' duration, repeated once, twice, or many times with 
intervening periods of normal temperature. It may last for from two or 
three weeks to two years, its average duration being about three months. 
Severe joint pain and swelling is present at the onset in 50 per cent, of the 
cases and neuritis and orchitis are frequent complications. As a rule, the 
first relapse is more severe than the original attack, being associated with 
chills, high intermittent fever and a diarrhea which replaces an antecedent 
constipation. 

The spleen may be enlarged moderately or attain large proportions. Blood 
cultures are obtainable from the second day to the fortieth week, during the 
maximum febrile periods. 

Differential Diagnosis. — From malaria it is differentiated by the absence 
of the specific hemameba of that disease, from typhoid by the joint pain, 
absence of rose spots, the failure of the agglutination test of Widal, from either 
by its own complete agglutination test in dilutions of at least 1-30 obtainable 
as early as the end of the first week. Aside from these procedures one must 
depend simply upon the differences in the general symptomatology, the tem- 
perature chart and the tendency to distinct relapses. 

Prognosis. — Oddly enough, the disease furnishes but 2 to 3 per cent, 
mortality, the loss of time, the discomfort and interruption of affairs being 
the chief inflictions. 

* Bruce states that nearly all cases occur in Malta and that the annual incidence among 
the people averages 30 per 10,000 and in the garrison, formerly, 370 per 10,000. 



ROCKY MOUNTAIN SPOTTKD FKVKR 



I055 



Probable 

intermediate 

host 



^ 



ROCKY MOUNTAIN SPOTTED FEVER 

The cause of this curious disease is unknown. It is prevalent in small 
districts of western Montana, Idaho, Wyoming, Utah, Oregon, Washington, 
California, South Dakota, Colorado and Nevada and particularly in a small 
area from 4 to 10 miles wide and 50 miles long on the western side of the 
Bitter Root River. It prevails only from the middle of March to the middle 
of Julv and seems to affect only those persons who have been bitten by the 
tick known as " Dermacen&or Andersoni" The presence and activity of this 

tick corresponds accurately to the time of disease 
prevalence. Dr. Chowning states that these 
were found in every case seen by him but might 
easily be overlooked because at times onlv 
present in the hair about the genitals. 

The disease has been known to the physi- Long known 
cians of Montana for over thirty years and was 
first reported formally by Maxey in 1899. 

In 1902 in response to a request from the 
Montana State Board of Health, Drs. Chowning 
and L. B. Wilson were sent from the University 
of Minnesota to investigate the disease. They 
reported the finding of an intra-, and extra- 
corpuscular hyaline organism to which they 
gave the name of piroplasma hominis. 

In 1906 King reported Dermacentor venushis 
{Andersoni) to be the carrier and transmitter 
and Ricketts succeeded in conveying the infec- 
tion to a monkey by the bite of this tick. 

The finding of piroplasma hominis by Wilson 
and Chowning has failed of confirmation. 
Wolbach reports an uncultivable spirochete. 
Causal Agent. — Dermacentroxenus rickettsi is a minute, intracellular, 
bacterium-like microorganism which does not stain by Gram's method and 
is best demonstrated with the Giemsa stain. It appears usually as lanceo- 
lates in pairs, about one micron in length. The organism is non-filtrable, is 
readily killed by most disinfectants as well as by heat and drying. It is 
uncultivable. 

Symptoms. — After an incubation period of from three to ten days, head- 
ache, nausea, muscular soreness, a chill or chilliness, and nose-bleed, are 
followed by a rapidly rising fever and an accelerated pulse and respiration. 
The rash appears from the third to the seventh day, first on the forehead 
and extremities, later on the chest, abdomen, and back. It is macular, bright 
red, and becomes petechial in severe cases. It is profuse everywhere except 
on the abdomen and desquamation may follow. The exanthem appears 
first on the ankles, wrists and back, the abdomen being least affected. Later 




-Rocky Mountain 
spotted fever. — Exanthem. 
(After J. F. Anderson). 



Rash 



Profound 
asthenia. 



1056 



MEDICAL DIAGNOSIS 



Contrast 
in mortality. 



the visible mucous membranes may be involved and even the palms of the 
hands and soles of the feet. 

With the establishment of the hemorrhagic character of the rash, areas 
of confluence may occur and necrotic spots may develop in the dependent 
areas. Desquamation follows but usually is not extensive. 

The character of the exanthem and the tendency to necrosis directly 
corresponds to the changes found at autopsy in the peripheral blood vessels. 
In fatal cases rapid anemia appears with sustained high temperature and 
a rapid weak pulse. Albuminuria is constant. The spleen is enlarged. 

Differential Diagnosis. — No confusion can arise if the salient points are 
recalled. The history of exposure, the tick bites, the discovery of the tick 
itself, the sporadic nature of the disease, its distribution, the character and 
time of appearance of the rash, are sufficiently distinctive. 

Prognosis. — In favorable cases termination by lysis is initiated by the 
twelfth day. The mortality averages 70 per cent, in Montana and pernicious 
cases of rapidly fatal course are seen but it is said to be very low in other 
states (1 to 3 per cent.).* One attack seems to confer lifelong immunity. 

TULAREMIA. — The relatively rare occurrence of this peculiar and 
relatively severe and disabling febrile infection has been recognized for 
several years within a very circumscribed area in Utah, during the months of 
June, July and August, under the name of " deer-fly fever." 

Its etiology appears to have been established by Dr. Edward Francis of 
the United States Public Health Service who, in 19 19, established the 
Bacterium tularense in cases investigated in the field, repeating his observa- 
tions on six cases in 1920. 

Dr. Francis asserts that in Utah the disease is conveyed from infected 
jack-rabbits to man by the blood-sucking fly Chrysops discalis. Cases of 
tularemia have been observed also in ground squirrels in Utah and California 
and the cotton-tail rabbit in Indiana. 

Symptoms and Course. —Following the bite of a deer-fly carrier the 
adjacent lymphatic glands become swollen and tender and on the third day 
the site of infection presents a black necrosing centre which sloughs and 
leaves a "punched out" ulcer, the healing of which leaves a characteristic 
permanent scar. The glands usually suppurate and demand incision and 
drainage. 

The fever is of the intermittent type and seldom exceeds 102 F. as a 
daily maximum. 

Chills may occur even in the early prodromal period and may be severe 
during the active stage of the disease. 

Profound prostration is present during the active stage which endures 
about four weeks. Recovery of strength is seldom attained until one or two 
months thereafter. 

Prognosis.— Death occasionally results but the mortality is light and 
apparently recovery after a tedious convalescence is the rule. 

* The Bitter Root Valley cases furnish mortality figures of 90 per cent. In Idaho 
the death rate is only 3 per cent. 



VARIOUS INFECTION^ io 



MILK FEVER {Milk Sickness). — This is a rare and frequently fatal dis- 
ease supposedly caused by the bacillus lactomorbi of Johnson and Harris, 
limited to the southern and western part of the United States, and appar- 
ently results from the ingestion of the uncooked flesh or milk of cattle 
suffering from "trembles." 

Symptoms. — A short period of malaise is followed by vomiting and epi- 
gastric pain, constipation and muscular tremors, with little or no fever. The 
symptoms closely resemble ordinary ptomain poisoning, and there may be 
active or typhoidal delirium, coma, or convulsions. 

MOUNTAIN FEVER. — There is no single disease to which this term may 
be properly applied. Most of the cases so denominated by the earlier 
writers were unquestionably unusual forms of typhoid fever. 

EPIDEMIC DROPSY.— Definition.— An extraordinary epidemic. " defi- 
ciency" disease of the Orient, of unknown origin, characterized by the abrupt 
appearance of dropsy of the cardiac type, usually preceded by fever, vomit- 
ing, and diarrhea, and often accompanied by facial erythema and a rubeolar 
exanthem on the limbs and trunk. It occurs in individuals whose diet is 
largely composed of '"dal" and polished rice. 

Whether this disease is distinct from beri-beri is not yet decided. Nerv- 
ous symptoms such as prickling, burning, or itching often precede the oc- 
currence of the dropsical condition, but, according to Manson, the disease in 
the epidemics is pure and unmixed with cases of frank beri-beri, a fact 
strongly adverse to the opinion held by many, that epidemic dropsy is neither 
more nor less than beri-beri with predominance of dropsy and slight nerve 
symptoms. 

Extreme cardiac weakness is frankly displayed in all cases. 

The mortality varies from 2 to 40 per cent, but fortunately the epi- 
demics are rare, widely separated chronologically and limited in distribution. 

EPIDEMIC GANGRENOUS RECTITIS.— This terrible ailment attacks 
children and the lower animals chiefly, and its cause is unknown. 

Rectal prolapse occurs and the clinical picture is one of gangrenous 
dysentery. 

It occurs only in Central America, Northern South America and some of 
the islands of the South Pacific, so far as is known at present. 

MILIARY FEVER {Sweating Sickness) . — In ancient times this disease was 
extremely prevalent and fatal throughout all Europe, but is now seen only 
in limited districts of Italy, France, Austria, Asia Minor, Germany, and 
Switzerland. 

With or without prodromata, the onset is marked by drenching sweats, 
persistent and recurrent, with from seven to ten days of high fever, attacks 
of paroxysmal tachycardia, subjective laryngeal and epigastric constriction, 
and on the third day an eruption consisting of erythema, miliary red papules, 
and tiny vesicles. Chantmesse believes that field mice carry the mysterious 
contagium, fleas serving as intermediary hosts. 

FOOT-AND-MOUTH DISEASE.— This is a severe epidemic form of febrile 
aphthous stomatitis a feeling the buccal mucous membrane and even the pharynx. 
67 



1058 



MEDICAL DIAGNOSIS 



It is due to the fitrable virus of Loeffler and Frosch, introduced usually by 
eating the flesh or uncooked milk of infected cattle and is extremely rare, but 
shows a considerable mortality ratio (10 per cent.). 

Children are attacked chiefly and the hands and feet may be affected. 

FLOOD FEVER {Japanese River Fever). — This is a rare disease limited 
to a small area of, and afflicting only workers on inundated land, among 
whom it spares neither age nor sex. Its exact cause is unknown and it has no 
specific morbid anatomy. 




Fig. 509. — Japanese Flood (or River) Fever. ("Tsutsugamushi.") The "Kedani 
mite" (Trombidium akamushi) , the carrier of this disease. "A minute orange-red arachnoid," 
common in the ears of field mice and quite harmless save in the particular inundated district 
affected. (SHU.) (From "Endemic Diseases of Japan," Imperial Institute for Infectious 
Diseases, ion). 

It is transmitted only by the bite of a minute, orange-red larval mite, 
Trombidium akamushi. 

Symptoms. — Ulcers in the axilla, groin, or neck are associated with re- 
peated chills, continued high temperature, moderate lymphatic involvement 
and profound toxemia. A coarse papular eruption appears on the sixth day 
and disappears promptly after several days. 

Prognosis. — The duration of the disease is from two to three weeks and 
the mortality varies greatly, running from 10 to 80 per cent, in different 
epidemics. 

GLANDULAR FEVER (Contagious Cervical Adenitis). — An acute cervical 
adenitis involving especially the glands lying behind the upper portions of the 
sternocleidomastoid muscle is occasionally encountered in children, chiefly 
between the ages of one and ten. 

The disease is mild but contagious, comes. on suddenly with fever, sore 
throat, and decided constipation or diarrhea. 

The glands are hard and tender, but seldom fuse or suppurate. Oc- 
casionally relapses occur and other groups of glands may become involved. 

Enlargement of the liver and spleen is sometimes observed and acute 
nephritis is not uncommon. The febrile period is brief and the glandular 
enlargement is of but two or three weeks' duration. 

PAPPATACI FEVER (Phlebotomus Fever) .—Definition.— An epidemic 
three-day fever caused by the titrable virus of Doerr and Russ, prevailing 
chiefly along the shores of the Adriatic, transmitted by the bite of a gnat or 



LEISHMANIASIS 



I059 



moth-midge (phlcbotomus pappataci) and resembling clinically abortive 
typhoid fever, or, oftener, an irregular dengue. 

The virus may be recovered from the blood during the first twenty-four 
hours only. 

Bradycardia constitutes one of the most important points in differen- 
tiation and neither liver nor spleen are enlarged. 

It is probably identical with the East Indian "Sand-fly Fever." 





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Fig. 510. — Pappataci fever. Fever chart. (After Franz Doerr and Taussig.) 

SIX-DAY FEVER.— This dengue-like fever is differentiated from that 
disease chiefly by its continuity and the accompanying splenic enlargement. 

Deeks reported cases from the Panama Canal Zone. 

SEVEN-DAY FEVER.— This, reported by Rogers, is probably an irregu- 
lar dengue of the type occasionally, or often, encountered in the Philippines, 
in which the febrile intermission is so slight or insignificant as scarcely to 
interrupt the febrile period (Stitt). 



LEISHMANIASIS 

("Kala Azar," ''Tropical Splenomegaly," "Dumdum Fever," "Black Fever") 

Historical Note. — This curiously obscure and deadly disease has for 
some years prevailed in a limited district of Assam, having commenced its 
onward march at Rungpore in 1870.* It extends along lines of communi- 
cation at the slow rate of 14 miles a year, its visitation lasting for five 
years and the natives believe that one year is required to render safe any 
house in which it has appeared. It spares no age and neither sex, and, 
what is more peculiar, attacks the acclimated quite as readily and violently 
as the stranger. Its mortality is frightful, being put at 90 per cent, by 
Manson, and its victims may linger on for a year or more. It seldom 
attacks Europeans. 

* The first case reported is said by V. Schilling to have occurred at Dum-dum near 
Calcutta. In 1869 British administrative officers in Assam had to deal with a severe 
epidemic in the Garo Hills. It was for many years regarded as a peculiarly severe and 
obscure form of malarial fever. 



io6o 



MEDICAL DIAGNOSIS 



Etiology. — Peculiar oat-shaped, circular or oval protozoan bodies ("the 
" Leishman-Donovan bodies' 1 ) 2 to 4^ in size, and first discovered by Irish- 
man and Donovan in 1903, are found in most cases if the spleen or liver be 
punctured, or they may appear in the leucocytes of circulating blood, or, as 




Fig. 



Fig. 512. 



Fig. 513. 



Figs. 511, 512, 513. — Liver and spleen in child suffering from leishmaniasis. 

(After Nicolle.) 

apparently free bodies, if the leucocyte host be damaged in making the smear 
preparation. On appropriate culture media they develop flagellar. 

In the blood they are most frequently carried by the large mononuclear 
leucocytes. They are abundant in the spleen, liver and bone marrow. 

The readiest and most certain method of recovering the specific organism 
' is by smears of spleen juice obtained by the somewhat hazardous splenic- 
puncture. 

The mode of conveyance of Kala azar is not yet established but it is 
1 probable that in India bedbugs are the carriers and that along the Mediter- 
ranean, fleas may transmit the disease. 

Symptoms. — The high fever, often preceded by vomiting or chill, may 
assume either a remittent or intermittent type, lasting one, two, four, or six 
weeks; then follows an apyrexial period, then an exacerbation, and so on for 
months, when the fever becomes persistent, though remittent, and profuse 
sweats characterize the remissions. Emaciation is extreme, the liver and 
spleen enlarge early, profound anemia supervenes, and a dirty gray pallor 
and brittle dry or falling hair add to the striking clinical picture. 



LEISHMANIASIS 



I 06 1 



One of the most characteristic features of the disease is the double febrile 
paroxysm in every ticenty-four hours. 

If the organism is present in the blood smears the diagnosis is simple 
ami direct. This failing, puncture of the liver is much safer than spleen 
puncture. 

In either case a preliminary coagulation test of the patient's blood is 
demanded, inasmuch as fatal hemorrhage has resulted in some instances. 

One suggestive symptom is the decided leucopenia, which chiefly affects 
the polymorphnuclear cells. 

The ratio of white to red cells may be but 1-2000 or 1-4000. The 
normal ratio is about 1-600. 

Termination. — The patient dies ordinarily from an intercurrent pneu- 
monia, dysentery, or exhaustion within twelve to eighteen months. 

Under modern treatment about 30 per 
cent, may recover. 

INFANTILE KALA-AZAR is another 
form of Leishmaniasis due to infection 
with the form known as /. infantum. 

It attacks infants exclusively and has 
long been known as an infantile splenic 
anemia along the shores of the Mediter- 
ranean. 

TROPICAL SORE ("Leishmaniasis 
Cutanea," Aleppo Boil, Nile Sore, etc.). — 
This disease, also a Leishmaniasis, is 
caused by I. furunculosus sive tropica and 
affects exposed parts of the body almost 
exclusively. 

It begins usually as an itching, red 
papule on the site of some insect bite or 
slight wound or abrasion and during weeks or months gradually increases 
in size and assumes the appearance of a sluggish furuncle. 

This stage is succeeded by one of persistent, painless, sluggish 
ulceration. 

The boil may be solitary or there may be a score or even more. Healing 
usually takes place only after the lapse of six to eight months. 

This condition masquerades under a host of names, in addition to those 
given above, e.g., "Oriental sore," "Bagdad sore," "Bouton d'Orient," 
"Uta" or "Espundia" (Peru), Bouba (Brazil). 

RAT BITE FEVER. — This curious infection is believed to be caused by 
the Streptothrix S. muris ratti. 

Nature of the Ailment. — Following rat bite, in a certain proportion of 
cases local inflammation of unusual severity is associated with enlargement of 
the tributary glands, chills, high fever, and pronounced toxemia. 

The initial attack terminates by crisis on or about the fourth day, only to 
be renewed in most instances after the lapse of a few days. 




-"Tropical sore." (After 
Cardamatis and Melissides.) 



1062 



MEDICAL DIAGNOSIS 



Not infrequently multiple relapses occur. 

The mortality is about 10 per cent. (Hata) and death occurs in delirium 
or coma. 

It is chiefly a disease of Japan and China, but recent reports would indi- 
cate a wide distribution, extending in fact all over the world. 

A somewhat morbilliform purplish rash may accompany the relapses. 




Fig. 515. — Tropical sore. {After Brauli.) 

VERRUCA PERUANA.— This disease was formerly regarded as a part 
of the ailment now described as ''Oroya fever" but has been proven to be a 
distinct yaws-like disease (infectious granuloma) prevalent in the same dis- 
tricts of Peru. 

Unlike yaws it is found to affect the viscera to some degree. 

OROYA FEVER. — Definition. — This extraordinary acute, infectious, 
febrile, hemolytic, disease is characterized by a period of malaise, followed 
by irregular remittent fever, excruciating bone and joint pain and tenderness 
and an incredibly rapid development of an anemia of the extreme pernicious 

type. 

Remarkable Hemolysis. — Within a period of four or five days the red 
blood cells may drop from 5,000,000 to 500,000, and the blood picture is 
that of Addisonian anemia, especially in the fulminant cases. 

To Strong and his colleagues of the Harvard Expedition we owe the 
separation of this disease from Verruca Peruana, with which it was formerly 
confounded. 

The two ailments occur exclusively in certain narrow hot Peruvian 
valleys lying from 3000 to 9000 feet above sea level. 

Strong confirmed the report of Barton (1909") with respect to the presence 
of rod-like bodies in the red cells, especially at the period of febrile onset. 
These he regards as intermediate between bacteria and protozoa and pro- 
poses the name Barton ia baciUijormis. 

The mortality of this disease is frightful, death occurring within two or 
three weeks in from 20 to 40 per cent, of the cases. 

The disease is wholly resistant to treatment so far as is known at the 
present time. 



OROYA FEVER AND HILL DIARRHEA 



1063 



HILL DIARRHEA "Simla Trot" }.— Definition.— A morning diarrhea of 
unknown origin, specially affecting Europeans visiting the higher altitudes 
after a residence in damp lowlands. 

It is widely distributed, not confined to India as was supposed formerly, 
seems to be especially frequent during the rainy season in the tropics and 
may assume an epidemic form. Its resemblance to sprue, with which it was 
long confounded, seems to lie wholly in the character of the stools, which 



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are pale, even white, very copious, and frothy, together with the associated 
flatulent dyspepsia which the two ailments possess in common. 

The diarrhea may be very active and urgent between the hours of 4 and 1 1 
a.m., after which time the patient is free for the remainder of the day. 

The ailment may or may not subside spontaneously if high altitude resi- 
dence is maintained, but disappears at once upon the return of the victim to 
the lowlands (Manson). 

SPRUE ; Psilosis," "Ceylon Sore Mouth," "Cochin China Diarrhea"). — 
Definition. — A tropical disease caused by Monilia psilosis (Ashford) charac- 
terized by an afebrile, but excessively painful stomatitis of the recurrent 
ulcerative type, vague digestive disturbances, chronic diarrhea, decided 
secondary anemia, and atrophy of the liver and the intestinal mucosa. 

The Causative Organism. — Monilia psilosis is thus described by Ashford: 
<: Monilia psilosis appears in fresh glucose bouillon cultures as a large, clear- 



Afebrile chron- 
ic stomatitis. 



1064 



MEDICAL DIAGNOSIS 



A distressing 
condition. 



Curiously 
characteristic. 



Progressive 
inanition. 



cut yeast with a large, brilliant nucleus. While the greatest variety of size 
and shape is seen in this protean organism, it may be said that it has few 
granules and tends to be round and from four to seven micra in diameter. 
In time in all, and especially in unfavorable media such as lactose, hyphae 
develop. Budding takes place from the side of the article, without sterig- 
mata, as well as. from the end of the terminal article, a succession of buds 
forming a chain of yeasts and giving rise to the name of the genus, Monilia. 
The best differential medium for primary isolation is Sabouraud agar, 
4 per cent, glucose, plus two acidity." 

Distribution. — It chiefly attacks Europeans dwelling in the tropics and is 
especially frequent in Java, Cochin China, Ceylon and Porto Rico. 

In the country last named it is on the increase, is much dreaded by Ameri- 
can residents and among them is even more fatal than tuberculosis. A few 
cases have been reported in the United States (Ashford). 

Symptoms. — Stomatitis. — The disease begins with buccal hyperesthesia 
which is followed after a considerable period by inflammatory redness and an 
extremely painful recurring superficial, disseminated ulcerative process along 
the sides, frenum and margins of the tongue and, later, on the buccal mucosa. 
Very characteristic ulcers appear opposite the posterior molars (Crombie's 
ulcers), but the tongue remains clean and late in the disease becomes smooth, 
glazed, centrally "cracked" and fissured, though red and oftentimes showing 
punctate or dotted ulceration along its anterior surface and margins. 

Salivation is usually profuse, and troublesome during the active periods. 

Dyspepsia. — This is distressing, yet indeterminate in type, flatulence 
being decided or extreme, and an apparently causeless nausea and vomiting an 
occasional occurrence. 

Diarrhea. — This, in its typical form is chronic, at first matutinal, repre- 
sented by only one or two stools daily, but extremely exhausting and debili- 
tating. Accessions of the diarrhea follow closely the exacerbations and recur- 
rences of the stomatitis. 

Stools. — The stools are characteristically and extraordinarily copious, 
pale, pasty, acid, " fermenting," "foamy" "mawkish" and "evil smelling." 
No pain attends their discharge. 

Early in the disease attacks of evanescent acute diarrhea may occur and 
the stools are dark and bilious. 

Many cases of an irregular type are seen and in these for a time at least, 
either the buccal, gastric, or intestinal symptoms may dominate or wholly 
fill the clinical picture. The complement fixation test is positive in this 
disease. 

Course and Termination. — Very gradually increasing anemia, debility, 
and emaciation terminates in chronic invalidism excessive exhausting diar- 
rhea, sallow, earthy pallor, or decided darkening of the skin appears, the 
patient becomes bedfast, gravity edema is present, and he dies of exhaustion 
or intercurrent disease. 

According to P. Manson, the outlook for recent cases is good under abso- 
lute rest and the milk cure. For ambulant cases such a diet is impracticable. 



TRENCH FEVER 



1065 



TRENCH FEVER.— This ailment of trench warfare which appears at 
present to be a definite clinical entity is separable into two clinical types, viz.: 
1. A brief abortive form in which the primary febrile period terminates 
usually within the week and is followed after an afebrile stage of a few days 
duration by a short relapse. 2. A form characterized by a more prolonged 
primary febrile period and multiple, periodic relapses. 

Aside from the fever, the chief clinical symptom is pain in the back and 
legs, and a remarkably and decided punctate basophilia.* 

Although a very large amount of work has been done with reference 
to the etiology of trench fever, its specific cause still remains in doubt and 
its diagnosis yet lacks the clarifying element of a pathognomonic sign or 
symptom or a clean-cut syndrome. 

Trench fever appears to be transmitted usually by the body louse, 
pediculus corporis, and it is not improbable that the cause may prove to be 
a species of rickettsia. 

The incubation period seems to vary between ten and thirty days and 
during this period prodromal symptoms of the type usually encountered in 
infectious diseases may be present. 

Apparently trench fever is a specific form of septicemia giving rise to a 
wide diversity of symptoms leading to frequent errors in diagnosis. 

A sudden onset is almost invariably present accompanied by vertigo, 
headache, pain at the back of the eyeballs, injection of the conjunctivae, 
and enlargement of the spleen. When the eyes are turned sharply to the 
right or left, nystagmus usually occurs and in a large proportion of the 
cases small erythematous spots appear over the chest, abdomen and back. 
These resemble in appearance and behavior the typhoid fever exanthem and 
are transient, enduring only a few hours. 

The urine usually contains a trace of albumin, but true nephritis is not 
observed. 

The blood shows no characteristic changes. A leucocytosis may be 
present but there is no constancy in its appearance. 

Comment. — This extraordinary ailment was of very great importance 
during the Great War on account of the number of cases occurring, though 
these were for the greater part mild and of short duration. It has been 
said that from one-fifth to one-third of all cases of illness in the British 
armies and about one-fifth of those in the German and Austrian armies 
might be classified as trench fever. The American troops in France were 
but slightly affected because of the fact that at the time of their appearance 
at the front, the mode of transmission of this disease was understood and 
every effort made to eradicate the body lice which proved the responsible 
agents. 

Inasmuch as the disease is readily transmitted by the whole blood but 
not by the plasma or by filtered blood containing its corpuscles in solution, 
it would appear that the virus is usually, but not invariably, filtrable. 

* See paper of J. W. McKee, A. Renshau and E. H. Brunt, Brit. Med. Jour.. Feb. 12, 
19x6, pp. 225-260. 



Two forms. 



io66 



MEDICAL DIAGNOSIS 



Extremely 
contagious. 



Mortality, 



Effect of age. 



Significant 
signs. 



Important 
fever-curve. 



Earliest posi- 
tive sign. 



MEASLES 

(Morbilli) 

Definition. — An acute, highly contagious febrile exanthem of childhood 
of unknown causation, conferring immunity, and characterized by marked 
catarrhal symptoms of the respiratory tract and a peculiar eruption. 

Etiology. — No organism has been proven as the causative agent. Hek- 
toen, Anderson and Goldberger have proven that the filtered blood serum 
produces typical symptoms when injected into the monkey (Rheous) and 
indeed its inoculability has long been known. Continued prevalence seems 
to confer a partial racial immunity, as the disease is terribly fatal when 
introduced into countries previously exempt. 

Contagiousness. — Practically every exposure of children under ten results 
in an attack, and, as it is contagious from its earliest appearance even before 
Koplik's spots appear, spreads by proximity, contact, and fomites and ceases 
to be contagious only with established convalescence, few children escape infection. 

The production of artificial immunity is being given much attention at 
the present time and there is reason to believe that definite results may be 
obtained. 

The mortality is terrific among the poorer tenement classes and in badly 
nourished infants and young children, but in private practice it should not 
exceed 3 per cent, among well-nourished youngsters. The chief mortality 
falls upon the first half decade of life and especially the period lying between 
the sixth and the twenty-fourth month. Children over five months old and 
under twelve years of age are remarkably susceptible, and the winter and 
spring are its chief seasons. Adults suffer very severe attacks but these 
usually lack the more serious and fatal complications. 

Comment. — Our experience during the period of mobilization for the 
Great War demonstrated the very great importance of measles as an army 
disease and this ailment was especially active following the entrance into 
the camps of the first draft during the fall of 191 7. In this earlier epidemic 
pulmonary complications were astonishingly frequent and this was especially 
true of empyema. 

Morbid Anatomy. — Merely that of the complications and a catarrhal 
inflammation of the respiratory tract. 

SYMPTOMS.— The presence of a marked coryza, injected conjunctivae, 
photophobia, and indications of slight fever may be the only signs noted at the 
onset and by their intensity the first, second and third always suggest the true 
cause in the case of children. Chill or decided chilliness is not common. 

Fever. — The fever rises steadily, reaching its maximum (103 to io5°F.) 
with the appearance of the exanthem {fourth day) . Its subsidence begins as 
the rash commences to fade, and the normal is attained, either by crisis or 
through a lysis occupying from two to four days. 

The Rash. — Koplik's spots appear early in 90 per cent., and the mucous 
membrane shows the eruption before the skin is affected. 







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MKASLKS 



1067 



These may be present from two to four days before the appearance of the 
exanthem ami appear first opposite the molar teeth as pearly gray (not white 
or yellow) spots, smaller than the head of a common pin, cadi lying usually 
but not always within a red aureola. 

Later they may extend to the inner surface of the lips, occur more widely 
distributed on the surface of the buccal mucous membrane and even on 
the soft palate. When present in large numbers, the whole surface involved 
is reddened and the discrete appearance of the spots is lost. They have 
then become a multitude of gray dots on a red congested background. 
They disappear as the body rash develops. 

The appearance of the true spots should be carefully studied inasmuch 
as somewhat similar lesions have been reported in other contagious diseases, 
and furthermore because of their great importance in early diagnosis. 

A t the end of the third or during the fourth day, and at the height of the fever, 
the general rash becomes manifest as a dusky mottling, becoming more distinctly 
red though still dusky, and, at the end of twenty-four hours {fifth day usually) 
palpably papular and u shotty. ,} 

Usually it appears first at the margins of the hair and in the region of the ears 
and the forehead and gradually spreads over the forehead, neck, face, chest, trunk, 
and lower extremities, often assuming a crescentic arrangement and reaching its 
acme and fading in its location before reaching its maximum in the later ones. 
Hence cases are likely to present rashes of varying stages of development in the 
different portions of the body. Desquamation, fine and branny, follows and 
lasts for about one week. 

Duration of Stages. — Period of incubation, one to two and one-half weeks. 
Period of invasion, three to four days. Period of developed rash, one week. 
Period of desquamation, one week. 

Complications. — Broncho-pneumonia is the most common and serious 
one, causing death in 30 to 40 per cent, of such cases in certain of the public 
services,' and even in private practice furnishing a heavy mortality. The 
disregard of this disease manifested by the laity is deadly in its effect, as 
children are exposed to pneumonia and other complications from sheer ignor- 
ance of its high mortality. Broncho-pneumonia is a deadly complication in 
sucklings and especially so during the year succeeding the first six months of 
life. Severe conjunctivitis and keratitis occur especially often in those poorly 
nourished and badly cared for, and the same may be said of severe gastro- 
intestinal disturbance, stomatitis or even gangrenous processes. The 
eyes may remain sensitive for a long period. Pertussis is frequently as- 
sociated with measles, tuberculosis is a 'not infrequent sequel, and the milder 
degrees of otitis media and affections of the nasal structures are not 
rare. 

The Urine. — Transient albuminuria is not uncommon, and Ehrlich's 
diazo-reaction is invariably present even in high dilution (1 : 100). 

Blood. — Leukopenia or a normal count is the rule during the period of 
active infection, a definite and sometimes a decided leucocytosis"(3o,ooo+) 
being present during the stage of incubation. 



Character and 
distribution. 



Desqua- 
mation. 



Important 
data. 



An underrated 
ailment. 



Sucklings. 



The eyes. 



Diazo- 
reaction. 



io68 



MEDICAL DIAGNOSIS 



Look out for 
small pox. 



Syphilis. 



Highly 
contagious. 



Filtrable virus. 



Strikingly 
objective. 



Diagnosis. — The combination 0} a febrile period of three full days associated 
with marked coryza, Koplik 's spots and the peculiar eruption serve to distinguish 
the disease from drug and serum rashes and rubella. 

The temporary measles-like rash of the preliminary stage of smallpox must 
always be borne in mind. Great variations in the disease exist; it may be 
trivial or virulent, febrile or afebrile, with a very slight or absent exanthem* 
The eruption may be hemorrhagic (black measles) and cases may, from the 
start, show predominance of nervous or pulmonary symptoms, and the lungs 
should be examined carefully at every visit. A case of persistent measle-like 
rash in the adult may prove a syphilis. 

MUMPS 

(Parotitis, Epidemic Parotitis) • 

Definition. — An acute epidemic, infectious, immunity conferring, highly 
contagious but usually trivial disease of childhood, of unknown causation, but 
due probably to the action of a filtrable virus, characterized by inflammation of 
the parotid gland and mild systemic symptoms. 

Etiology.— Children under four and adults are but slightly susceptible. 
The disease is transmissible in any stage by contact, contiguity, or, possibly, 
to some slight degree, by fomites, but still lacks a specific causative agent. 

Martha Wallaston has described a filtrable virus obtained from the 
sputum, of great potency when passed through a series of susceptible 
animals, reproducing in them all the leading clinical and pathologic changes 
of the disease, f 

Incubation Period. — Forty-eight hours to three weeks. Duration. Ac- 
tive symptoms about one week, followed by gradual subsidence. 

Morbid Anatomy. — An acute parenchymatous inflammation of the 
parotid gland. 

Symptoms. — Pain and swelling in the parotid region, in front of or below the 
ear, usually bilateral, but often single.% Fever usually mild (io2°F.) and of 
short duration. Dry mouth and intolerance of acids. 

The appearance of pain and swelling may be preceded by tenderness 
just posterior to the angle of the jaw, and a peculiar mottling of the skin of 
the chest may also be an antecedent symptom lasting for several days but 
preceding the parotid swelling by only twenty-four or thirty-six hours. 

The involvement of the surrounding tissues may be so great as to wholly 
disfigure the victim. 

* A hot wet pack or full bath, is sometimes necessary to develop the rash. 

f E. C. Rosenau (1915) reports that he obtained, by catheterization of the stenonian 
duct, pure cultures of streptococci which, when injected into dogs intravenously, pro- 
duced with absolute constancy a parotitis and also pancreatitis or appendicitis in some 
instances. This streptococcus strain is apparently identical with that reported by Isabella 
Herb in 1909. These findings do not appear to have been confirmed. 

% Cases are occasionally encountered in which the submaxillary gland is primarily or 
alone affected. 







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SCARI.KT 1T.YKR 



1069 



The cant of the head to the affected side, or its erect rigidity in bilateral 
involvement together with the distressed shapeless countenance makes a 
"figure of fun" and is likely to excite laughter rather than sympathy. The 
ailment is actually extremely painful and harassing. 

Complications. — In the comparatively rare cases in adults unilateral or 
rarely bilateral orchitis is a frequent complication (20 to 30 per cent.), 
though rare in children. Suppuration of the gland by infection through 
Stenon's duct is a rare development. Rarely, in the female, ovarian con- 
gestion or inflammation or painful swelling of the breasts may be found. Re- 
cently several observers have reported a metastatic pancreatitis as occur- 
ring with some frequency in certain epidemics. The duration is about 
one week. 

Orchitis is followed by atrophy in 40 to 50 per cent, of cases presenting 
this complication. 

Inasmuch as this may mean sterility in bilateral cases, the patient should be 
kept absolutely in bed until full subsidence of the infection is attained. 

SCARLET FEVER 

{Scarlatina) 

Definition. — An acute infectious and highly contagious fever of children, of 
unknown causation, conferring immunity and characterized by a sudden onset, 
the prompt appearance {second day) of a punctate bright scarlet exanthem termi- 
nating in desquamation, and showing a marked tendency to inflammatory in- 
volvement of the kidney, middle ear, throat, and cervical glands. 

Etiology. — The disease is conveyed chiefly by direct contact and fomites, 
less often by proximity, the secretions being, according to late investigations, 
more potent than the desquamated scales. In hospitals severe and compli- 
cated cases should be kept away from the mild and uncomplicated. 

The incubation period is relatively short, seldom or never exceeding seven 
days {Ker). 

It attacks chiefly children over one and under sixteen years, but adults 
enjoy only a relative immunity until the age of twenty-five is passed. It is 
rare in persons over forty years of age (eight of 1400 cases reported by 
Roily from the Leipzig Clinic). 

Mallory described protozoan bodies {Cyclosterion scarlatince) apparently 
characteristic of, and peculiar to, the disease, but no causative organism is 
proven. The "leucocytic inclusions" of Dohle are not peculiar to this 
disease and both are now regarded as products of degeneration. 

Very recently (191 5) Mallory and Medlar have reported a gram-positive 
microorganism {bacillus scarlatince) as present constantly upon the tonsils, 
faucial pillars, soft palate and uvula during the first forty-eight hours. 

The streptococcus theory lacks any substantial support despite the com- 
mon findings in scarlet fever, inasmuch as streptococcic infections with any 
known strain do not with any constancy produce the phenomena of scarlet 
fever nor do they establish the type of immunity so marked in that disease. 



Orchitis. 



Ovaritis. 



Mastitis. 



Testicular 
atrophy. 



Specific cause 
unknown. 



1070 



MEDICAL DIAGNOSIS 



Age, physique 
and climate. 



Abrupt onset. 



High initial 
fever. 



Early rash. 



Points of elec- 
tion. 



Peculiar facies. 



Lamellar 
peeling. 



Diagnosticaily 
suggestive. 



Prevalence. — It prevails throughout the year, but chiefly in the autumn 
and early winter months and covers nearly the whole globe. 

Mortality. — The general mortality varies from 10 to 15 per cent., and in 
children under six years of age it may reach 25 or 30 per cent. As in other 
diseases of this group, the mortality varies greatly in private as compared 
with public-service practice, and in weaklings as compared with the sturdy. 
A damp cold climate seems to increase the severity and frequency of complica- 
tions, and hence the mortality. 

SYMPTOMS.— With or without antecedent malaise there is (a) an abrupt 
onset, usually marked by vomiting with or without nausea, and commonly by 
sore throat; indeed the lutter symptom may be dominant. 

The uvula and anterior pillars of the pharynx are almost invariably fiery 
red and the angina tonsils are swollen and often enlarged greatly. 

A follicular exudate may be present dotting the tonsils, or the exudate 
may be yellowish or yellowish gray. 

(b) Fever, 100 to io$°F. at onset, diminishing by lysis with the complete 
development of the rash and reaching normal in a week or ten days, unless com- 
plications occur. 

(c) The Rash. — This appears in from twelve to twenty-four hours, first on 
the chest, and spreads with great rapidity. It is really punctate, the color being 
deepest about the hair follicle, but it appears diffuse and is commonly described 
as a boiled-lobster-like redness which spreads over the whole body in a few hours. 
As in every other eruptive fever, it varies greatly in intensity, in some cases escap- 
ing superficial observation unless intensified by a hot wet pack or bath. It should 
be remembered that it is most intense about the flexor aspect of the joints, the groin, 
and. inner aspect of the thighs, and on the anterior surface of the upper chest. 
In marked cases it is unmistakable and the fact that about the upper lip and 
upper chin it is often almost absent gives a char cater istic facies. 

It appears first usually on the sides of the neck and upper chest and moves 
downward fading gradually above as it becomes more intense below. 

It fades in from three or four to seven or eight days and a remarkable 
desquamation follows, quite unlike that of measles. The skin peels and 
may come away in large sheets. Exfoliation may be complete in a few days 
or last for three or four weeks, and the scales are infectious, though probably 
less so than has been believed. The order of desquamation is usually: 
chest and neck, fourth to seventh day; hands, twelfth to fourteenth; feet, 
fourteenth to twenty-first. 

(d) Rapid Pulse. — Excessive rapidity may be present before the appear- 
ance of the rash and persist throughout the active stage. 

(e) Strawberry tongue, light white or grayish furring punctuated by red 
and prominent papillae is a somewhat prominent feature after the first two or 
three days. 

The Blood. — A decided polymorphonuclear leucocytosis is present usu- 
ally and may reach 50,000 or even 60,000 cells per cubic millimeter in 
severe cases. 

Complications. — The danger in scarlet fever lies in its complications and 




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SCARLET FEVER 



IO71 



of these nephritis is most to be dreaded. This when present takes the form 
of an acute nephritis, developing usually at the end of a week. Mere febrile 
albuminuria is common and sharp congestion may occur and promptly 
subside. 

The blood-pressure readings should be taken daily by the physician and any 
definite rise in systolic pressure should direct attention to the kidneys, the urine 
should be measured and a specimen examined at least once in twenty-four hours* 
and the patient should be carefully guarded from exposure to cold and wet for 
some time after the disappearance of all active symptoms of scarlatina. 

Suppurative otitis media is another dangerous complication, resulting 
oftentimes in mastoid abscess, septic meningitis, general sepsis, and perma- 
nent deafness. The throat should be kept as clean by sprays and gargles as 
the circumstances permit, and the ears should be watched carefully, espe- 
cially in infants. Swelling of the cervical glands is common and may result 
in extensive infiltration and suppuration. 

Pharyngitis and Tonsillitis. — These may»be extreme and a true or pseudo- 
diphtheritic membrane may be present. The occasional coincidence of scar- 
latina and diphtheria is not to be forgotten. 

Endocarditis, pericarditis, myocarditis, and even pancarditis frequently 
result and the heart should be carefully watched. Parotitis, septic arthritis, 
broncho-pneumonia, lobar pneumonia, pleuritis, and empyema are rare com- 
plications, but active delirium and even convulsions may be present. 

Patients must not be pushed in convalescence for persistent weakness is likely 
to be an indication of myocardial inadequacy, f 

Diagnosis. — Sudden onset, vomiting, fever, sore throat, a typical rash, and 
a rapid pulse are unmistakable, but many cases arise which tax the resources 
of the cleverest clinician. Doubtful rashes may be made plain sometimes by 
the hot wet pack or hot bath. Excessively rapid pulse is important in connection 
with any other suggestive symptom. The hard pulse suggests nephritis but 
renal involvement may be present without hypertension. A secondary rise 
in temperature always suggests a complication. 

Cases occur with no discoverable rash and no fever, and these may transmit the 
disease in its typical form to other children. 

There can be little doubt that the severity of scarlet fever has been 
materially modified during late years. And, furthermore, it must be noted 
that the tendency to complications and the mortality alike are influenced 
markedly by climatic conditions, varying more or less strikingly in different 
portions of our country. 

Another factor greatly influencing mortality is the virulence of the 
individual epidemic. A considerable number of cases observed by the 
writer during the prevalence of an epidemic in the northern section of 

* The early administration of urotropin and the free use of Vichy and cream should 
diminish the frequency of this dreaded complication. 

I The author encounters each year cases in which irreparable damage to the heart 
has resulted from the almost universal failure to guard the heart in convalescence from 
acute prostrating diseases. 



Nephritis. 



Safeguards. 



A cause of 
deafness and 
meningitis. 



Diphtheria. 



Other 
complications. 



A common 
error. 



Hard pulse. 



1072 



MEDICAL DIAGNOSIS 



Location an< 

associated 

symptoms. 



Trivial 
symptoms. 



Evanescent 
rash. 



Polymorphic 
rash. 



North Dakota over a decade ago showed an appalling mortality, many 
cases dying before any rash developed, and renal complications being 
extremely common. 

Age is a factor always to be considered in prognosis; the younger the 
affected child, the greater being the danger. 

Sex plays a smaller part although it is held that the mortality in the male 
exceeds that in the female. 

The utmost caution should be observed with regard to the mild cases 
lest an under-estimation of the possibility of severe complications should 
lead to neglect of those precautions which always should be observed. 

Spurious Rashes. — Unfortunately, roseolas are common and often due 
to trivial causes. In differentiation one must bear in mind that the scarlet- 
fever rash appears first on the chest, is seldom unassociated with sore throat, 
rapid pulse, enlarged lymphatics, and decided fever and desquamation, follow- 
: ing the order given in a preceding paragraph. Rubella should never be mis- 
taken for it as the eruption appeals first on the face and is macular. Indiges- 
tion. Scarlatiniform rashes, evanescent and incomplete, are not uncommon in 
children as a result of dietary indiscretion but such rashes lack the other 
essential features of scarlet fever. Drug rashes may be traced to their cause 
and lack cardinal signs. Septic rashes are known by their association with 
other signs of sepsis, onset, etc. Syphilis. Scarlatina-like rash is rare in 
syphilis, and the other concurrent signs make the diagnosis. Febrile Roseola. 
Simple (non-epidemic). Roseola exactly simulates mild scarlatina, but its 
benign character and the history of repeated attacks may serve to distinguish 
it. All suspicious cases should be isolated, and no chances taken. It is a 
bastard syndrome. Duke's "fourth disease" is discussed separately. 



RUBELLA 

(Rotheln, Getman Measles) 

Definition. — A trivial acute contagious exanthematous disease of unknown 
causation conferring immunity and chiefly affecting children. 

Symptoms. — After an incubation period of from fourteen to twenty-three 
days, the disease begins with slight malaise, mild catarrhal symptoms, occasionally 
a slight angina, trifling fever, and on the second or even the first day the rash ap- 
pears on the face, scalp and throat, spreading rapidly over the body, the old areas 
usually fading as it extends. 

Either the measles or the scarlatina rash may be closely simulated, but 
neither type is constantly displayed over the entire body and the color is but a 
"faded red." The disease protects from neither of these ailments and the 
triviality of its symptoms and the multiformity of the rash will usually 
readily distinguish it. 

Neither catarrhal symptoms nor sore throat are marked, but a stiffness of 
the neck from, swelling of the post-cervical glands is common and may precede 
the eruption for several days. 



RUBELLA 



I073 



There is practically no mortality or serious complication and the diazo- 
reaction is usually absent. 

Differential Diagnosis. — Doubtless many cases of rubella of the scarlatin- 
iform type or rather, such of these as are seen first during the second day 
of eruption, are miscalled "scarlet fever." 

The primary rash is less brilliant and coarser than that of scarlet fever and 
yet finer, more definitely circular and less blotchy than that of measles. 

On the second day it has assumed a decidedly more scarlet-fever-like 
appearance, but it lacks the fine punctate spotting and- on the inner aspect of 
the thighs and groin may be distinctly morbilliform. On the foot it may still 
retain its primary discrete circular arrangement. The color is, as previously 
stated, u faded red, " not scarlet. 

The catarrh is too decided for scarlet fever and usually too slight for 
measles and both the strawberry tongue of the former and Koplik's spots of 
the latter are absent. An evanescent crop of discrete red spots may appear 
on the soft palate or even the buccal mucous membrane but these lack the 
pearly gray points of " Koplik's spots" so characteristic of measles. 

FOURTH DISEASE {" Filator-Duke's Disease v ).— This transient febrile 
exanthem of unknown causation may prove to be a distinct disease if it 
can be clearly shown that neither scarlet fever nor rubeola confers immunity 
against it, and that it is not a mere indigestion rash, but it is very like cer- 
tain cases of rubeola or mild scarlatina. 

Incubation. — Its incubation period is said to vary from nine to twenty 
days and is usually symptomless. 

Onset. — The scarlatina-like rash appears abruptly and in two hours 
may cover the entire body though the abdomen and thighs are likely to 
be already affected. It is usually a lighter and less vivid red than that of 
scarlet fever, affects the body more than the face, or. exclusively, and tends 
to avoid the area about the mouth as in that disease. The rash endures usually 
but a few hours, lasting but for a day or two at the longest and is followed 
sometimes, according to Duke, by a desquamative period lasting one or 
two weeks. 

The author has seen a number of cases which might be called the "fourth 
disease," but in nearly every instance a dose of castor oil has wrought a 
magic disappearance of symptoms. Fever is slight and usually lasts only 
during the active eruptive stage. Injected conjunctivce may be noted. No 
adequate proof of the existence of a " fourth disease" has yet been 
adduced. 

A "Fifth Disease" has also been described but like the "fourth" has so 
far not achieved and is not likely to attain an independent status. 

ESCHERICH'S INFECTIOUS ERYTHEMA.— This harmless, slightly 
contagious ailment is unreported in this country and offers practically no 
constitutional symptoms of consequence. 

An erysipelas-like flush appears first on the face and spreads to the body 
where it affects chiefly the exposed lateral and extensor surfaces of the 
limbs producing there a map-like configuration. Upon the body the exanthem 
68 



May be 
miscalled. 



Important 

differential 

points. 



Still sub- 
judice. 



A dubious 
entity. 



io74 



MEDICAL DIAGNOSIS 



assumes the form of a more or less closely packed agglomeration of discrete 
crescentic patches. It is of slight clinical interest. 

DIPHTHERIA. — (Cynanche maligne, putrid sore throat, suffocative angina, 
membranous croup.) 

Definition. — An acute highly infectious, contagious and profoundly toxic 
disease, due primarily to the Klebs-Loeffier bacillus, but often a mixed infection, 
characterized by the development of a nasal, pharyngeal or 
laryngeal false membrane and especially affecting young 
children. 

Dissemination and Distribution. — The disease is 
well-nigh universal and is readily disseminated by con- 
tact, contiguity (cough dissemination), clothing, drink- 
ing utensils, pencils, school books, and intermediaries, 
such as parents, nurses, physicians, and certain persons 
who undoubtedly carry the germ, but are themselves 




Fig. 517. — Diph- 
theria bacillus (bacil- 

unafTected. Such may carry the germ for months or Loeffler? Pleomor- 
years and some of them are culturally positive yet non- phic, non-motile, non- 
virulent as to the strains carried. So also foodstuffs, fl age iiate, non-lique- 
pet cats and dogs, room or street dust may convey it. fying, non-chromo- 
Individual Susceptibility. — A decided natural im- ftntivTted^and 
munity to diphtheria exists in the great majority of stained by all 
individuals. This is clearly indicated by the results brook has described 



(1) a virulent type 
with clubbed extrem- 
ities and polar gran- 
ules, (2) granular 
type, (3) barred type, 
(4) solid type. 



obtained by the application of " Schick's intracutaneous 
test." 

-It would appear that 75 to 80 per cent, of newborn 
babes, 40 to 50 per cent, of children between one and 
five years of age, 75 per cent, of those between the 
ages of ten and fifteen, and 90 per cent, of adults are thus protected; 
(See "Schick's Test.") 

The introduction of the newer methods for the production of artificial 
immunity have made it possible to protect individuals for periods of several 
years' duration. 

Morbid Anatomy. — Aside from the false membrane itself, the interest 
centers about the heart, nervous system, and kidneys which are the chief 
sufferers from the diphtheria toxin. The most important conditions are 
myocarditis and paralysis of the vasomotor center (the two most frequent 
complications causing sudden death), laryngeal stenosis and peripheral 
neuritis. Anterior poliomyelitis or even hemorrhages into the spinal cord 
are common and the cranial nerves are quite frequently affected. Con- 
gestion of the kidneys is almost invariable and acute nephritis not uncom- 
mon. The spleen is hyperemic, the lungs not infrequently congested or the 
seat of bronchopneumonia. 

Symptoms. — No disease is more variable in its symptoms and the modern 
physician has learned to expect diphtheria without marked fever or malaise 
and even in the absence of marked throat symptoms or the presence of an ap- 
parently frank and relatively innocent tonsillitis, while on the other hand what 



DIPHTHERIA 



I075 



appears to be a true membrane upon the tonsils and pharynx may prove non- 
diphtheritic. 

Ordinarily there is chilliness and general malaise, the fever rising to 102 ° 
to 103 during the first day, and there is nearly always sore throat, and what 
is far more important as an early sign and in dubious or larval cases, enlarge- 
ment of the glands at the angle of the jaw. If the child has been sick for some 
days its appearance and evident weakness may be out of proportion to the 
temperature and local signs, yet here again exceptions occur and extensive 
membrane and marked glandular involvement may co-exist with slight 
systemic disturbance. The pulse is usually rapid and not infrequently 
irregular and irritable from the onset, but its more significant variations 
appear, as a rule, later in the disease, when it may be very rapid, very slow, 
or show decided arrhythmia, even to heart block. It is, moreover, weak and 
compressible in any established case unless there be some decided renal 
involvement. 

The appearance of the throat is variable and it may be that of a mere con- \ 
gestion or simple follicular tonsillitis with a readily detachable pultaceous 
exudate, but more often shows a definite patch or extensive membrane spreading 
to the faucial pillars and perhaps to the uvula, naso-pharynx or even the larynx. 
It is gray or drab (mouse color), dirty and usually shaggy and if removed leaves 
a raw bleeding surface which it quickly re-covers. 

The spread of the membrane is sometimes astonishingly rapid and even on 
the physician's first visit it may have reached an extreme development. The 
nervous symptoms of the early stage may be nil or consist of restlessness or 
delirium. In the later stages a state of profound nervous depression may be 
evident, with or without low delirium, stupor, or terminal coma. 

Attention should be paid to the nose and larynx no less than to the throat in 
every case suggesting diphtheria, as the membrane may be limited to these regions, 
and the utmost care and caution should be exercised in allowing the child to 
assume the sitting posture and in getting it out of bed during convalescence. So 
also the urine should be frequently examined and the heart auscultated and 
percussed at each visit. 

The wise physician will use antitoxin promptly in dubious cases without 
waiting for a laboratory report, though these are now furnished with remark- 
able promptness. Nasal diphtheria may at times only be detected by a 
rhinoscopic examination, laryngeal cases by the laryngoscope, but the evi- 
dence of related stenosis in either case, together with the symptoms of pro- 
found exhaustion which almost invariably accompany them will point the 
way. In the former an irritating nasal discharge is common. 

Membranous croup has properly been shelved by modern methods of diag- 
nosis and replaced by laryngeal diphtheria which in 99 per cent, of such cases 
is the proper descriptive term. The symptoms of dyspnea and suffocation 
from laryngeal membrane do not need description, but no more terrible picture 
is seen in medicine and, if urgent, it of course demands immediate recourse to 
intubation, and that failing, to tracheotomy. Both the nasal and laryngeal 
forms yield a higher mortality, in the latter not only because of the obstruction, 



A valuable 
sign. 



Heart 
symptoms. 



Diphtheria 

without 

membrane. 



The 
membrane. 



Nervous 
system. 



Nose and 
larynx. 



Antitoxin. 



'•Membranous 
croup." 



Stenotic 
symptoms. 



1076 



MEDICAL DIAGNOSIS 



Sudden 
deaths. 



Suicides. 



^11 recover. 



Culture, the 
only certain 
means. 



Wound 
membranes. 



but more because of the higher degree of toxemia associated with these two 
varieties. 

Complications. — Myocarditis and acute dilatation is the most common 
one and, together with acute vaso-dilatation, accounts for many cases of 
sudden death. In controllable children efficiently treated with large doses 
of antitoxin it should occur less frequently than it does now. The uncon- 
trollable ones practically commit suicide. Endocarditis is not uncommon, 
and in any event a weak, rapid, excessively slow, irritable, or irregular pulse 
demands the utmost care and caution not only during the attack, but long 
after it. 

Even mild cases of diphtheria must be safeguarded carefully during con- 
valescence inasmuch as serious after-effects or complications may arise in them 
after all active symptoms have disappeared. 

The kidneys may also become seriously involved and the urine should 
be watched carefully throughout the illness and tested even after convales- 
cence. The daily examination of the heart and determination of arterial 
tension are imperatively demanded. 

Complicating Paralyses. — These maybe extreme and severe, or localized 
and relatively slight. They most commonly affect the palate, occur during 
convalescence and almost invariably recover completely. The complication 
may be expected in between 10 and 15 per cent, of all cases even though 
treated with antitoxin. Diaphragmatic paralysis is a rare event, but may 
cause death. 

A most misleading and readily overlooked paralysis is that of accommodation, 
which may if disregarded involve serious trouble in school work. 

Profound hemorrhages are unusual and nephritis may, but seldom does, 
prove persistent. Anemia should receive attention as soon as the membrane 
has disappeared and not be postponed until late in convalescence. 

Differential Diagnosis. — The symptoms described enable anyone to make a 
reasonably sure diagnosis in most cases, but this is always to be controlled by 
cultural methods. The most important points are the membrane, its distribution, 
its common tendency to spread rapidly and involve adjoining surfaces, decided 
evidence of toxemia, glandular swelling, and in certain cases nasal or laryngeal 
stenosis. 

In taking a culture due regard must be had for the situation of the mem- 
brane and an attempt made to reach the larynx or nasal passage with the 
swab if the pharynx is free from exudate. 

Follicular Tonsillitis. — The onset is often more severe than is usual in 
diphtheria, the primary exudate is likely to be purely follicular (spots) and 
to show less tendency to rapid spread, is lighter, clearer, and less adherent, 
does not, as a rule, extensively involve surrounding structures and the 
glandular involvement is less marked. If operations have been recently 
performed the wounded surface may be covered with a membrane closely 
resembling that of diphtheria and lead to error * 

* Unfortunately true diphtheria also develops readily upon an operation wound 
and occasionally upon the vulva or within the vagina. 



MENINGEAL INFECTIONS 



IO77 



Prognosis. — There are differences in epidemics and the surroundings, 
previous health, and resisting power of the individual child cut a consider- 
able figure, but, practically, the whole outcome depends upon the promptness 
with which antitoxin is administered and the adequacy of the dose. It is im- 
possible to get accurate statistics, but we know that without antitoxin the 
mortality reaches from 50 to 60 per cent., while with antitoxin in. private 
practice where cases are promptly seen and children well nourished it may 
not exceed or reach 5 per cent. 

VINCENT'S ANGINA.— To Prof. Vincent we owe our knowledge of an 
angina which, ordinarily assuming the for* of an ulcerative or ordinary 
tonsillitis or pharyngitis, may closely simulate diphtheria. Two organisms 
are described, one a fusiform bacillus {Bacillus jusij or mis), the other a spiro- 
chete {Spirochceta macrodenis). 

The microorganisms responsible for this disease have assumed great 
prominence of late because of their apparent identity with the microorgan- 
isms responsible for so-called "trench mouth" so prevalent in the armies 
during the Great War. It would seem from investigations made during and 
following the war period that the usual primary site of infection is the gum 
margins and that many individuals in civil life carry these without showing 
the graver symptoms of the disease. 

Amongst soldiers the readiness of conveyance from one to another may 
be brought about through the handing about of pipes and cigarettes, the 
common use of drinking utensils, and like causes, and the number of indi- 
viduals carrying the pathogenic organisms is very much larger than is the 
case in civil life. 

Obviously, in every case of Vincent's disease involving the tonsil, pharynx 
or buccal mucous membrane, the gingival surface should be thought of as 
the primary . source of the infection. 

It is also evident that in all cases of apparent diphtheritic infection 
proving negative to culture, Vincent's angina should be thought of and 
proper laboratory tests resorted to promptly. 

MENINGEAL INFECTIONS 

The characteristic individual symptoms of meningitis are very similar in 
all its acute forms, differing chiefly in degree. The lesion is in every case 
essentially an inflammation of the pia mater and arachnoid, localized or gen- 
eral, and, in its different forms, shows a more or less well-defined predilection 
for certain regions. 

Various Forms. — We distinguish'. (1) Epidemic cerebro-spinal menin- 
gitis due to the meningococcus of Weichselbaum* (2) The simple or sporadic 
form, which is probably due to the same germ. (3) Tuberculous meningitis, 
due to direct tuberculous invasion and associated in 80 per cent, of all cases with 
a preexisting tuberculous focus in other portions of the body, which may be evi- 

* Recently it has been found that various strains exist and that one or the- other of 
these may be the active-factor in the individual case. It is necessary therefore to identify 
the strain present if potent antisera are to be obtained. 



Act promptly. 



"Trench 
mouth." 



IO78 MEDICAL DIAGNOSIS 



dent only upon a painstaking postmortem investigation* (4) Syphilitic men- 
ingitis. (5) Secondary meningitis due to septic infection or the toxins of acute 
infectious diseases. (6) Serous meningitis, (a) diffuse, (b) circumscribed. 

With the exception of the syphilitic and secondary forms the disease shows a 
special tendency to develop in infancy and early childhood. The syphilitic 
form almost invariably appears within the three years following the primary 
infection. 

MORBID ANATOMY. — In the epidemic form the entire pia mater of 
both brain and spinal cord is involved, but to the ordinary symptoms of 
meningeal inflammation are added those indicative of an acute febrile toxemia. 

In the septic and secondary forms, the pia of the convexity is chiefly 
affected, often in limited areas and the base may entirely escape, this being 
especially true of cases due to direct injury or extension of disease from the 
mastoid cells or nasal structures. 

In tuberculous meningitis the involvement is so often limited to the base 
as to give it the name of "basilar meningitis," though it would seem that 
syphilitic meningitis was quite as well entitled to the term. 

In cerebrospinal meningitis the general inflammation of the meninges of 
the brain and cord is associated with a nbrinopurulent or seropurulent 
exudate, most abundant at the base of the brain and posterior surface 
of the cord though, in malignant, rapidly fatal, cases, nothing may be 
found but an intense congestion. In those of long duration there is 
thickening of the meninges and yellow areas mark the seat of past 
exudation. 

The ventricles contain turbid fluid, and, in chronic case's, may be greatly 
distended. Foci of purulent infiltration and of hemorrhage may be found, 
and cranial and spinal nerves are of course enveloped by the exudate which 
constantly contains the meningococcus, f In some cases the central canal is 
dilated. In purulent meningitis there is a tendency to the formation of 
multiple abscesses and the exudate will yield cultures of the associated 
germs. 

In chronic inflammation of the pia there is an increase in connective 
tissue producing linear surface projections and a marked tendency to adhe- 
sions. By compression, cerebral nerves may be destroyed, ventricular open- 
ings obliterated and hydrocephalus produced. 

Usual Appearance of Exudate in Various Meningeal Inflammations. — 
With respect to the macroscopic appearances of the exudate, actinomycosis is 
indicated by yellowish granules; pyogenic cocci by a distinctly purulent exu- 
date; meningococcus cases by a fibrinopurulent or seropurulent exudate; 

* This finding means rather less than is usually believed, unless an active focus is present. 
About 80 per cent, of our adults probably carry old lesions, and older children would prob- 
ably run to 40 per cent, at least. (See Tuberculin.) Infants and little children show a 
much lower percentage, however. 

t This germ described by Weichselbaum in 1887 is aerobic, non-motile, occurs in pairs, 
fours, or short chains, and unlike the pneumococcus does not grow on gelatine, but on 
blood serum, and shows small circular smooth colonies. 



MENINGEAL INFECTIONS 



IO79 



whereas it is thick and grayish yellow or yellowish green and gelatinous in 
tuberculosis. 

Tuberculous Meningitis. — The development of miliary tubercles is 
superadded to an inflammation with a more or less characteristic exudate. 
The tiny gray miliary tubercles appear chiefly in the choroid plexus, along 
the Sylvian artery, on the inner surface of the dura, on the membranes of the 
cord, and even in the retina. The usual changes, i.e., hyaline and caseous 
degeneration, occur and tubercle bacilli are ordinarily readily found in the 
exudate. 

Syphilis is indicated by the presence of soft grayish-red areas, most 
common at the base, tending to undergo caseous degeneration, absorption, 
or cicatricial contraction. Both the dura and the cortex may be 
involved. 

Hydrocephalus may result from an arrest of the flow of the cerebro-spinal 
fluid secreted by the choroid plexuses of the lateral ventricles by blocking, 
compression or adhesion of the "aqueduct of Sylvius" or the "foramen oi 
Monro." In many cases of tuberculosis and practically all cases of syphilis 
the exudate is non-purulent. 



EPIDEMIC CEREBRO-SPINAL MENINGITIS 

("Petechial fever " "Spotted fever " " Malignant purpuric fever " "Brain fever") 

Definition. — An acute, contagious leptomeningitis, strikingly, though not 
wholly, epidemic in type, caused by the Meningococcus intracellularis meningi- 
tidis, and transmitted by contact, contiguity and healthy intermediaries carrying 
the meningococcus in the naso-pharynx. 

The incubation period varies from a few hours to a 
week or ten days, and the onset is usually sudden, though 
headache, anorexia and pain in the back may precede it. 
It affects individuals of both sexes equally, most 
commonly attacks those between ten and twenty-five 
years of age and seldom occurs in adults who have 
passed the age of forty-five. 

Symptoms. — In some instances a preliminary stage 
occurs which is marked by decided and often severe 
nasopharyngeal symptoms. This is followed after 
several days by the more decided evidences of estab- 
lished infection. There are chills, causeless projectile 
or regurgitant vomiting, headache of increasing severity, associated in little 
children with the plaintive, wailing cry representing its exacerbations, 
severe backache, usually painful cervical and dorsal rigidity and moderate 
fever (101 to 102 F.). Auditory and visual hyperesthesia coexist with 
restlessness, irritability and muscular tremor. The head is retracted {boring 
occiput), opisthotonos or, more commonly, orthotonos may occur and, in 
children, general convulsions. 




Fig. 518.— Epi- 
demic Spinal Menin- 
gitis. Meningococcus 
in centrifugated cere- 
bro-'spinal fluid. 
Stained with Loef- 
fler's Methylene Blue. 



Hydro- 
cephalus 



Irritative 
symptoms. 



io8o 



MEDICAL DIAGNOSIS 



Facial spasm, strabismus and ptosis are common, pain in the head, back 
and extremities is decided and progressive and, less frequently, the trunk muscles 
may be paralyzed. 

Hyperesthesia of spinal or general localization is often noted and 
marked irritability may give place to delirium, stupor and finally coma. 
Albumin, sugar, and in malignant cases, blood, may be present in the urine. 

The fever curve is extremely variable, some cases showing hyperpyrexia, 
others almost no fever. 




Fig. 



(After Knopf elmacher.) 



Respiration is not markedly increased. The pulse is sometimes remark- 
ably slowed and almost always weak, but in children may be much accelerated. 

Leucocytosis is present in all cases (20,000 to 40,000).* The bowels are 
usually constipated, the spleen moderately enlarged, excessive vomiting, with- 
out nausea and of the projectile type, is an unusual but troublesome com- 
plication. 

Skin Rashes. — The cutaneous symptoms vary greatly, herpes is almost 
constant and purpuric spots occur in from two-thirds to three-fourths of the cases. 

* Leucocytosis is sometimes present in tuberculous cases though not so constantly. 



MENINGEAL INFECTIONS 



I08l 



Dusky mottling, erythema, rose spots, urticaria and various eruptions may be 
present. 

Malignant cases may kill so promptly that the brain shows at autopsy 
only an acute congestion. They are sometimes apyretic and are almost 
invariably associated with purpuric rash and feeble pulse, somnolence and 
profound asthenia. 

Intermittent Form.— This is characterized by a febrile curve of a dis- 
tinctly pyemic type. A chronic form may succeed the acute. 

Abortive Form. — This "type" is characterized by a severe onset, an 
extremely short duration and a sudden termination, followed by rapid con- 
valescence. Certain other mild types present symptoms hardly more than 
suggestive which promptly subside and in each of these varieties there is 
abundant opportunity for damaging erroneous conclusions. 

Complications. — These are, chiefly, pneumonia, often of a true meningo- 
coccus type, septic arthritis, peri- and endo-carditis and parotitis. Con- 
valescence may be greatly retarded by persistence of headache, nervous 
irritability, mental impairment, or long-persisting cranial nerve paralysis. 
Optic neuritis occasionally occurs as do purulent conjunctivitis, choroiditis 
and iritis. Permanent deafness and persistent ocular palsies are very com- 
mon and the frequency of nasal catarrh suggests the nasal secretion as a 
possible chief vehicle of infection. 

Kernig's Sign. — Flex the thigh sharply upon the abdomen, the leg upon 
the thigh; if meningitis is present, extension of the leg 
is then prevented by contraction of the hamstrings. 

This sign is present in 90 per cent, of the cases, 
but also is to be found in sciatica, diseases of the hip 
and knee-joint and lesions of the cerebellum or upper 
motor neurons and to a less degree in old age or 
after prolonged fixed recumbency. 

Brudzinski's Phenomena.- — These may sometimes 
be helpful in diagnosis and are referred to elsewhere 
under "Synkinesias." 

Diagnosis. — The presence of an epidemic, and the 
characteristic symptoms of cerebrospinal irritation and 
compression ordinarily make the diagnosis easy, yet the cerebral symptoms 
present in other acute febrile conditions are often misleading. Lumbar puncture 
is the decisive test. 

The rash, if present, is of great assistance in diagnosis. Herpes, leuco- 
cytosis and diminished urinary chlorides assist in the differentiation from 
typhoid of the meningeal type; the physical signs, from pneumonia, though 
either disease may co-exist with meningitis (see also "Tuberculous 
Meningitis," "Differential Diagnosis"). 

Prognosis. — Over 50 per cent, of the deaths occur in the first week and 
the mortality under Simon Flexner's serum treatment ranges from 20 to 
50 per cent, according to the early or late administration of the remedy 
and the type of patients, being higher in children than in adults and most 



Rapidly fatal. 



Errors 
common. 




Convalescence 
tedious. 



Residual 
lesions. 



Exact 

procedure 

accessary. 



Present in 
other condi- 
tions. 



Fig. 520. — Kernig's 
sign. Improper method 
(After Sahli-Wiener.) 



Chief features. 



Importance of 
early treat- 
ment. 



I082 



MEDICAL DIAGNOSIS 



Technic. 



Point of 
election. 



Children vs. 
Adults. 



Depth of 
puncture. 



Pressure 
indications. 



6pinal fluid. 




;2i. — Kernig's 



Fig. 

sign. Proper method, 
i.e., preliminary flexion 
of thighs on abdomen 
followed by attempted 
extension of leg on thigh. 



excessive in those children under one year of age. Hyperpyrexia, coma, 
repeated convulsions and sudden fall of fever are unfavorable signs. 

LUMBAR PUNCTURE.— Place the patient on the side, the body so bent 
as to get the maximum dorsal curve. Carefully count the vertebrce and intro- 
duce the sterile hollow needle slightly (0.5 cm.) to one side of the median 
line between the third and fourth lumbar vertebrce* or, better still, between the 
fourth and fifth at the level of the iliac crests, the needle point being directed 
toward the center oj the canal and slightly upward. 

Sterilization of the skin with iodin is necessary 
and sterile graduated tubes should be at hand to 
receive and measure fluid. 

In children, a point midway between two spinous 
processes should be chosen; in adults it should pas^ 
just below the lower margin of the upper process 
of the chosen space. A long needle, (9 to 10 cm. in 
length and o . 6-1 . 2 mm. calibre) carrying a stylet, 
is needed, the distance traversed varying from 2 cm. 
in children to from 4 to 6 cm. in the adult. 

Pressure is indicated by the force of the flow, 
and normally represents 5 to 7 mm. of mercury, 
which may be increased to from 15 to 60 mm. in 
meningitis and tumors (Sahli). It is easily measured by attaching a small 
(1 mm. caliber) mercury manometer. Any admixture of blood interferes 
seriously with cytodiagnosis. It often appears temporarily only, and in such 
cases a good specimen may be secured. If persistent a repetition of the pro- 
cedure at another sitting may be necessary. 

Normally the fluid is clear and limpid, specific gravity 1006-1013, and but 
slightly albuminous (0.02 to 0.05 per cent.). Marked cloudiness and the 
presence of leucocytes points to septic meningitis, the fluid being relatively 
clear in tuberculous meningitis and cerebral abscess. High albumin content 
is also significant though occasionally encountered in tumor and apoplexy. 

Globulin Content. — This is far more important than the test for albumin 
in that only the faintest trace is present in normal spinal fluid. 

In most cases of cerebrospinal syphilis and paretic dementia it is decidedly 
increased. 

Globulin Test. — Rose & Jones' modification of the Nonne-Apelt method is 
simple and definite. 

Test. — To 2 c.c. of a saturated solution of Merck's ammonium sulphate 
add 1 c.c. of cerebrospinal fluid by running it slowly down the inside of the 
inclined test tube. 

A delicate grayish white contact ring should appear at about three 
minutes. 

The differential value of the interesting but complex " colloidal gold-test" 
is not yet determined fully. 

* To avoid the spinal cord Sahli prefers the interval between the fifth lumbar and the 



MENINGEAL INFECTIONS 



I08 3 



Caution. — Lumbar puncture is a procedure of importance and some 
risk and must not be made a matter of hasty routine procedure, nor 
performed under adverse conditions save in emergency. 

Lateral recumbency for the patient, the withdrawal of only small amounts 
of fluid in all save meningeal cases, and absolute rest in bed for 24 or 48 hours 
in the dorsal recumbent posture, following exploration are all matters of 
importance. 

Headache, often severe and persisting over several days, may follow lum- 
bar puncture in a considerable portion of patients and need excite no serious 
alarm. 

In the case of cerebral tumors, puncture is attended by considerable danger 
if large amounts of fluid are withdrawn. 

ACUTE TUBERCULOUS MENINGITIS.— The symptoms of this ail- 
ment are in general exactly the same as in other forms of meningitis, but, as 
assisting differential diagnosis, there is frequently a history of preexisting 
active tuberculosis in other parts of the body, or the disease may be a part of 
an acute miliary process. Furthermore, there are usually marked prodromal 
symptoms such as a general failure or impairment of health extending over several 
weeks, loss of weight and appetite, irritability, headache and restlessness. 

First Stage. — The actual onset is occasionally somewhat abrupt in chil- 
dren and there is beginning cervical rigidity, the curious whining " hydro- 
cephalic cry,"* apparently due to abrupt exacerbations of the headache. The 
pulse, at first rapid, becomes slow and irregular, the respirations irregular and 
sighing and the pupils are generally contracted (stage of irritation). Projec- 
tile vomiting may or may not occur. 

Second Stage. — In the second stage there is obstinate constipation, marked 
emaciation, retraction of the abdomen (scaphoid belly), boring occiput, stupor 
and irregular or dilated pupils, often associated with strabismus. The 
temperature is usually moderate in both stages (101 to io3°F.). 

Third. Stage. — The third stage (paralysis, coma). Paralysis of the ocular 
muscles is common, optic neuritis may be present, diarrhea may replace con- 
stipation and the victim lies in a "typhoid state," with partially open eyes and 
dilated pupils. 

Temperature may at this stage be subnormal, the pulse rapid and there may 
be ante-mortem hyperpyrexia. 

The Duration. — This varies from a few days to a month, from two to 
three weeks being the common period. Occasionally instances of a 
chronic course are encountered some of which lack the pronounced initial 
symptoms. 

Kernig's sign is of course present in this form and the spinal fluid usually 
contains tubercle bacilli and shows mononuclear cell predominance, f 

The tubercle bacillus usually may be determined readily in the spinal 
fluid but a proper procedure involves the preservation of a carefully drawn 
specimen for 1 2 hours in the ice box. 

* Occasionally screaming is marked and almost constant. 

f Animal inoculation is sometimes required to prove the presence of tubercle bacilli. 



Preexisting 
disease. 



Prodromata 
marked. 



Peculiar cry. 



Scaphoid 
belly. 



Spinal fluid. 



1084 



MEDICAL DIAGNOSIS 



Symptom 
diversity a 
feature of 
meningitis. 



Contrast 
decided. 



Meningo- 
coccus absent. 



Septic type. 



Meningo- 
coccus absent. 



Brain tumor 
symptoms. 



The clot which forms is then withdrawn and direct staining of smears is 
undertaken. 

Inoculation of guinea pigs should be a routine procedure when facilities 
are available. 

General Comment. — The greatest diversity of symptomatology must 
be expected in a lesion involving the brain stem and perhaps the cortex in 
an inflammation associated with the outpouring of an exudate. The pupil- 
lary symptoms are quite constant as regards miosis of the early stage and the 
irregularity and dilatation of the later periods. Not only projectile vomiting, 
but convulsive seizures or even tetanic contractions or catalepsy may be 
encountered in the earlier periods, and ocular palsies may exist alone or be 
associated with extensive cranial involvement. 

Prognosis. — Practically all cases die. 

Differential Diagnosis. — Tuberculous meningitis, in contrast to the epi- 
demic form, is almost invariably of gradual onset; shows less fever and that 
often of the inverse type; rarely shows any leucocytosis, in sharp contrast 
to the epidemic form, in which leucocytosis is constant and decided; only 
in exceptional cases shows herpes; pursues a slow course; presents fever, spinal 
symptoms and, on lumbar puncture, yields an exudate showing no meningo- 
cocci, mononuclear cells in predominance and tubercle bacilli. 

Rigidity and retraction of the neck is extreme in the epidemic form, 
less marked and, in rare instances, absent in the tuberculous form. 

A family history of tuberculosis or active pulmonary or glandular foci 
may be demonstrated by physical signs or radiography and retinal tubercles 
are sometimes revealed by the ophthalmoscope. 

SUPPURATIVE MENINGITIS.— This differs from the tuberculous and 
the epidemic form alike in the distinctly septic fever curve, often with pro- 
nounced and repeated chills and sweats, and in its usual freedom from pur- 
puric manifestations and herpes alike. 

Lumbar puncture reveals a predominance of polymorphonuclear leuco- 
cytes, as in the epidemic form, but the meningococcus is lacking by cultural 
tests and other pyogenic cocci are found in abundance. 

Caution. — It should be remembered that redness and swelling of joints 
may occur in the course of epidemic or septic meningitis, but not at the onset 
as in acute rheumatism. One need but know the fact of their possible 
appearance to avoid confusion. 

SYPHILITIC MENINGITIS.— This combines symptoms of brain tumor 
with those of meningitis; is essentially chronic in type and peculiarly variable 
in its meningeal manifestations. It cannot well be confused with the acute 
forms. The slowly developing and progressing symptoms are those of 
brain tumor, headache being pronounced and usually increased at night, and 
irritability, change in disposition and lack of appetite are prominent features. 

Causeless vomiting and vertigo may be present and eye symptoms or 
facial paralysis may indicate involvement of the cranial nerves. In fact 
nearly all such persistent cranial nerve involvements are of syphilitic origin. 

Cerebellar ataxia and polyuria may occur and, if the Sylvian fissure be 



MENINGEAL INFECTIONS 



I08 5 



involved, there may be hemiplegia or aphasia. To name all of the symptoms 
would be to review the whole subject of brain symptomatology. 

The essential feature is the distinctly slow, halting, indeterminate, onset and 
progress, interrupted by the intervals of betterment in many instances and the 
ready response of the condition to treatment. 

The diagnosis is usually assisted by a history of syphilis within three years 
or visible evidence of previous infection and positive Wassermann and luetin tests. 
Without a nti syphilitic treatment an absolute diagnosis between syphilitic 
meningitis and brain tumor can hardly be made. 

ALCOHOLIC MENINGITIS.— The form of meningitis known as wet 
brain deserves special mention because of its occasional occurrence in alco- 
holics and certain peculiarities in its course. 

It usually terminates a long debauch and is frequently a terminal event 
in delirium tremens. Its characteristics are stupor or coma with low mutter- 
ing delirium, hallucinations and delusions. There is general muscular ten- 
derness, cutaneous hyperesthesia, contraction of the pupils, and after a 
short time muscular rigidity, occipital retraction, loss of control of the sphinc- 
ters, exaggerated reflexes and scaphoid belly. The temperature is variable, 
often being normal or slightly raised throughout the disease, occasionally 
higher, especially at the close. The final stage may never be reached, the 
case terminating in recovery. The diagnosis is based largely upon the pecul- 
iar delirium and the history of alcoholism and is sometimes assisted by a 
knowledge of the occupation. 

It must be regarded as an expression of low grade infection by any one of 
several pathogenic microorganisms. 

SECONDARY MENINGITIS.— These cases present merely the symp- 
toms of meningitis as already described, usually in the presence of a sugges- 
tive, antecedent acute or chronic disease, or the history of traumatism, 
accidental or operative. 

In acute diseases error is likely to occur from two sources: one, the fact 
that certain acute febrile ailments such as pneumonia may present marked 
meningeal symptoms without true meningitis; the other, the liability that 
true meningeal symptoms may be masked by those of the disease which it 
complicates. These difficulties apply of course only to the stage of irritation 
and the doubtful diagnosis may almost always be made certain by lumbar 
puncture (see "Diagnosis" of "Epidemic" and "Tuberculous" forms). 

"Circumscribed Serous Meningitis." — This probably does not deserve 
separate consideration, representing as it does a condition whose symptoms 
are determined merely by its more or less fortuitous maximal localization in 
the cerebellarpontine angle. 

Nevertheless, the condition is one which might give rise to serious diag- 
nostic error by reason of the peculiarly otic character of its symptoms. 

These are: deafness, tinnitus aurium, pain behind the mastoid process, sub- 
occipital headache, facial nerve involvement, and high intracranial pressure. 

It may complicate almost any form of meningitis and is often confounded 
with brain tumor. One of the most interesting and characteristic symptoms 



Wide range 
of symptoms. 



Slow onset and 
therapeutic 
test the 
features. 



History of 
alcoholism. 



Hallucinations 
marked. 



Occupation 
may be sug- 
gestive. 



Lumbar 
puncture in 
doubtful cases. 



io86 



MEDICAL DIAGNOSIS 



Pressure 
symptoms. 



is the so-called "pointing-error" a modification of the older "touch- test,"* 
in ataxia. 

The preliminary induction of so-called "caloric" horizontal nystagmus is 
prerequisite to the performance of the test. The attempts to carry out 
touch-movements show a constant deviation error in the direction opposite 
that of the induced nystagmus. 

INFANTILE MENINGITIS.— A word is necessary concerning the special 
symptoms present in cases of simple meningitis affecting babes. The period 
of maximum susceptibility seems to lie between the third and sixth month. 

The symptoms are usually sudden in onset, and frank in their character; 
pain in early stage being indicated by pulling the hair and constant crying or 
screaming. Emaciation is peculiarly rapid, and hydrocephalus is usually 
evident by the second week, the head enlarging and assuming the typical 
outline, the fontanels bulging, and changes in the eyes, such as undue promi- 
nence, strabismus, and the usual pupillary symptoms, being evident. The 
tendency in the simple cases is to chronicity, and recovery occurs in perhaps 
20 per cent. Many serious and permanent impairments persist, these being 
chiefly deafness, mental defects and blindness. 

CHRONIC REMITTENT MENINGITIS.— The symptoms of this ail- 
ment are essentially those of chronic syphilitic or tubercular disease of the 
meninges and therefore consist almost wholly of pressure phenomena. Any 
form of meningitis may, however, become chronic. 

Whether we should recognize as a distinct ailment the so-called "serous 
meningitis" of this type would seem to be doubtful. 

Under the names of "Primary Idiopathic Hydrocephalus" or "Quincke's 
Disease" we have been giving special recognition probably to various wet 
meningitides of diverse bacillary or toxic origin. 

// would seem to be sufficient at present to regard these as chronic subinfec- 
tions for the greater part, but hold clearly in the mind the fact of their occasional 
occurrence. 

The forms with an abrupt onset are peculiarly misleading, the picture being 
often that of brain tumor (vomiting, headache, optic neuritis and cerebellar 
ataxia) or that of acute hydrocephalus. 

The essential points lie in the fact that in such cases we deal with evidences of 
high intracranial pressure, a limpid, clear, spinal fluid containing few cells, 
with remissions and with chronicity. 

LETHARGIC ENCEPHALITIS 

During the winter of 1918-19 there appeared in the United States what 
was apparently, so far as this country was concerned, a new epidemic involv- 
ing the central nervous system and representing an encephalitis with distinct 
lethargic symptoms. It is probable that the first cases arose in Vienna 

* The elaborate mechanism and the technic of the complex and difficult ' pointing 
error" tests is described fully in Dr. L. F. Barker's admirable work, "Monographic 
Medicine," Vol. IV, pp. 169-176, 1916. 



LETHARGIC ENCEPHALITIS 



1087 



during the winter of 1916. It is also probable that the disease itself is not 
a new one and may conform to what in 1890 was termed "nona" in Europe 
where cases seem to have been reported in Austria, Italy and Switzerland. 
It is also suggested that the disease may be identical with what was called 
''sleeping sickness," an epidemic of which occurred in Germany in 171 2. 

It has been thought by many that lethargic encephalitis was one of the 
sequels of influenza but this would seem to be improbable in view of the fact 
that the first cases reported abroad occurred before the date of the influenza 
epidemic of 19 18. Nevertheless there seems to have been a close relation- 
ship in the past between the epidemic occurrence of the two diseases.* 

Etiology. — It is evident that the disease is communicable and in some 
instances institutional outbreaks have occurred. On the other hand there 
are relatively few examples of multiple cases in the same household. 

Many efforts have been made to discover the specific organism responsible 
for this curious disease and several observers have recovered and cultivated 
successfully microorganisms which they believe causative. Nothing so far 
is proven, however, and the etiologic factor remains a mystery. 

Pathology. — Those portions of the central nervous system especially 
affected are cortical and represent chiefly the tissues in the neighborhood of 
the third ventricle, the aqueduct of Sylvius, the lateral ventricles, the optic 
thalamus, the pons and medulla. The lesions chiefly take the form of 
cellular infiltrations in the nerve tissues themselves, cellular aggregations 
about the blood vessels, edema, and small, often microscopic, perivascular 
hemorrhages; these changes occurring both in diffuse and circumscribed 
(nodular) forms. The spinal cord is affected relatively late, but may show 
changes in the cervical portion. 

Symptomatology. Onset. — Nothing is known definitely of the incuba- 
tion period and there seem to be few or no prodromal signs. The onset 
is strikingly sudden in many cases, but usually there is a prodromal period 
varying from a few days to a month or more. During this time the patient 
may experience unusual somnolence, headache, the varying degrees of 
asthenia, defective memory and disturbances of vision. 

Initial Symptoms. — Associated with an inflammation of the upper 
respiratory tract, there are chills, chilliness, general malaise, anorexia, 
nausea, headache often severe, and more or less generalized pain. 

Fever. — This may be present at the outset or be delayed in its appearance, 
and in most instances does not reach high figures, the usual case showing a 
reading of from ioi°F. to io2°F. Exceptionally the range is higher and 
may reach or even exceed io4°F. In many instances the temperature 
drops to subnormal after a few days and shows thereafter only an occasional 
rise, usually of moderate range. 

Later Symptoms. — The dominant and outstanding feature of the disease 
is the drowsiness and lethargy. The patient appears dull and apathetic, 
prolongs unduly the natural sleeping hours, and can be aroused only with 

*There would appear to be no substantial reason for assuming any direct connection 
between encephalitis lethargica and acute poliomyelitis. 



Tissues 
involved. 



Chief 
lesions. 



Drowsiness. 



io88 



MEDICAL DIAGNOSIS 



Usually 

develops 

gradually. 



Clearness of 
mind. 



Other signs. 



Paralysis. 



Rigidity of 
muscles. 



Erythema. 



Occasional 
Kernig's sign. 



Diagnosis one 
of exclusion. 



High death 
rate. 



some difficulty. This symptom may be present at the outset of the disease 
but is usually developed gradually and progressively. It resembles in 
most cases the profound sleep encountered in children and is associated 
with the same difficulty in arousing the individual to consciousness. Vari- 
ants occur, representing on the other hand a mere deepening of this condition 
into actual stupor, the passage into coma, or, in a small number of cases, 
the occurrence of delirium. 

One of the most striking things in connection with the somnolence in 
many instances is the clearness of mind shown by the patient when aroused 
with difficulty from deep stupor. 

Blurred vision, diplopia, vertigo, tinnitus aurium, photophobia, muscle 
twitchings and tremors may develop "and be associated with restlessness, 
irritability, or more or less profound mental depression prior to the onset 
of the deeper lethargic stage. 

Third nerve paralysis and facial paralysis may occur, and symptoms of 
meningeal irritation are present usually in some degree and at times so 
markedly as to suggest an actual meningitis. Rigidity or spasticity of the 
muscles of the extremities is a relatively common symptom and this may 
involve the face and produce a mask-like countenance. 

Early in this disease cutaneous manifestations may be present in the 
form of diffuse erythema or a morbilliform rash. 

Duration and Course of the Lethargic State. — The lethargy may continue 
throughout weeks or even months, even in cases making a full and com- 
plete recovery, and the recovery of mental function ordinarily is gradual. 
Indeed the same statement applies to other symptoms of the disease. More 
rarely, a relatively rapid recovery occurs not only from the somnolence but 
from the paralyses as well. 

The Spinal Fluid. — The spinal fluid in these cases is quite unlike that in 
meningitis, being clear, showing but a slight increase in the number of cells 
per cubic millimeter, and no pathologic globulin content. The cells present 
are both mononuclear and polymorphonuclear. 

A factor leading to errors in diagnosis is the occasional appearance of 
Kernig's sign in this disease. 

Diagnosis. — Obviously, in this disease the diagnosis is one of exclusion. 
Meningitis, brain tumor, typhoid or paratyphoid fever are the three condi- 
tions most likely to cause confusion. The application of the usual test for 
typhoid and paratyphoid would serve to exclude that disease; the history 
and the examination of the fundus oculi would usually suffice to exclude 
brain tumor; and the normal spinal fluid content would exclude meningitis. 

Prognosis. — The death rate is not as yet definitely established, but is 
high, the reports varying from 20 to 40 per cent. 



PLATE XI. 




Microorganism causing epidemic poliomyelitis. (Flexner and Noguchi.) 
Fig. i. — Culture in ascitic fluid tissue medium of Noguchi, showing opalescence. 
The translucent zone above is paramne. 

Fig. 2. — Solid culture showing colonies and line of demarcation, between the opalescent 
colony-filled medium below and the unaffected upper level. {From the Journal of Experi- 
mental Medicine, Vol. XVIII, 1913.) 



ACUTE INFECTIOUS POLIOMYELITIS 



1089 



ACUTE INFECTIOUS POLIOMYELITIS 

(Acute Anterior Poliomyelitis, "Infantile Paralysis") 

Through the brilliant work of Simon Flexner and his colleague, Noguchi, 
the cause of this immunity-conferring, but deadly and disabling, scourge of 
children and young adults is proven to be an extremely minute, filtrable 
cultivable, non-motile, virus, for which Barker has proposed the name, 
Flexneria noguchii. 

The resistance of this virus is extremely great both to cold and 
drying, though it is readily destroyed by heating, and, fortunately, by 
sunlight. 

It has been grown successfully by Flexner and Noguchi on ascites-fluid- 
agar to which a sterile bit of rabbit's kidney is added. Air is excluded from 
the culture by a layer of paraffin oil. 

The specific virus occurs singly, or, in pairs, chains, or groups, which are 
Gram-positive and with the Giemsa stain appear as minute globular or 
globoid bodies varying in diameter between 0.15 and o.3/j.*t 

It retains its virulence even when grown for 20 generations on an artificial 
medium and shows a most striking elective affinity for the spinal cord and 
brain. 

The disease is readily inoculable into monkeys, is easily passed on through 
a series in experimental work, is constantly present in the nose, throat and 
central nervous system, whatever the type or degree of severity of the infec- 
tion, and persists for weeks or months in the naso-pharynx after all active 
symptoms have subsided. 

Flexner seems to feel convinced that all channels of infection are wholly 
subordinate in importance to direct contact or contiguity. 

The fly is one of its carriers through food substances and it is disseminated 
also by dust but fortunately its actual contagiousness is slight. 

Natural immunity is decided and a comparatively small proportion of 
exposed individuals contract the disease. 

About 90 per cent, of all cases occur in the first decade of life, 60 per 
cent, under the age of three years, and nearly all arise during the summer 
months. % 

It is distinctly an epidemic disease, though sporadic cases occur and its 
incubation period is from two to fourteen days. 

A fleeting passive immunity only has been attained in monkeys by the 
use of immune serum, but on the individual infected the disease confers 
absolute immunity. 

*Flexner and Noguchi: Jour. Exper. Med., Vol. X, 108, 1913. 

f Various observers have reported what they have believed to be the causative 
microorganisms, notably Geirsvold who reported a diplococcus and, very recently, E. C. 
Rosenow who reports a streptococcus. At the present time, the virus of Flexner and 
Xoguchi only is generally accepted as capable of producing the typical cord changes. 

% Severe winter epidemics have been reported but are most unusual. 
69 



1090 



MEDICAL DIAGNOSIS 



The virus may remain in the nasopharynx for at least five months after 
recovery, but it is seldom infective after six weeks. 

Morbid Anatomy.— Contrary to our older conceptions it is actually a 
polio-myelo-meningo-encephalitis, with predominant destructive lesions in 
the ganglion cells of the anterior horns of the spinal cord which results in 
varying degrees of degeneration of the components of the lower motor 





Al 






Fig. 522. — (3) Separate globoid bodies. X 1000. (4) Aggregated masses of globoid 
bodies. X 1000. (5) Chains and pairs of globoid bodies. X 1000. (6) Chains of globoid 
bodies compared with streptococcus pyogenes. (7) Agar fragment showing pairs of globoid 
bodies compared with streptococcus pyogenes. X 1000. (Flexner and Noguchi, Journal 
of Experimental Medicine, Vol. XVIII, 1913.) 

neurons affected, axis cylinders, nerve roots, peripheral nerves and the 
muscles activated by them. The chief pathologic change is one of peri- 
vascular lymphangitic inflammation and round-cell infiltration about the 
central arteries each of which supplies a segment of the cord about 5 cm. in 
length, which corresponds to the focal nature of the changes noted in the 
disease. 



ACUTE INFECTIOUS POLIOMYELITIS 



IO9I 



I 

I 



**k 





m 



im 









is 




'■^: M.:* 



v •* s ; 



«_d 










1 



m 



Fig. 523. — (8) Spinal cord showing degeneration of nerve cells and invasion of leucocytes 
(neurophagocytosisj. X 144- (9) Perivascular and interstitial mononuclear cell infiltra- 
tion of medulla. (Flexner and Xoguchi, Journal of Experimental Medicine, Vol. XVIII, 
IQT3-) 



IO92 MEDICAL DIAGNOSIS 



Round-cell infiltration of the pia-arachnoid is present and chiefly marked 
on the anterior surface of the cervical, sacral, and lumbar enlargements. 
Extensive foci of infiltration and edema are evident in the white substance 
of the cord which accounts for the fleeting nature of some of the symptoms 
observed. 

In extreme or fatal cases, like changes are found in the pons, medulla, 
centrum ovale and cortex but the ganglion cells seldom or never undergo 
such destruction as is a constant finding in the cord segments chiefly 
affected. 

This disease, like epidemic cerebrospinal meningitis, is a general infection 
I showing a peculiar elective affinity for the brain and cord and exerting its 
pathogenic effects predominantly upon the cells of the anterior horns.* 

Symptomatology.— The onset is variable; in certain cases the paralysis 
is unconnected with any definite febrile attack; more commonly (80 per 
cent.) there is slight or moderate fever lasting about twenty-four hours, and 
malaise, while rarely, in young children or infants high fever, diarrhea, 
vomiting, delirium, convulsions and coma may be present. 

The more' severe the primary attack, the more rapid is the onset of paralysis. 

Pain and tenderness in the affected limbs may first attract attention but 
are usually absent or unimportant and the paralysis may be complete in from 
twenty-four to forty-eight hours after the onset. It may involve all four extrem- 
ities, rarely one, of tener both legs and especially the peroneal and tibia] 
I groups, and tends to recede in certain muscle groups and become marked 
and permanent in others. 

Whenever a large muscle tract is involved, great inequality of damage is 
evident and certain muscles such as the forearm extensors are almost immune. 
Secondary contractures occur late in the disease. 

It should be remembered that the onset of this disease is sudden, the paraly- 
sis appears within from twenty-four to forty-eight hours, the lesions soon become 
fixed, the paralysis is abrupt, flaccid, complete, atrophy rapid and extreme, re- 
flexes and normal electrical reactions lost, sensation unaffected, and the sphinc- 
•ters and facial muscles rarely involved. 

Cardinal Early Symptoms. — 1. An extraordinary pain response to every 
movement, passive or active. 2. Marked hyperesthesia of short duration. 3. 
Profuse sweating. . 

In a large proportion of the cases these symptoms are present before 
paralysis supervenes. 

Chief Clinical Types of the Disease. — There are three chief types. 

1. The Respiratory Type. — In this the physician or parents may be misled 
by the appearance of what seems to be a simple coryza, bronchitis or, more 
frequently, a sore throat. 

2. The Gastrointestinal Type. — In this form there may be nausea, vomit- 
ing, diarrhea, or obstinate constipation. - Vomiting may be present only on 

*The characteristic changes were admirably summarized by H. E. Robertson and 
A. J. Chesley in 1910. ("Pathology and Bacteriology of Acute Anterior Poliomyelitis," 
Archives of Internal Medicine, Vol. VI, p. 233-269). 



SMALLPOX ioc;3 

the first day or persist for several days. Diarrhea is very common (two-thirds 
of cases) in some epidemics. Appetite is lacking and the tongue heavily 
coated in many instances. Such cases resemble a so-called bilious attack 
and are usually so treated. 

3. The Meningeal Type. — Headache, vertigo, tremor, twitching, unsteady- 
gait and even convulsions may be encountered. In this form or the others 
spontaneous pain along the spine, with marked tenderness, may be observed. 
Slight rigidity of the neck and spine may be present. 

Misleading Factors in Diagnosis. — There can be no doubt that a large 
number of cases escape diagnosis and act as unconscious carriers of virulent 
organisms for weeks, while mixing freely with their kind. It is evident that 
the onset even in the usual case may be of the most misleading character, simu- 
lating influenza, neuritis, rheumatism, meningitis, gastroenteritis, scarlatina, 
tonsillitis, herpes zoster, a simple u bilious attack," or even (in the mother's mind) 
"growing pains." 

Save during a severe epidemic, the greater number of cases have no medical 
attendance until paralysis has declared itself. 

It is now certain that a large number of cases are abortive and do not show 
paralysis, although they are as highly infective as those of tht most fatal type. 

These facts emphasize the necessity of determining the character of the 
deep reflexes and seeking for the cardinal symptoms of the eaily stage in 
all sick children during any epidemic, and importance should be ascribed, 
not only to diminished reflexes, the usual finding, but also to any 
abnormalities in response. 

It must also be Temembered that suggestive weakness may be 
present even though decided paresis or actual paralysis is lacking. 

Prognosis. — The disease is a terrible one by reason of the strong tendency 
to persistence of the paralysis. In certain cases, brisk and persistent elimi- 
native treatment may result in complete or partial recovery. 

The actual mortality varies in different epidemics but runs between 2 and 
20 per cent. Death occurs usually before the end of the fourth day in fatal 
cases. 

As to recovery from paralysis much depends upon the severity and 
degree of the original attack and the institution and persistence in a proper 
line of treatment. 

Many cases show betterment under treatment extending over a period 
of two years, and probably more than 20 per cent, make a complete func- 
tional recovery. 

SMALLPOX 

(Variola) (A. S. pock, bag or pocket) 

Definition. — An acute infectious and highly contagious disease, conferring 
immunity and characterized by a definite mode of invasion and a peculiar 
eruption. 

Historic Note. — Smallpox was so called originally in contradistinction 
to great pox (syphilis). It has existed for thousands of years in Eastern 



IOQ4 



MEDICAL DIAGNOSIS 



Smallpox vs. 
Great pox. 



Formerly 
inevitable. 



A medical 
hero. 



Inoculation. 



Organism 
unproven. 



Prowazek's 
bodies. 



countries, was introduced into Europe in the eighth century, and by the tenth 
had become so general throughout Europe that prior to the day of Jenner, 
few persons failed to show on the face its characteristic pits.* It was first 
brought to the American continent by the Spaniards in the sixteenth century, 
and to Massachusetts in 1633. The aborigines and negroes seem to be espe- 
cially susceptible and the disease flourishes in its most virulent form on virgin 
soil. Once so general and fatal, it has in our day become a comparatively 
rare disease with a low mortality. For this we have to thank that great and 
courageous physician, Edward Jenner, who, being convinced of the identity 
of cowpox and smallpox, in 1796 vaccinated, and six weeks later inoculated 
with smallpox virus, a boy of eight, reporting the success of his experiment in 
June, 1798. To appreciate his courage one has only to read the journals of 
that period in which he was most heartily denounced and abused. Prior to 
this time, Lady Wortley Montagu had become convinced of the value and 
efficacy of inoculation as practised in the far East and succeeded in her efforts 
to introduce this procedure into England, f Unfortunately, the extreme care 
characteristic of Eastern nations in choosing a proper £ge, season, and state 
of health was not observed by their English imitators, with the result that 
the good accomplished was overbalanced by the extreme mortality and 
disease incidence engendered. The Asiatic races had for centuries success- 
fully practised inoculation upon a most rational basis; nevertheless, the 
disease is still a scourge in India, where effective vaccination is rendered 
extremely difficult by the attitude of certain of the people, who believe 
smallpox to be a form of purification sent by the gods and who object to 
the use of cows for the production of vaccine. 

Etiology. — The cause of variola is not yet fully proven, though it is 
evident that its virus is contained in the contents of its vesicles and pustules 
and in the scabs themselves, even though dried and old. It is improbable 
that the general body secretions and excretions contain it, save as a result of 
contamination by the products of its exanthem and its presence in the blood 
is doubtful. The virus does not pass through colloid filters, but is otherwise 
filtrable. Prowazek has utilized this fact for the removal of ordinary bac- 
teria by filtration. A second filtration using a colloid filter leaves a residue 
which should contain the virus. This he has found to consist of very minute, 
coccoid bodies which multiply by subdivision and when injected into the cor- 
nea of a rabbit produce "Guarnieri's corpuscles" (Cytorrhydes variola) 
within which the "initial bodies" develop, subdivide and form the small 
elementary corpuscles (chlamydozoan bodies) which he believes to be the 
cause of the disease. Whether this be true or not, so far as is now known, 
they occur only in variola and vaccinia, never in varicella. 

Age and Sex. — No age and neither sex is exempt, and rarely intrauterine 
disease may exist if the mother be affected. 

Unvaccinated pregnant women apparently are peculiarly susceptible. 

* An old writer has said, "From smallpox and love few escape." 

t Coincidently Cotton Mather and Dr. Boylston braved adverse public opinion and 
mob violence in Boston in the same cause. 



SMALLPOX 



IOQ5 



Morbid Anatomy. — The condition of the patient who has died of small- 
pox is sufficiently indicated by the symptomatology. The lesions of the vis- 
cera are essentially those of profound toxemia and high fever. 

Contagiousness. — The infectious element exists in the secretions, excre- 
tions, pustules, and probably in exhalations from the lungs, and the skin con- 
veys it through the medium of the dried scales which are readily converted 
into dust. Though contagious at all stages, the frequent exposures without 
infection indicate that its early periods are comparatively innocuous. The 
contagium is difficult to destroy and remains active for long periods, hence the 
radical measures employed in the disinfection of rooms in infected houses. 
The question of conduction through the air is still sub judice, but has much 
to support it. It may be conveyed not only by the clothing, but by room 
dust, by rats, mice, flies, or vermin, and the patient ceases to be an infective 
agent only when the last bit of desquamating skin has been removed. The 
severity of the disease bears no relation to that of the case from which it is derived. 

Individual Susceptibility. — This varies greatly, a few being apparently 
immune, even though unvaccinated, and those sufficiently vaccinated being 
either wholly immune or subject only to mild attacks. 

Varieties of Smallpox. — There are six distinct forms, varying greatly in 
severity, namely, varioloid, discrete, confluent, hemorrhagic, malignant, and 
verrucose. Since the Spanish-American war a mild form of smallpox has 
prevailed in this country and spread widely, especially in country districts, 
because of its close resemblance to chickenpox, and further because the pro- 
longed immunity resulted in careless disregard of the necessity for vaccina- 
tion. According to some observers, the light form is gradually becoming 
more virulent. 

Period of Incubation. — From seven to fifteen days. 

Characteristic Symptoms. — (a) Sudden onset, often with chills or, in 
children, convulsions, (b) Headache, intense and frontal; this corresponds to 
the congestion of meninges found at autopsy, (c) Severe backache (conges- 
tion of the membranes of the spinal cord), (d) Vomiting, (e) Severe pain in 
the limbs. (/) High initial temperature (103 to io$°F.), followed by a marked 
recession and a high secondary rise associated with suppuration of the vesicles. 

Note. — The pains are more severe than in any other definitely eruptive dis- 
ease and in the presence of an epidemic these symptoms must be given great 
weight, though they are in no sense indicative of the severity of a given case. 

Eruption. — Rarely the disease occurs without any true eruption or a tardy 
one, and in from 10 to 20 per cent, of the cases misleading initial rashes occur 
during the first two days. These assume one of six forms:. (1) Erythematous. 
(2) Urticarial {very rare). (3) Morbilliform. (4) Scarlatiniform. (5) Pur- 
puric. (6) Astacoid {lobster-like). 

The morbilliform and scarlatiniform initial rashes may be extremely 
misleading and it is said that the sixth variety indicates a fatal issue. 

The scarlatiniform eruption is usually distinctly localized and limited 
to {a) the inner surface of the thighs, {b) the lateral thoracic areas, (c) the lower 
abdomen, {d) the axilla. It may persist until the appearance of the true rash. 



Remarkably 
transmissible. 



Early stages 
slight. 



Fomites and 
carriers. 



Natural and 

acquired 

immunity. 



Six forms. 



Tearing 
I backache. 



Peculiar fever. 



Important 
initial rashes. 



Localization. 



1096 



MEDICAL DIAGNOSIS 



Macules, 
papules, and 
vesicules (3 d* 
4th day). 



Umbilication 
(5th-6th day of 
rash). 

Pustulation 
(6th-i2th day 
of rash). 

Secondary 
fever. 



First on 
mucous mem- 
branes; next, 
the face. 



The morbilliform {measles-like) rash usually appears early (second day), 
lacks the dark, central, raised portion of the true measles macule, the skin 
feeling smooth, and is fleeting, seldom lasting more than a few hours. It 
chiefly affects the face and extensor surfaces of the limbs, though occasionally 
most manifest in the area represented by the triangle (Semon's) formed by 
two lines passing from between the knees to the respective anterior superior 
iliac spines and connected by a transverse base line. 

The Typical Eruption. — On the third day of the disease bright red macules 
appear, readily blanched by pressure, these rapidly becoming hard elevated 
" shot-like" papules. At the end of twenty-four hours these show vesicles 
and the vesicular stage reaches its full development usually by the fourth day 
of the eruption. The vesicles rarely exceed J4 i ncn i n diameter, contain a 
milky fluid, and are surrounded by distinct though narrow areolae. By the 




Fig. 524.— Confluent smallpox in the unvaccinated adult. {After Ricketts and Byles.) 

fifth or sixth day depression of the apices of the vesicles is noticeable. This 
u umbilication^ is usually general by the end of the first week of the disease 
(seventh or eighth day). Almost coincidentally the vesicles become distinctly 
purulent {pustulation being general from the eighth to the tenth day and associated 
Witty a secondary temperature rise to 102 — 104-f-. F.). The whole process is 
completed usually by the end of the twelfth day. By the fourteenth, desquama- 
tion should commence and be completed at the end of three or four weeks. 

Parts Affected. — The eruption chooses by preference the portions exposed 
to light, chafing, irritation, and injury, and upon them reaches its highest develop- 
ment. Externally it usually first appears on the face and near the border of the 
hair, yet the mucous membrane may be still earlier involved, the rash appearing 
on the buccal mucous membrane, tongue, soft palate, pharynx, and even upon the 



SMALLPOX 



IO97 



stomach and rectum in the virulent cases. In none do the mucous membranes 
escape. The wrists are also affected early, and, like syphilis but unlike vari- 
cella, it involves the palms of the hands and the soles of the feet, a point of con- 
siderable importance in differential diagnosis. The involvement of the 
larynx may cause distressing cough and even fatal edema. 

Confluent Smallpox. — In this form all symptoms are intensified and in 
the stage of pustulation the patient presents a frightful appearance and a foul 
and characteristic odor. The face is a swollen and unrecognizable mass of 
fetid sores, though on the body and legs the eruption often remains discrete. 

Hemorrhagic Form (Purpura variolosa, Black Smallpox, Variola hemor- 
rhagica) .— As indicated by the name, the eruption is distinctly hemorrhagic 
in type, the patient presenting a frightful appearance. In some cases hemor- 
rhage occurs from any or all mucous membranes and it has proven fatal 
in from three to four days after the onset of hemorrhagic symptoms, though 
in others, of milder type the hemorrhages are limited to the vesicles and 
pustules. 



Palms 
affected. 



Odor. 




Fig. 525. — Smallpox. Confluent case in unvaccinated child. {Courtesy of Mr. Dames. ,f 

Malignant Smallpox. — This is characterized by low fever, scant or absent 
eruption, profound asthenia, and a fatal issue with or without hemorrhage, 
death occurring between the third and seventh days. 

Variola Verrucosa. — This varies from the other forms only in leaving a 
warty growth after desiccation and hardly deserves separate classification. 

Varioloid. — This is an attenuated smallpox, modified by vaccination, 
natural immunity, or a previous attack. It differs from true variola in the 
following particulars: (a) Short duration, (b) Irregular o>- incomplete erup- 
tion which runs a rapid course, (c) The absence of any marked secondary tem- 
perature rise, (d) The early completion of desquamation. 

The initial symptoms are usually but not necessarily mild and the eruption 
may or may not be limited to the face and hands. 

It need seldom cause error if one will remember that the genesis, development, 
and structure of the pustule wherever found is usually typical. 

Complications. — These are easily inferred from the symptoms and path- 
ology of the disease, being chiefly connected with the suppuration and pro- 



Mild 

symptoms. 



1098 



MEDICAL DIAGNOSIS 



In unvac- 
cinated, great 
mortality. 



In vaccinated, 
negligible. 

Disease type, 
age and 
physique. 



found toxemia. It suffices to name them as follows: edema glottidis, necro- 
sis of cartilages, broncho-pneumonia (sometimes initial), lobar pneumonia 
(rare), pleurisy (not uncommon), pseudo-angina, diarrhea (especially in 
children), albuminuria (true nephritis is rare), orchitis, ovaritis, parotitis, 
abortion, fatal delirium, myelitis, myocarditis, neuritis, pyemic abscess, 
general tuberculosis, local gangrene, arthritis (suppurative or not), bone 
necrosis, otitis, iritis, keratitis, purulent conjunctivitis, phlebitis, etc. 

The heart muscle suffers severely from the toxemia during the attack, 
but endocarditis and pericarditis alike are rarely encountered. 




Fig. 526. — Smallpox. Soles of the feet in stage of desiccation. (After Ricketts and Byles.) 

Prognosis. — Absolute figures are out of the question. Assuming a severe 
epidemic, from 25 to 50 per cent, of the unvaccinated will die; among the 
vaccinated (varioloid) the mortality will vary according to the efficacy of 
the primary vaccination and its proper repetition (see "Vaccination"), 
and with the age and physical condition of the person attacked. 

The mortality in all unvaccinated cases is exceptionally great in infants and 
young children. Efficiently vaccinated persons are practically immune and in 



VACCINATION 



IOQ9 



those attacked the mortality should not exceed from five-tenths of 1 per cent, to 
1 per cent. 

Of the hemorrhagic and malignant cases, practically all die within the first 
week, and the same is true of unvaccinated children under one year of age. Dis- 
sipation and preexisting disease increase the virulence of the primary attack 
and its mortality, and the more profuse or confluent the facial eruption, the 
greater is the death rate. Pitting is unusual nowadays in the ordinary forms. 

Diagnosis. — In the presence of an epidemic, all cases presenting extremely 
severe pain in the head, back and limbs, and vomiting, must at once be under 
suspicion. 

Indeed, lacking an epidemic, they are still important and the greatest care 
should be observed when such severe symptoms are associated with the sug- 
gestive and peculiarly located initial rashes. 

The typical eruption is unmistakable and the course of the fever especially 
significant, viz., appearing on the third day, primarily high and dropping 
to normal, or, in severe cases, to ioo°F. or 100. $°F., only to reappear with 
pustulation. 

The greatest stress must be laid upon certain features aiding the recognition 
of the eruption of smallpox, viz. : 

1. 77 appears primarily on the face and wrists. 

2. The face, forearms and wrists are always" predominantly affected. 

3. The trunk is least affected. 

4. Profuse lesions on the palms of the hands and soles of the feet strongly 
counts for smallpox as against chickenpox. 

5. The shape of the smallpox vesicle is rounded or conical and it appears 
deeply and firmly seated. 

6. The vesicles do not collapse when pricked. 

7. True widespread umbilication is characteristic of smallpox.. 

8. The uniformity of the lesions as to stage of development over any given 
area is of great signifimnce. (For further differential diagnosis, see 
"Chickenpox" and "Syphilis.") 

VACCINATION. — The origin of vaccination with cowpox virus as the 
supplanter of inoculation from smallpox pustules is, as before stated, directly 
traceable to the keen observation and rare courage of Dr. Edward Jenner, 
who first proved its efficacy on May 14, 1796. As a result of his brilliant work 
millions of lives have been saved, and smallpox has lost its terrors in every 
intelligent and civilized country. Few remain who deny the efficacy of 
vaccination, but they are of the type who would insist that the sun moves 
around a stationary earth. Wherever vaccination is required and enforced 
by law, smallpox is a negligible factor. 

Extent and Duration of the Protective Influence. — It should be clearly 
understood that to be effective and efficient vaccination must be repeated at 
certain intervals. First performed in infancy, it should be repeated at the age 
of puberty, and always in the presence of any especial liability to exposure* 

* In the old days the greatest mortality occurred in infants and young children, but 
owing to the general practice of early vaccination' they are now the best protected of the 
age groups. 



Pitting. 
Suspects. 

Initial rashes. 

Fever. 



Cardinal points 
in differentia- 
tion. 



A boon. 



IIOO 



MEDICAL DIAGNOSIS 




VACCINATION 



IOI 



The experience of every physician shows almost absolute immunity to be the 
result of intelligent and repeated vaccination however direct the exposure. 
Furthermore, the disease if contracted by a vaccinated person is almost invariably 
the mildest possible (varioloid). The false idea that one vaccination in infancy 
or childhood is absolutely or approximately protective throughout life is alto- 
gether too widespread among the laity and much of the prejudice against vac- 
cination, aside from that depending upon pure ignorance, obstinacy, or more or 
less ingenious misrepresentation, is the result of the vaccination of the earlier 
days when the virus was usually taken from the vaccinated human being, 
and the operation performed with scant regard for the danger of septic infec- 
tion. The antivaccinationists still talk of the transmission of syphilis as- if 
an innocent heifer could acquire and transmit a disease of this peculiar 
nature. It should be remembered that even though a person has been actually 
exposed to smallpox, vaccination will ordinarily either confer complete im- 
munity or greatly modify the disease, it being understood that the time elapsing 
between exposure and development shall have been sufficient to allow of 
some action on the part of the vaccine. As between cases of even 
doubtful vaccination and the unvaccinated, the ratio of mortality is as one 
to four. 

Preparation of Vaccine. — The material for vaccination is now invariably 
obtained from the heifer, and the so-called humanized lymph should not be 
used, except in emergency. Various reliable firms that prepare this sub- 
stance maintain farms and conduct their inoculations and the recovery of 
the virus under the most perfect sanitary conditions. The source of the 
lymph is the vesicle produced by the inoculation of the udder of the cow. 
This is allowed to dry on sterilized ivory points or quills, or is treated with 
glycerine and collected in sterilized glass tubes, so contrived as to permit their 
use without danger of contamination. 

Method. — The region of the deltoid insertion of the arm or the outer sur- 
face of the thigh or calf should be thoroughly cleansed with alcohol (cologne. 
bay rum) and washed off with boiled water, then lightly but rapidly and 
multiply incised, not scarified, with a very sharp blade (the blades of "safety" 
razors serve admirably) in such a manner as will carry the cut into the cutis 
and yet produce no free bleeding, which must be avoided. The procedure is 
practically painless if properly performed. The vaccine is placed upon and 
gently rubbed into the prepared area, allowed to dry thoroughly and after- 
ward the affected portion is covered with one of the numerous forms of 
"shields" readily obtained at any drug store.* 

A very neat, but less certain procedure, consists in the intradermic intro- 
duction of glycerinated lymph with a sterile hypodermic needle. 

All vaccinated persons should be warned of the danger of conveying 
virus from the point of vaccination to other portions of the body. 

Sequence of Events in Vaccination. — A reddish papule should make its 
appearance in from three to five days, promptly becoming vesicular, filled with 

* According to the author's experience, these, if properly constructed and firmly an- 
chored by accessory short strips of adhesive plaster, are far better than a gauze dressing. 



Immunity 
attained. 



Revaccination 
necessary. 



Antivacci- 
nationists. 



The maligned 
heifer. 



Vaccination 
after exposure. 



Humanized 
lymph passe. 



Bovine 
lymph. 



Points and 

glycerinated 

lymph. 



Vaccination 
technic. 



Shields. 



II02 



MEDICAL DIAGNOSIS 



clear lymph and later umbilicated. Its maximum development is reached at the 
end of seven or ten days, when its contents become purulent in appearance. 

A brilliant areola surrounds the pustule, underlain by a tender and more or 
less firm or brawny area. During the succeeding three or four days pain and 
tenderness become localized along the region of the lymphatics and their 
tributary glands may be slightly or decidedly swollen and inflamed, with 
fever and malaise.* The itching is intense, and scratching frequently causes 
secondary infection, hence in infants the movement of the arms must often be 
restrained. Occasionally a general eruption closely resembling chickenpox 
may appear or there may be a distinct roseola. In from ten days to two weeks 
these symptoms disappear, desiccation being complete, as a rule, by the end of 
the fifteenth or sixteenth day, the scab falling about a week later. A depressed 
pitted scar is left behind varying in size with the severity of the process. 
All sorts of Variations may be met with, such as long periods of incubation, 
entire absence of constitutional symptoms, or, in some instances, a more pro- 
longed and severe stage of suppuration. A thoroughly good vaccination usually 
leaves a scar which persists throughout the whole life of the individual. In an 
unvaccinated person one should never rest content with a single vaccination, 
and in the presence of direct opportunity for infection or during an epidemic 
it is wise to repeat every vaccination if the first fails. It would appear 
certain, moreover, that cases presenting unusually severe symptoms, owe these 
rather to secondary infection than to the true virus, so that some severe 
"takes" are less protective than the thoroughly typical and milder form. 

The Previous Health. — Common sense should determine the propriety 
of vaccination in exceptionally delicate and diseased children, and a proper 
period chosen. As to the site of the vaccination, the female infant or adult 
should, as a rule, be vaccinated on the leg, the male on the arm, the resulting 
scar being of no moment to the latter. One should always inquire as to the 
right- or left-handedness of the male candidate, and vaccinate him on the 
less useful arm to ameliorate so far as possible the discomfort and incon- 
venience of any temporary disability. 

VARICELLA 

{Chickenpox) 

Definition. — A trifling infection of unknown causation, characterized by 
transient fever and a vesicular eruption, but absolutely unrelated to smallpox. 

Etiology. — Children are peculiarly susceptible between the ages of one and 
eight years, adults remarkably resistant. It prevails chiefly in the spring 
and autumn, spreads rapidly, and one attack usually protects for life. 

* The signs of inflammation and glandular abscess are often far more alarming than the 
actual result merits, but, rarely, septic conditions are encountered. In an experience 
covering nearly two decades and including two years of municipal service the author has 
never had or seen one case of death, deformity, paralysis, or invalidism, rightly attribut- 
able to modern vaccination, and is convinced that the few bad results reported are almost 
invariably due to previously existing syphilitic or tuberculous taint, or lymphatism. 



WHOOPING COUGH 



1 103 



Symptoms. — In from one to two weeks, rarely three or even four, after 
exposure the symptoms of mild infection appear. 

Malaise, chilliness, pain in the legs and back are associated with a mild 
fever, rarely exceeding 101 to io2°F. Some children show no fever or signs of 
illness save the eruption which appears within twenty-four hours in the form of 
minute, irregidarly placed papules changing in a few hours to vesicles. 

The chest and back are first attacked, and it then spreads to the face, scalp, 
neck and extremities. It is especially well marked on the back, which 
usually shows the oldest lesions, and is attended by a troublesome itching. 
The forearms, wrists and hands are usually but slightly involved. Roseolar 
forms of brief duration and a pemphigoid type are seen rarely. 

Differential Points. — The following points serve to distinguish varicella 
from smallpox or varioloid : (a) In chickenpox but few or no vesicles in a given 
case umbilicate. (b) The contents are serous, not purulent, though a few may 
suppurate and leave pits, (c) The unilocular vesicles are emptied by a single 
puncture, (d) They rarely have an areola, (e) They come in successive crops 
lasting two or three days and form superficial crusts which desquamate in a week 
or ten days, if) The vesicles, therefore, are seen in all stages, i.e., the erup- 
tion is not uniform, (g) The spots may be few in number, are scattered widely 
and do not tend to become confluent, (h) The secondary fever of suppuration is 
lacking, (i) Vesicles rarely appear in any considerable number upon the palms 
or soles. (J) Varicella is relatively rare in the adult, (k) But two or three 
hours are required for the passage from papule to vesicle. (I) Guarnieri's 
bodies are lacking* im) The order of involvement and its extent are the exact 
opposites of smallpox (see also "Smallpox"), 

Duration. — A week to two weeks. 

Prognosis. — Almost invariably good. 

Complications. — Ordinarily lacking and seldom serious. The eruption 
occasionally appears in the mouth and hard palate, but rarely or never 
involves the conjunctivae, larynx, or trachea. The vesicles always variable 
in size, in rare instances become bullae, and in any case the otherwise harmless 
vesicles may be infected by scratching. Cachectic children in this as in other 
infections may present a peculiarly virident and profuse eruption. 

WHOOPING COUGH 

{Pertussis) 

Definition. — An infectious disease of childhood caused, probably, by the 
Bordet-Gengou bacillus, self-limited and immunity conferring, character- 
ized by peculiarly violent paroxysms of cough, followed by a u whooping 
sound." 

The disease is highly contagious, especially before the appearance of the 
characteristic paroxysms,f but adults enjoy comparative immunity. Infants 

* Inoculation of the rabbit's cornea is required for their production in variola or vaccinia 
. f It is comparatively innocuous later, but still contagious, and great individual variations 
in this respect are found to exist. 



Trivial 
symptoms. 



Vesicular 
eruption 
(2nd day). 

Sites of 
election. 



Contagious 

in all stages. 



no4 



MEDICAL DIAGNOSIS 



Age. 



Still unde- 
termined. 



Peculiar 
cough. 



"Whoop" may 
be absent. 



Paroxysms 
easily excited. 



Lymphocytosis. 



and very young children (six months to five years of age) are peculiarly 
susceptible, and at all ages female predominance is evident. It is a disease 
chiefly of early spring. 

Etiology. — An influenza-like bacillus is believed by Bordet and Gengou 
to be the causative agent. It is Gram-negative, is grown with some diffi- 
culty on potato blood agar and its colonies possess a peculiarly tenacious, 
mucoid character. 

Unlike the influenza bacillus which it strongly resembles it is never intra- 
cellular. Its discoverers reported that it gave the complement fixation test 
and Klimenko and Frankel have produced the disease in monkeys by in- 
oculation. On the other hand these reports are not completely confirmed 
and the organism is not yet fully accepted as the causative agent. 

Mallory, Homer and Henderson believe that the characteristic lesion 
consists of masses of the bacilli lying between and adhering to the cilia of 
the trachea and bronchi. 

Incubation. — Two days to two weeks. 

Duration.^ — Eight to ten weeks. 

Prognosis. — Good in robust young children, bad in weaklings, nurslings, 
and the aged. 

Morbid Anatomy. — Practically none save that of any complicating diffuse 
bronchitis, broncho-pneumonia, emphysema, or cardiac overstrain. Death 
by inanition, starvation, and inhalation or deglutition broncho-pneumonias 
are rare phenomena. 

SYMPTOMS. — A coryza or mild bronchitis is associated with a series of 
short barking coughs, progressively urgent and explosive in character, the 
protracted expiratory efforts resulting in glottis spasm and a terminal long- 
drawn stridulous inspiration, the "whoop." The seizures vary in severity 
and frequency, and absence of the whoop may obscure diagnosis, but the cough 
is peculiarly explosive and paroxysmal. Attacks may be almost constant or 
occur but once or twice a day, the average being 15 to 20. 

Any emotion, pleasurable or otherwise, food, dust, overheating, or a cold 
draught may provoke the dreaded paroxysm. The child may vomit, the 
urine or feces may be passed involuntarily, hernia may be produced, rectal 
prolapse may appear and hemorrhages may occur from the nose, ears, or 
under the skin or conjunctiva. 

Glands. — A general though moderate enlargement of the lymph nodes is 
present, especially marked in the peri-bronchial and cervical regions. 

The blood shows a decided primary leucocytosis,* later a lymphocytosis 
and finally an eosinophilia (Barach). 

The lymphocytosis begins before, and reaches its height during, the parox- 
ysmal stage. The primary increase is in the small mononuclears, later the 
large mononuclears show a decided or proportionate increase. 

* Counts of 85,000 are reported for the primary stage but the average is 20,000+ and 
some observers give much lower figures. In the acute stage with pneumonic compli- 
cations counts of nearly 200,000 are reported. A blood count may or may not aid diag- . 
nosis, but should always be made in doubtful cases. 



SYPHILIS 



1 105 



The urine may contain a trace of albumin and fever may be present or 
absent. 

Diagnosis. — The presence of an epidemic, decided leucocytosis or lympho- 
cytosis, a persistent bronchitis, and the paroxysm of urgent, short, barking, 
rapidly repeated coughs with or without the whoop is sufficient usually for 
diagnosis. 

In the case of a child any cough which persists and shows a tendency to 
nocturnal urgency of a spasmodic character, should excite suspicion. 

In any case, the question of an existing " 'spasmophilia" must be 
considered for two reasons, viz., first, the ailment may be merely an 
intensified cough of non-specific origin and, second, the spasmophilic state 
may greatly increase the frequency of seizures in true pertussis. (See 
"Spasmophilia.") 

Complications. — There are many. It is frequently associated with 
measles, with subcutaneous, interstitial and true pulmonary emphysema, 
pneumothorax, persistent vomiting leading to inanition, cardiac dilatation, 
enlargement of the bronchial glands, general convulsions, cerebral hemor- 
rhage, broncho-pneumonia, and lobar pneumonia, or even pulmonary tubercu- 
losis. Adenoids greatly increase its dangers and add to the severity of the 
paroxysms. 

Comment. — The laity regard pertussis too lightly. It is a disease of high 
mortality through its pneumonic complications, often induced by a foolish 
disregard of ordinary precautions. Of children under one year, 25 per cent, 
die. Between one and two years, 15 per cent. Above these ages the mortality 
is slight, but it will be seen that the disease is formidable and deadly if lightly 
regarded. Among the ignorant and poor attending the public services of great 
cities it stands second to pneumonia as a cause of death in infants. 



Many and 
grave. 



Adenoids. 



A formidable 
disease. 



Infant mor- 
tality high. 



SYPHILIS 

("Lues venerea" "Pox") 

Etiology. — The Treponema .pallidum of Schaudinn and Hoffman (1905) is 
now fully accepted as the proven causative organism on the basis of Noguchi's 
brilliant work fulfilling the requirements of Koch's law, and has been found in 
practically all lesions from the primary sore to the gumma, as well as in the 
circulating blood. The germs abound in congenital syphilis and are in gen- 
eral most abundant in the lesions of greatest virulence, though radical anti- 
syphilitic treatment usually causes their prompt diminution or apparent 
disappearance. . 

Smear Preparations. — With dark field illumination (using the ultra- 
condenser) and in salt solution the germ and its motility may be studied 
without staining, but usually (a) the smear is dried in the air and placed 
in absolute alcohol for one hour, (b) To each drop of a modified Giemsa 
stain* 1 c.c. of water is added, and in this staining fluid the specimens remain 

* Giemsa-Losung fur die Romanowsky Farbung, put up by Griibler. 



uo6 



MEDICAL DIAGNOSIS 



Readily 

transmitted. 



Protean. 



Essentially 
▼enereal. 



Extra -genital 
infection. 



The 

"syphilitic' 
a menace. 



Tertiary 
lesions not 
often con- 
tagions. 



from one-half to twenty-four hours, the longer period being more reliable. 
In a properly stained specimen the organism is violet and the nuclei of any 
leucocytes present a blackish-red. In making smears from a primary sore, 
vigorous scrubbing with soap and water should precede a slight curettement. 

The Spirocheta refringens is often encountered in large numbers in all 
superficial lesions, in contrast to the Treponema pallidum* which seldom ex- 
ceeds two or three to the field. The former is 
highly refractile, broader, readily takes a deep 
stain, and its spirals are not typically corkscrew- 
shaped, but undulant. 

Mode of Conveyance. — Syphilis in an active 
form may be, and usually is acquired, less often 
inherited. Dilute inherited syphilitic infection 
is of course well-nigh universal, but is for the 
greater part symptomless. 

It is both contagious and infectious, confers 
almost absolute life-long immunity, and further- 
more is capable of affecting each and every struc- 
ture of the human body so diversely as to make it 
the chief of protean diseases. 

Given an abraded skin or mucous membrane 
in a non-immune and contact with the secre- 
tions or blood of a syphilitic, infection almost 
certainly follows. Less frequently, prolonged 
contact or retained virus alone may produce it 
on a sound mucous membrane. The disease is 
essentially venereal, sexual intercourse being 
the means of transmission and sexual organs 
the usual seat of primary lesions. Yet owing 

to the irregular and unusual forms of intercourse and the communicability 
of the disease through certain secondary lesions and by means of inter- 
mediate substances, we find labial, lingual, tonsillar, mammillary, and 
rectal infections as well as the digital sore not infrequent in physicians, 
dentists, laundresses, rag pickers, etc. It follows also that syphilis may 
be innocently acquired with or without sexual congress. Husbands infect 
innocent wives and less often a guilty wife transfers the disease of her 
lover to an unsuspecting husband. The innocent girl carrying an oral 
chancre for which the mucous patches of her fiance are responsible 
is no rare client and may infect other family members. The individual 
syphilitic is a menace to all about him during the active stages, as the secretions 
of his lesions, his blood and his lymph, are alike virulent. Fortunately breast 
milk, saliva, and usually the semen are not infectious unless contaminated 
through local sources. The tertiary lesions are seldom sources of infection 
unless relatively early or co-existent with late secondary lesions. High 

* The "treponema" of syphilis was first called Spirocheta pallida, but it was found 
that this name had previously been applied to another organism by Ehrenberg. 




Fig. 528. — Treponema Pal- 
lidum (in center) and the 
Spirocheta refringens. 



SYPHILIS 



1 107 



degrees of heat or cold seem to destroy the virulence of the secretion, other- 
wise active even in a state of desiccation. 

Modifying Influences. — As to its later course no correct inferences can 
be drawn from the primary symptoms or the site of the lesion, though the 
general rule governing all infections which leads us to expect the severer manifes- 
tations in persons of bad habits, poor physique or a vitality impaired by ante- 
cedent or co-existent chronic disease holds good in this one. The ravages of 
acquired syphilis in children are exceptionally violent and widespread. 

The Three Stages.— The primary stage of syphilis comprises the time 
elapsing between the recognition of a local lesion at the site of infection and the 
appearance of the constitutional symptoms and eruption of the secondary period. 
It is represented by the development of the chancre and coincident swelling of the 
adjacent lymph glands {syphilitic buboes). 

The third stage or tertiary period marked by soft nodular growths of 
peculiar structure (gummata) may be entirely lacking in efficiently treated cases 
or may appear despite the most active and prolonged specific medication. 

Extending beyond these circumscribed and classified periods is an insid- 
ious larval activity of indefinite or life-long duration which makes the individ- 
ual liable to develop degenerative diseases of an apparently non-syphilitic 
nature. Such are locomotor ataxia, paretic dementia, arteriosclerosis, aorti- 
tis, apoplexies, aneurysm, and the nephritides. 

This fact has led life-insurance companies to exact a long period of immunity 
and evidence of radical and efficient treatment as prerequisite to acceptance as 
" first-class risks," yet the actuarial report of the " combined investigation" 
committee shows the futility of the requirement, by the enormously excessive death 
rate experienced. (See "Cardiovascular Syphilis.") 

The Initial Lesion or Chancre and the Bullet Bubo. — After an incubation 
period of from ten days to six weeks the first characteristic symptom is 
apparent in a single papule often a part of an herpetic eruption at the point of 
infection, whether genital or remote, which increases in size, becomes indurated, 
and may remain as a dry plaque or show an eroded surface with scant secre- 
tion.* The feel is that of a split pea, save that in certain cases, especially 
in the female, the induration may be lacking. Its usual location is the 
vulva or the prepuce, but it may appear upon any portion of the geni- 
tals or in neighboring or distant parts and always represents the actual site 
of infection. The glands representing the lymph drainage of the affected 
part undergo a painless enlargement, known, when in the groin, as the 
bullet bubo. 

The Secondary Stage — Within from six to eight weeks after infection 
systemic infection is manifested by general glandular swelling, mental depression 
or irritability, insomnia, malaise, pallor, pain on pressure over or near the 
ster no chondral joints, neuralgia, nocturnal headache, joint pains and exertion- 
dyspnea, fever being rare or, if present, trivial. As these subside the exanthem 
develops. 

* Multiple lesions are not uncommon in women, but are relatively rare in men, and 
sometimes, "satellite" indurations of later formation may be observed. 



Many factors. 



Acquired lues 
in children. 



After effects. 



Insurance 
experience. 



Incubation. 



Papule or 
erosion. 



Induration. 



Bubo. 



Constitutional 
symptoms. 



no8 



MEDICAL DIAGNOSIS 



Exanthem. 



Peculiarities 
must be 
known. 



Early 
eruptions. 



Earliest form 
often over- 
looked. 



Readily 
recognized. 



Commonest 
type. 



Distribution. 



Lenticular. 



Lichenoid. 



Exanthemata of the Secondary Period. — Their characteristics must 
be thoroughly understood because of their great importance in diagnosis. 
These are: (a) Their polymorphous tendency. This may merely represent 
different stages in the development of a certain type or show a true mixed 
eruption. Such polymorphism is the rule in syphilis, (b) Symmetry and 
tendency to general distribution, (c) The tendency to follow skin lines in ar- 
rangement. As is seen especially in profuse eruptions and particularly in the 
oblique parallel lines of eruption from the back downward obliquely to the 
front, (d)- The absence or trivial degree of itching, (e) The tendency to oval 
elliptical or circular forms. (J) The prompt response to mercurial inunctions 
or more active treatment, (g) The tendency to shift their pigment to the periphery 
of the lesion* is characteristic especially in the case of disappearing or past 
lesions. In the former a central faint red may be surrounded by a lighter 
area, in its turn encircled by a deeply pigmented border. In the latter the 
whole inner area is white (syphilitic leukoplasia). 

Varieties of Syphilitic Exanthemata. — The earlier syphilitic eruptions 
show a marked tendency to predominant involvement of the abdomen, front of 
chest, and anterior surface of arms. 

Roseola. — This, the earliest form, chiefly affects the trunk and is so evanescent 
and otherwise symptomless as, in many instances, to escape the patient's 
notice.f The brownish-red pea- sized macules are seldom raised above skin 
level and leave no trace. 

Large Macular Syphilide. — Unlike roseola this is due to actual round-cell 
infiltration, is usually slightly raised and frequently, by central fading or border 
coalescence, forms the varieties known as "gyrate," u circinate," "annular," 
etc. The color is livid in the lower extremities, copper color in the upper, and 
its pigmentation may persist for considerable periods or give place to the 
white areas known as cutaneous leukoplasia. 

The Papular Syphilide. — This may be pure or mixed with the macular or 
pustular form and is the commonest syphilide and the most diverse in size and 
orm. It may be distinctly papular, nodular, or flattened, and in size varies 
rom a pinhead to 2 cm. or more. Its distribution may be general or in later 
types limited to the genitals, palms, soles, or other areas. % Resembling psoriasis 
in some respects, it lacks the silvery scales and peculiar localization of that 
disease and seldom involves large areas, occurring usually in small patches. 

The lenticular form is a rash of brief (seven to fourteen days) duration fol- 
lowed by desquamation and leaving no permanent markings. Its nodules 
are grouped and especially involve the extremities and trunk. 

The flat, glistening form involves especially the face and is sharply defined, 
flattened, and centrally depressed. It also leaves no permanent marks. The 
lichenoid papules are grouped, not generally distributed, persistent, become crusted 

* The coppery or ham-colored eruptions, though extremely suggestive, are neither in- 
variable in nor are they peculiar to syphilis. 

t Dashing ether upon the surface of the body will often bring out a phantom-like, but 
clearly specific roseola. 

X Any papular or pustular form may be hemorrhagic in grave or complicated cases. 



SYPHILIS 



1 109 



and leave tiny pits. Among the later forms are the orbicular papules which 
show a ring-shaped border and central depression, and chiefly affect the genital 
region. The tubercular form, very late and persistent and closely allied to 
tertiary eruptions, is grouped, scaly or crusted, richly pigmented, and may 
terminate in ulceration which leaves permanent scars. 

The Pustular Syphilides. — These are rarely early but may co-exist with 
the papular form and are associated with marked general symptoms (fever, 
malaise, pallor, etc.). The exanthem may closely resemble acne or even smallpox 
at the outset, and may form extensive crusts. Ulceration, superficial and 
spreading (echthyma syphilitica) or deeper, may occur and the crusts may so 
arrange themselves as to be termed syphilitic rupia. They leave peripherally 
pigmented, smooth, shiny, loose scars. Hemorrhagic : forms of syphilides occur 
and mean a serious case as in other exanthematous diseases. 

Palmar Syphilides. — Both the palms and soles may be involved in the 
late secondary papular syphilides and this eruption is of almost pathognomonic 
significance* If these papules form between the fingers or toes the result is 
maceration and oftentimes decided inflammation, and if the matrix of the 
nail or its margin be attacked syphilitic onychia is produced, the nail becoming 
dead and being finally cast off. There is frequently a perionychia due to 
suppuration at the nail margin. 

Indurative Edema. — On and near the genitals the secondary processes 
may assume a most severe type of excoriation, inflammation, and even indura- 
tive edema, and these lesions are highly contagious and probably the most 
frequent source of infection. Fissures, ulcers, and venereal papillomata are 
associated with this condition. 

The Hair. — Syphilis of the scalp commonly takes the form of pustules 
which by coalescence may produce more or less irregular or scattered spots 
of baldness, sometimes replaced by gray hair, but usually, under efficient 
treatment, promptly taking on a normal hew growth. A less common 
form is the seborrheic, which leads to diffuse baldness. 

The Buccal Cavity. — This region is one of the most important in con- 
nection with the diagnosis of syphilis in its secondary stage. The earliest 
change in the tongue consists of prominence of the papillce with small spots oj 
whitish exudate; these areas later becoming raw and glistening, and, at the edge, 
converted into ulcers. Many variations occur in the form and distribution of 
such lesions. 

The faucial pillars, tonsils, and soft palate should always be inspected for 
such u mucous patches,'' as well as the lips and inner aspect of cheeks where 
fissures and ulcers may be detected. Indeed the kidney-shaped, gray-bordered 
ulcer of the tonsil is one of the earliest secondary manifestations, and may be 
painless and so escape the patient's notice. 

Tertiary Syphilis. — This is essentially the gummatous stage and should 
never appear in a marked form in those of good constitution who have received 

*The late Mr. Berkeley Hill used to say that he always taught his students that any 
eruption in the palm was syphilis, and the exceptions are so few, aside from smallpox, that 
the dogmatic statement was justifiable. 



Tubercular. 



Suggests 
variola. 



Hemorrhagic 
types. 



Onychia and 
perionychia. 



Excoriations. 



Fissures, 
ulcers and 

warts. 

Baldness. 



Tongue. 



"Mucous 
patches." 



Important 
regions. 



May never 
appear. 



IIIC 



MEDICAL DIAGNOSIS 



destrucci 
lesicsi. 



OiSrOUi, 



S::: *-i -i:i 



adequate treatment, though in those less fortunate it assumes the most terrible 
types of destructive lesions, affecting the osseous as well as the soft tissues and 
leading to frightful suffering and humiliating deformity. Large pustules 
may appear in this stage (pus tula major) with rapid necrosis and coalescence, 
foul discharge and severe pain, or the various gummatous neoplasms may 
op in various parts of the body, internal and external. 

The cutaneous gumma varies in size from a buckshot to a mandarin orange. 
It is somewhat soft in consistency and at first spares the true skin; the tendency, 
\ however, is to disintegration which may or may not involve the skin according to 
the deep or superficial situation of the growth. In certain instances the peculiar 
serpigenous ulceration so characteristic of the disease may appear and leave 
its characteristic sinuous, reniform or semicircular scars. The gumma ta may 
involve the bone, periosteum, muscles, joints, or tendons , the painful swellings 
of which are common in the earlier stages, and if the inflammation be severe 
may result in fibrous ankylosis. 

Syphilis of the stomach has already been referred to, the soft palate is often 
affected at its junction with the bony portion, the process tending to a pathog- 
nomonic perforation ; or the hard palate itself may be involved. Indeed, space 
will not permit a description of the gummatous changes, inasmuch as they may 
involve any region of the body and are dealt with in other sections. 

Syphilis of the Respiratory Tract. — The discover}- of the causative 
organisms of syphilis and the studies bearing upon its persistence 
and localization have greatly broadened our knowledge of its etiologic 

Formerly syphilis :: the respiratory tract was a somewhat dubious entity 
when one went below the larynx. 

In this region the congestion attending :he secondary eruption, the 
occasional occurrence of mucous patches, and the occurrence of gummata 
were quite readily recognized and accepted. 

Involvement of the trachea alone is one of the rarest of syphilitic mani- 
festations. In its tertiary form it may result in partial or even complete 
tracheal stenosis, and the same change may occur in the large bronchi when 
the seat of gummatous invasion, ulceration and healing with resulting scar 
contraction. 

In the lungs, luetic involvement is rare, though less so than was believed 
:': rzierly. 

Aside from the so-called "white pneumonia" of the luetic fetus or infant 
little is known of the lung changes due to the congenital form. 

Acquired syphilis of the lung may be gummatous, take the common 
form of a fibroid induration or show catarrhal changes in association with 
idiiur;-.::-. 

- -philitic phthisis" is the term applied to those rare cases of pulmonary 
syphilis in which gummata have broken down and cavities resulted. 

There are practically no distinctive signs or symptoms in any way 
characteristic of syphilitic involvement of the respirator}" tract, but one 
should bear in mind its possibilities in confusing the clinician and leading 



SYPHILIS 



IIII 



him to wrong diagnostic conclusions as to the specific etiologrc factor present 
in a given case. 

The Wassermann test is helpful and the old therapeutic test 
invaluable. 

The Lymph Glands. — A general glandular hyperplasia characterizes the 
secondary stage and may be exaggerated in any group of glands which drains 
an ulcerating surface. The post-cervical, inguinal, axillary, epicondylar, and 
posterior mastoid glands are especially affected and are easily palpated. 
Occasionally a similar glandular swelling occurs in a tertiary period, not infre- 
quently ending in necrosis. The tongue may be the seat of tertiary as well 
as secondary changes in the form of leukoplasia or gummata, the latter of 
which may produce painful or permanent fissures and deforming scars, as the 
result of ulceration. "The so-called syphilitic psoriasis as affecting either the 
tongue or buccal mucous membrane is recognized by the presence of whitish 
patches which are hard and horny to the touch. These are easily eroded and 
constitute an intractable and painful tertiary lesion. 

Hereditary Syphilis. — Little need be said concerning the appearances 
in this condition beyond that contained in the first section of the book. 
The unfortunate inheritors suffer especially from the following lesions: (a) 
Syphilitic hemorrhage of the new-born leading to death shortly after delivery. 
(b) Ulceration and hemorrhage from the navel, usually uncontrollable and 
resulting in death. (c) Snuffles. The nose is blocked by syphilitic 
inflammation and there is usually an excoriating secretion and a specific 
periostitis which may produce saddlenose. (d) Excoriations, due to macera- 
tion of papular and pustular eruptions about the nates. (e) Marked nutritive 
disturbances which give to the child a wizened, senile appearance, the skin 
being dull, inelastic, and often hanging in folds. (/) Pemphigoid lesions, 
which occur early in infancy {the first few days) and usually justify a fatal 
prognosis. 

In addition one finds enlargement of the liver and spleen, epiphyseal 
inflammation and even separation, iritis, keratitis, conjunctivitis, etc. 

Syphilis Hereditaria Tarda. — This term is applied to those forms of heredi- 
tary syphilis which appear about the fifth year or sometimes as late as the twelfth 
and tend to last until the age of twenty or twenty-one. The Eutchinsonian 
syndrome is: a hazy cornea or actual interstitial keratitis, increasing deafness. 
and crescentically notched, prominent upper incisors. To these Mracek 
would add a flat or depressed nose, fine scars at the angle of the mouth, on 
the upper lip, or on the mucous membrane of the lips, radiating from the 
nares, and prominent frontal bosses, together with a manifest arrest of 
development. 

Prognosis. — Recent developments, especially such as relate to the 
frequency of occurrence of living specific syphilitic organisms in many chronic 
diseases both of the nervous and the cardiovascular systems, show clearly 
that complete cure is relatively rare. 

Undoubtedly the most effective therapy is that which is both early and 
intensive, preferably instituted before "secondaries" develop. 



Glands most 
accessible. 



Tongue. 



Buccal 
membrane. 



Pathogno- 
monic signs 



'Snuffles.' 



"Sore 
bottom. 



Senile phys- 
iognomy. 



Jonathan 

Hutchinson's 

syndrome. 



III2 



MEDICAL DIAGNOSIS 



Therapeutic 
test. 



Specific tests. 



It should be noted that there is a growing belief that mercury remains 
the most potent and reliable of single remedies. This does not preclude the 
use of arsphenamin which has certain advantages associated with its rapid 
action, and no doubt both may be employed with advantage, and that one 
supplements the other. 

In any event, treatment must be continued until the Wassermann reac- 
tion is negative and the patient's blood must be tested at regular intervals 
over a period of not less than two years. Its reappearance calls for the 
immediate resumption of therapeutic measures. 

Comment. — The student must remember that syphilis is the most protean of 
diseases and frequently assumes forms unrecognizable by any. save the Wasser- 
mann, luetin, and therapeutic, tests. Whether the patient be infant or adult, male 
or female, cleric or convict, as a possibility, it always exists, for the innocent 
suffer even as the guilty, though less often, and the physical results of the errors 
of youth cannot always be obliterated. 

In this connection it may be said that when one encounters conditions 
important rule peculiarly baffling and indeterminate in their symptomatology, syphilis, dis- 
turbances of the internal secretions, or drug addiction should always be 
considered. 

ULCERATING VENEREAL GRANULOMA 



Definition. — A superficial extremely chronic ulceration, occurring chiefly 
in the tropics, almost invariably genital in site, transmitted, probably by 
sexual intercourse, and frequently associated 
with the presence in the lesions of a spirochete 
closely resembling Treponema pallidum. 

Symptoms. — The appearance of a papule 
on the penis or labia minora, unattended by 
constitutional symptoms, is followed by super- 
ficial painless erosion, exposing a sluggish gran- 
ulating' surface, which yields a profuse, foul 
smelling discharge. 

Cicatrization of old areas may attend the ex- 
tension of the process. 

The superficial painless erosion or ulcera- 
tion may or may not extend to the groins 
and inner surface of the thigh and, rarely, is 
destructive. 

It shows a decided tendency to excessive 
chronicity and extensive scarring, affecting the 
general health but little or not at all, and shows 
no tendency to glandular changes. It does not 
respond to anti-syphilitic treatment and the Wassermann test is negative. 

YAWS ^^Frambesia"). — A tropical disease due to Treponema pertenue 




Fig. 529. — Granuloma venereum. 
(After Wendtlandt.) 



YAWS 



III3 



/# 


*\ 


1 


\ 


\ i 





Fig. 530. — Treponema pertenue. The cause of yaws (Frambesia). {After Miihlens.) 




Fig. 531. — Yaws. — Initial lesion on breast of mother. General infection (secondary 
stage) in child. (After Henggeler.) 



1 114 



MEDICAL DIAGNOSIS 



Three stages. 



Incubation. 



The 

"Mother" yaw. 



Lymph 
nodes. 



Fever 
andjeruption. 



Preferential 
sites. 



(Castellani) and characterized by papular, tubercular and ulcerative skin 
lesions, appearing in three stages like syphilis, the tertiary phase, only, pro- 
ducing the deeper ulcerative lesions. 

Initial Lesion. — After a period of incubation averaging three weeks, 
nocturnal headache, dyspeptic symptoms, joint pains and an irregular fever 
usher in the primary effect in the form of single or multiple papules at the 
site of inoculation. Superficial fissuring ulcerations follow, exposing a rasp- 
berry-like base of sluggish fungoid granulation (the " mother yaw") exuding 
a seropurulent discharge. 

Tenderness and enlargement of the lymph nodes may accompany or 
shortly precede the appearance of the primary lesion which is almost in- 
variably extragenital. 





Fig. 532. — Yaws. Tertiary ulcer. 
(After Bdrmann.) 



Fig. 533. — Yaws. Note tubercles in 
face and around mouth. (Stitt's " Tropical 
Diseases.") 



The "mother yaw" may desiccate and disappear or, more commonly, 
persist as a fungous mass of exuberant granulation tissue. 

Secondary Stage. — In from six to twelve weeks after the coming of the 
initial lesion, another attack of fever and malaise appears, and a generalized 
eruption of papules similar both in character and course to the primary lesion 
becomes manifest. This involves by preference the junctional tissue con- 
necting the skin and the mucous membranes (Stitt), the papules and tubercles 
appearing chiefly around the. nose, forehead, mouth and anus, plentifully 
over the neck, anus, legs and buttocks, sparsely over the trunk and scalp. 

This secondary stage lasts for several months or years, the tubercles 
appearing in successive crops. 

Tertiary Stage. — This is not constant in appearance but represents the 
one period of yaws characterized by the .formation of gummatous nodules 
and deep ulceration. 



YAWS 



III 



In no stage are the viscera affected. 

Mortality. — There is almost no mortality, }4 per cent., and the disease 
chiefly attacks children and confers immunity. 

Differential Diagnosis. — The 

following points have seemed to 
disprove the apparently reason- 
able assumption that yaws is 
syphilis. 

i. An individual suffering from 
yaws may contract syphilis. 

2. A person suffering from 
"syphilis" may contract and pass 
through typical yaws. 

3. The primary and secondary 
eruptions are identical in yaws, 
not so in syphilis. 

4. Certain distinct morpholog- 
ical differences obtain as between 
Treponema pallida and Treponema 
pertenue. 

5. Unlike syphilis yaws does 
not affect the viscera or the 
mucous membranes. 





Fig. 534.— Yaws. Note so 
trunk involvement. 



lewhat unusual 
(Stitt.) 



Fig. 535. — Yaws. — Secondary 
lesions. (After Henggeler.) 



6. Unlike syphilis yaws does not affect the central nervous systems. 

7. The primary lesion of yaws is almost invariably extragenital. 
Reasons for believing yaws an attenuated syphilis: 



iii6 



MEDICAL DIAGNOSIS 



i. Monkeys rendered immune to syphilis are immune to yaws, but yaws 
infected monkeys are not immune to syphilis (Levaditi and Larrier). 

2. Salvarsan is more specific for yaws than for syphilis. 

3. Gangosa, probably a tertiary yaws, gives nearly 70 per cent, positive 
luetin reactions and yaws yields a higher percentage of positive Wassermann 
tests than does syphilis. 




Despite the authoritative opinion held against the identity of the two 
diseases, it would seem possible that with better knowledge the future 
may reverse this decision. 

GANGOSA {"Muffled Voice").— This disease is probably merely a terti- 
ary form of yaws, nearly all patients showing scars of that disease or admit- 
ting past infection. 



GANGOSA — GOUNDU — AINHUM 



III7 



In this ailment or stage the mucous membranes are viciously attacked. 

Preferentially the destructive process first attacks the soft palate, invades 
the floor of the nasal passages, the nasal septum and the fleshy and cartilag- 
inous structures of the nose itself, often destroying the eye. 





Fig. 537. — Goundu. A curious disease of the Tropics called "big nose'' in the districts 
harboring it. Apparently it is nothing more than an osteoplastic periostitis due perhaps 
to yaws. The affection is painful at the onset and attended by purulent nasal discharge. 
After six or eight months this ceases and painless tumors result which usually attain the 
size of half a hen's egg, but may become so large as to interfere with, or even destroy the 
eves. (Manson.) 




Fig. $$S.—Ainhnm. This tropical disease of unknown origin begins as a constricting 
fissure, around one or more of the toes, which increases its pressure gradually until actual 
amputation results, with or without attending ulceration. 



During the course of the destructive ulceration the breath is foul and 
repulsive. 

Gangosa is extraordinarily responsive to anti-syphilitic medication wheth- 
er this be salvarsan or mercury, and about 70 per cent, react positively to a 
luetin test. 



iii8 



MEDICAL DIAGNOSIS 



Syphilitics. 



Pathogno- 
monic signs. 



Usually simple. 



Obscure cases. 



ERYSIPELAS 

Definition. — An acute infectious and contagious disease due to a strain of 
the streptococcus pyogenes* and characterized by lymph tract extension and a 
spreading dermatitis associated with marked toxemia. 

Etiology. — The disease is particularly common and easily induced in 
women after delivery, in cases of surgical operation and in elderly patients 
or those debilitated by chronic disease. Imperfectly treated syphilitics 
are especially liable and may suffer excessively, f In no disease is recurrence 
more commonly observed. 

Symptoms.— After an incubation period varying from one day to a week 
and with or without slight malaise, tingling or burning of the affected surface, 
there is chilliness or an actual rigor and a high, somewhat irregular and remittent 
fever (103 ° to i05°F.) associated with marked leucocytosis. 

The afected skin is dull crimson, swollen, tense, presents a raised margin at 
the line of advance and later may become covered with tiny or large blebs. 

It tends to spread most readily over the regions covered loosely by integu- 
ment, and although the face is its favorite seat, it but seldom extends to the 
scalp. Per contra, the eyelids and ears may become so enormously swollen 
and edematous as to produce a superficial necrosis and the same is true of the 
scrotal tissues. Gangrene is not an uncommon complication in old people. 

In favorable cases it remains but a few days, gradually fades and is fol- 
lowed by desquamation, the fever ending usually by crisis. The neighbor- 
ing lymph glands are moderately enlarged during the attack. Relapses are 
common and in unfavorable cases the process may shift its seat and a typhoid 
state may develop. 

Differential Diagnosis. — The author knows of no other disease that 
presents these symptoms save primary phlegmon of a mucous membrane, 
which may so closely resemble erysipelatous infection as to make primary 
differentiation difficult or impossible. 

The rare and curious ailment described by Rosenbach under the name of 
il Erysipeloid" % presents the same outward appearance but lacks febrile 
manifestations and is extremely sluggish in its extension. It should be re- 
membered that the reddening may be misleadingly slight and pale in pro- 
foundly cachectic patients and afebrile cases doubtless occur. In an ad- 
vancing process the older areas fade gradually after one or two days. 

The characteristic raised border soon declares itself in almost every instance. 

The diffuse redness of ordinary erythema or of phlegmon, therefore, 
stand apart clearly. 

* Fehlheisen's streptococcus erysipelatis has been conclusively proven to be identical 
with the S. pyogenes. 

f In cases of imperfectly treated syphilis in the tertiary stage the onset of erysipelas may 
be attended by immediate periostitis and necrosis of the facial bones and base of the skull 
which may produce tremendous deformity and death within a few days. They seem to melt 
away. 

% Also called "crab-bite." Three hundred and twenty-nine cases of this type, 323 
of which arose from this cause, were reported by Gilchrist in 1903. 



LEPROSY 



III9 



The vesicles and bullae so commonly encountered on the surface are also 
helpful points in diagnosis. 

PYEMIA AND SEPTICEMIA.— These are essentially surgical conditions 
and need no extended description in this volume. 

Diagnosis. — This depends upon a septic temperature or one which may 
resemble at first that of typhoid fever or malaria, but is associated with marked 
leucocytosis in any resistant patient, lacks the Widal test of typhoid and hem- 
ameba of malaria and is oftentimes associated with scarlatina-like rashes or 
toxemic jaundice. Pyemia must be traced to its focus and is distinctly septic 
from the start having a widely remittent or intermittent temperature associated 
with recurring chills and sweats. Aside from the surgical conditions, these 
two diseases are likely to be confused only with typhoid fever in the former 
case and malaria in the latter, or with both. Ordinarily, care and a study of 
the symptoms is always sufficient to make a differential diagnosis. It is 
also necessary, however, to have in mind malignant endocarditis as a possi- 
bility, and the heart should be examined in every case where either septice- 
mic or pyemic symptoms are present. Advanced tuberculosis is a septicemia 1 
in part, but offers few difficulties in its pulmonary form, and as an acute 
miliary process lacks leucocytosis. 

The blood cultures are of great service in these cases. 

LEPROSY 

Prevalence. — This, the most ancient of known diseases, is caused by the 
bacillus lepra and still prevails throughout the world, though to a very limited 
and rapidly diminishing degree in Europe and North America, and, indeed, in 
all countries where modern methods of control through segregation have 
been attempted. 

The Bacillus Leprae. — (Armauer Hansen, 187 1). — The bacillus is some- 
times morphologically indistinguishable from the tubercle bacillus and resists 
decolorization in the same manner. It cannot be readily cultivated, stains 
more easily, and does not produce tuberculosis in inoculated guinea-pigs. 

Duval and Wellman have successfully employed specially treated human 
placental tissue as the basis of a culture medium. The Bordet and Gengou 
reaction has so far proved non-specific for the lepra bacillus but specific agglu- 
tinins have been obtained. Deycke asserts that in preparations stained by 
the Ziehl-Neelsen method the following points of differentiation often may 
be observed: (1) Pointed ends. (2) Great numbers found. (3) Tendency 
to occur in groups. (4) Frequency of intracellular organism. Much has 
shown that some lepra bacilli are not acid fast and distinguishes two groups. 

Mode of Conveyance. — Much difference of opinion still exists concerning 
the direct and hereditary conveyance of this disease. As regards the latter 
it is probable that leprosy, like tuberculosis, may, but rarely does, exist in slightly 
the fetus, and that in nearly all cases it is acquired, the young children of 
leprous parents being especially exposed to the bacilli which may be found 
in nearly all of the excretions and secretions of affected cases.* Most 

* Statistics show that 93 per cent, of the children of lepers escape infection. 



A vanishing 
disease. 



infectious. 



II20 



MEDICAL DIAGNOSIS 



Primary sore 
and constitu- 
tional 
symptoms. 



intimate contact seems indispensable to infection, inasmuch as nurses and 
doctors in leprous settlements are rarely attacked, and it is probable that 
the nasal passages represent the usual channels of infection though it is said 
to occur even through the skin and to be conveyed through clothing as in the 
case of washerwomen especially. Inoculation experiments as applied to man 
have proved unsuccessful save in one case of Arning's who inoculated an 
Hawaiian criminal who later developed the disease. 

The solitary instance is not sufficient to establish the communicability 
of the disease by artificial means. 




Fig. 539. — Tumor-like leprosy nodules. (Deycke.) 

The anesthetic form is but slightly communicable, the tubercular type most 
dangerous, although the necessity for some intermediate change in the 
virus antecedent to transfer of infection is suggested strongly by its vagaries 
of transmission. No intermediary host is known. 

Incubation Period. — From two to ten or even twenty years may elapse 
between known exposure and the development of recognizable symptoms. 

Sex. — The incidence in the male is double that in the female. 

Development of Leprosy. — The close resemblance of leprosy to tubercu- 
losis in many particulars is no less remarkable than the likeness of its stages 
s to the development of syphilis. The initial lesion is believed, by some author- 
ities, to be represented by an ulcer or excoriation on the nasal septum. 
There is a prodromal stage resembling the second stage of syphilis in that it is 
associated with transient fever, headache, joint pains, and commonly with 
epistaxis, possibly due to the septal ulceration, and after several months or 



LEPROSY 



II2I 



even a year or two a febrile paroxysm is accompanied by macular eruptions. 
The circumscribed erythematous patches are generally distributed, chiefly 
affecting the back of the hand, the forearm, the face, the malar and supra- 
orbital regions being especially affected, the scalp usually spared. 

The macules may be hyper esthetic early, but later become anesthetic, either 
centrally or wholly. They are at first transient, but tend to become per- 
sistent and pigmented. Without further advance they may show a loss of 
pigment and then constitute the dead white, shiny areas of "white leprosy.' ; 




Fig. 540. — Macular anesthetic leprosy. (Deycke.) 

A definite third stage is represented by three forms, the nodular or tubercular, 
the anesthetic, and the mixed. 

Nodular leprosy may lack the macular stage and the subcutaneous tubercles 
are flat, hard and elastic to the touch, and most numerous about the ears and 
face. Their increase in size and the infiltration of the affected parts produces 
the "leontine fades." With occasional disappearance and reappearance in 
individual areas, they nevertheless multiply and ultimately involve the 
greater portion of the body and mucous membranes and break down into 
ulcers which discharge hosts of bacilli and bacillary emboli and cause horrible 
deformities from tissue loss and cicatricial contraction. 

Anesthetic Leprosy. — This is characterized by an extensive painful 
neuritis due to direct invasion of the nerves by the bacilli. Extensive anes- 
thesia results, associated with bullae, spreading ulceration, and subsequent 
contractures. Muscular atrophy is widespread, and fingers and toes may be 
completely destroyed. 
71 



Macular 
eruption. 



Macular 
anesthesia. 



"The silver 
men." 



Third stage. 



Leontine 
facies. 



Necrosis and 
deformity. 



1122 



MEDICAL DIAGNOSIS 



Three diag- 
nostic criteria. 



Sources of 
infection. 



Vitality of 
spores. 



Mixed leprosy represents merely a combination of the two forms. 

Differential Diagnosis. — Any difficulty is limited to the early cases of the 
macular or anesthetic type. Three diagnostic criteria are available, (i) 
The easy recognition of the bacillus in the blood of a leprous nodule or, in 
anesthetic cases, in the fragment of a nerve, usually also in the nasal secretion, 
which may be increased by the administration of an iodide. (2) The central 
anesthesia of early macular areas. (3) The administration of pilocarpin to 
show the absence of perspiration in the involved areas (Baelz). 




Fig. 541. — Characteristic leprous nose. Areas of pigment atrophy on arms. (Deycke.) 

ANTHRAX 

(Malignant Pustule, Charbon, Wool Sorter's Disease) 

Etiology and Distribution. — This world-wide scourge of cattle and sheep 
may be conveyed to man through direct contact or by the handling of wool 
and hides, the channels of entrance being chiefly wounds or abrasions of the 
skin, the pulmonary tract, the infected stings of insects, and the gastro- 
intestinal tract. The germ is strikingly resistant, the spores especially so, 
infection being possible after years through laboratory cultures or in pastures 
containing the buried bodies of infected animals. It grows readily on ordi- 
nary media at temperatures between 12 and 45°C, producing in gelatine 
stab cultures the inverted pine-tree figure. They produce spores only in 
culture and stain with all ordinary dyes. The disease is rare in the United 
States, common in England, France, Germany, Austria, Italy, South Africa, 



ANTHRAX 



1123 




South America, Turkey, and Asia Minor, very frequent in certain parts of 
Russia, particularly Siberia. 

Symptoms. — The disease may be external or internal, in the former assum- 
ing the type of "malignant pustule" or "malignant anthrax edema." The 
latter form is usually pulmonary, more rarely intestinal. 

Malignant Pustule. — From three days to a week after exposure the 
development of a small itching papule is followed by a rapidly increasing 
inflammation and infiltration and the formation of a 
hemorrhagic vesicle which becomes necrotic and bears 
upon its infiltrated marginal zone similar smaller vesicles. 
Coincident with the rapid spread of the inflammation 
adjacent lymphangitis and glandular swelling are evi- 
dent. The induration and edema are extreme and the 
necrosis may be extensive, yet pain is slight or absent. 
Fig. 542. — Anthrax Marked constitutional symptoms are evident in forty- 

h thwW). ^ A'''" non- ei S ht hour5 when the § erm reache3 the blood > but tne 
motile, non-chromo- active septic phenomena including the fever subside in 

Sic bacXTread- the later sta S es ' the 5e P tic typhoid state preceding death, 
ily cultivated, stained Malignant Anthrax Edema. — Primary constitutional 
hi^hlv esist t symptoms, excessive gangrenous edema, with a predi- 

lect ; on for the eyelids, head, hand, and arm, charac- 
terize this variety. The patient's mind may be clear and free from 
apprehension in either of the preceding forms. 

Internal Anthrax. — [a) Wool Sorter's Disease. — A sudden onset with 
chill, prostration, severe pain in the back and extremities, a temperature 
(102 to 103 °), with chest pain, rapid breathing and in some instances 
marked bronchial symptoms, characterize this form. The pulse is weak, 
vomiting and diarrhea may occur, violent cerebral symptoms are noted, and 
death may result within twenty-four hours, (b) The intestinal form is due 
to ingestion of the germs and is characterized by chills, moderate fever, 
vomiting, diarrhea, marked prostration, dyspnea, phlegmon, or petechias 
and enlarged spleen. Hemorrhage may occur from free mucous surfaces, 
and, unlike the external form, anxiety is marked and there may be terminal 
convulsions. It is rare in man, but is the usual form of the disease in cattle, 
sheep, and goats. 

Diagnosis. — The occupation of the individual is usually suggestive and 
the history of an itching papule and its vesication and necrosis should lead 
to an immediate examination of the contained serum, either microscopically 
or by inoculation of white mice which are very susceptible. A progressive 
course with falling fever eliminates phlegmonous erysipelas and diffuse cellulitis 
and malignant edema shows tissue crepitation. The germ can often be 
recovered from the blood within forty-eight to seventy-two hours after the 
onset, but may be long delayed. 

Prognosis. — The mortality is variable but always high in the internal 
forms and those of the external type in which the face is involved; less so if 
the extremities are affected. 



External 
forms. 



Characteristic 
lesion. 



Constitutional 
symptoms. 



Curious 
predilection. 



Pulmonary, 
gastro- 
intestinal and 
cerebral 
symptoms. 



Hemorrhage. 



Occupation. 



Falling 

temperature. 



I I 24 



MEDICAL DIAGNOSIS 



Saliva the 
medium. 



Important 
factors. 



Incubation 
period. 



Incidence and 
exposure. 



Extreme 
irritability and 
spasms. 



HYDROPHOBIA 

(Rabies , Lyssa) 

A fuller knowledge and radical precautions have rendered rabies a rare 
disease in America, England, and Germany. It depends upon a specific 
as yet unproven virus conveyed to man chiefly by the dog, and always by 
direct inoculation. Though the disease affects cats, skunks, wolves, cows, 
sheep, and even birds, it is extremely rare in horses and hogs. The salivary 
secretion is the chief carrier, the nervous system the main focus of this hitherto 
unknown virus.* The incubation period varies with the age of the victim, is 
shortest when following wounds of the face and head, but depends also upon 
the size of the wound, the protection of clothing, and the animal convey- 
ing it. Ten days and six months represent the extremes of incubation, the 
average time being forty days. The infected dog stands below the wolf and 
cat in virulence, though far oftener infected. It is stated that infection 
follows in about 15 per cent, of dog bites, as compared with about 40 per 
cent, for wolves, but it would seem that the severity of the lesion might be 
chiefly accountable. The mortality varies from 50 to 80 per cent., but has 
been greatly reduced by the Pasteur preventive treatment. 

Symptoms. — The Premonitory Stage. — This is characterized by renewed 
redness of the wound, irritability, insomnia, apprehension, and marked 
mental depression. Photophobia and hyperacusia may be present. Hoarse- 
ness and dysphagia usher in the second stage. 

The patient may be suspicious, solitary, morose, excitable, and loquacious, 
show delusions or, later, maniacal delirium. 

Period of Hyperesthesia and Spasm. — (Duration two or three days.) 
Excessive reflex irritability appears, the slightest stimulus, physical or mental, 
excites painful and violent reflex spasms, affecting chiefly the mouth and 
larynx and accompanied by subjective dyspnea. The mind is clear except 
during the convulsions and the paroxysms excited by attempts to swallow 
even water account for the use of the term u hydrophobia ■ " Fever may be 
absent, but is usually present in moderate degree. Attempts to injure others 
are rare and confined to the paroxysms. 

The Rabies Virus and the Negri Bodies. — Negri's bodies are angular, 
round or oval, varying from 1 to 20/* in diameter. Negri's original claims 
have been substantiated by other observers and the bodies seem to be almost 
or quite constant and found in no other disease. They are found most 
readily in the Cornu Ammonis. By this means a diagnosis can be made 
within twenty-four hours, and fortunately the bodies are quite resistant to 
postmortem changes and are present early in the disease. That they are the 
cause of the ailment remains unproven but their presence in a suspected 
animal is proof of rabies. Proscher has described extremely small (0.2/x), 
diplococci as a constant finding, and Noguchi has recovered and successfully 

* The richer the nerve supply of the inoculated part, the more rapid and severe the 
course of the disease. 



TETANUS 



1125 



Imaginary 
hydrophobia. 



cultivated, from the brain and spinal cord of infected rabbits killed before 
the period of exitus is reached, what he believes to be the rabies virus. 

He finds granular chromatic corpuscles varying in size from 0.3^ to limit 
of visibility, together with minute, pleomorphic chromatoid particles 0.2-0.4/z 
in width and o . 4-0 . 5/x in length. 

These bodies have been carried through several generations and produce 
typical rabies in susceptible animals. He also encounters occasional larger 
corpuscles resembling Negri bodies and the sporulation forms originally 
reported by Negri, but hitherto unconfirmed. 

Certain changes in the sensory and sympathetic ganglia have been reported 
by van Gehucten and Nelis and are believed by these observers to be specific 
and constant. 

Terminal and Paralytic Stage. — Subsidence of the spasms, progressive 
paralysis, gradually developing coma, and progressive cardiac weakness 
terminate life. 

LYSSOPHOBIA 

{Pseudo-hydrophobia) 

This is merely an hysterical manifestation on the part of one bitten by 
a suspected animal. Fever is rare and the signs of hysteria usually manifest, 
though naturally the irritability, apprehension and mental depression may 
exactly simulate the premonitory stage of the true disease. The excessive ' 
hyperesthesia, true spasm, and other indications of actual infection can 
hardly be exactly simulated. 

Diagnosis. — The greatest enemy of the patient and diagnostician is the 
officious public servant or citizen who promptly destroys and disposes of a sus- 
pected animal, for the first step should be the transfer of the living animal or of 
the fresh brain and medulla to the hands of the bacteriologist for the purpose of 
the inoculation of animals and the infinitely more important detection and iden- 
tification oj the Negri bodies. 

If the dog is apparently well, its isolation may be undertaken, but if the 
slightest evidence of rabies exists he should be scientifically dispatched in such 
a manner as will leave the brain uninjured. 

Such action not only promotes prompt diagnosis and efficient treatment, 
but often prevents an unfounded hydrophobia scare and the persecution 
and slaughter of innocent animals. 

Persons bitten in the face should be placed under Pasteur preventive treatment 
at once, without waiting even for the results of the laboratory tests. 

TETANUS 

{Lockjaw) 
Extraordinary Virulence. — The bacillus is inoculable in animals and its Marvelous 

toxicity. 

peculiar toxin is fatal m the extraordinary dose of 0.23 mg. 

As tetanus neonatorum, the disease especially affects new-born children 
in countries or districts where uncleanly methods are followed in the care 
of the navel. The soil of certain regions is peculiarly infectious, and the germ a sou dweller. 



Hydrophobia 
scares. 



1126 



MEDICAL DIAGNOSIS 



Incubation. 



Locked jaw. 



Risus, 
sardonicus. 



Spinal flexion. 



Fever. 



Head tetanus. 



Primary intra- 
nasal lesion. 




usually enters the body through a punctured or contused wound. The fatalities 
attending the use of toy pistols are well known. 

Under the new National law all serums and vaccines must now be tested 
fully for freedom from tetanus bacilli or spores by animal inoculation before 
being placed on the market. 

The Great War, of necessity brought about the systematic wholesale 
use of antitetanic sera, and the results tended to establish its great value 
with respect both to lessened incidence and reduced mortality. 

Symptoms. — After a period of incubation of about a week or ten days, 
or more rarely two weeks, a subjective sensation of constriction of the neck 
and jaws with difficult mastication is followed by a tonic spasm of the muscles 
which lock the jaw, and an outdrawing of the mouth and 
raising of the eyebrows causing the risus sardonicus. 
By gradual involvement the muscles of the trunk and 
extremities are affected, producing rigid extension 
(orthotonos) , or violent posterior flexion of the spine 
(opisthotonos), and more rarely lateral (pleurosthotonos) 
or anterior flexion (emprosthotonos). The duration of 
the spasms is variable, relaxation usually incomplete; 
they are initiated by the slightest irritation and are 
extremely painful. The fever is usually moderate or 
perhaps absent, more rarely there is hyperpyrexia. 
Spasm of the glottis may cause dysphagia and paralysis 
of the facial muscles may occur, but in children spasm 
may be limited to the production of the risus sardonicus. 

Diagnosis. — Strychnin poisoning lacks the early 
involvement of the muscles of mastication and the rigidity 
between spasms. 

Prognosis. — Of idiopathic cases about 50 per cent, die, traumatic cases 
80 per cent. The head tetanus, due to wounds of that part, in its acute 
form, is almost invariably fatal; if chronic, the mortality may be only 25 
per cent. 

GLANDERS 

(Farcy) 

Primarily a disease of the horse, it is communicable to man through the 
agency of the bacillus mallei. It is essentially an infective granuloma, actual 
contact is the usual method of conveyance, and it is encountered in both 
acute and chronic forms. 

Aeute Glanders. — (Infection through the nostrils.) Three or four days 
after infection there is fever and evidence of local sepsis. The mucous mem- 
brane of .the nose becomes involved within forty-eight or seventy-two hours, 
nodules forming which undergo necrosis, the ulcers yielding a mucopurulent 
discharge. All erysipelatous-like facial swelling is followed by a pustular 
eruption, swelling of the hands, arms, legs, and feet may occur and there is 
marked lymphangitis and glandular involvement in the drainage areas 



Fig. 543. — Tetanus 
bacillus (Bacillus 
tetani) . A long 
slender bacillus with 
single polar spore, 
flagellate, motile, 
anaerobic, non-chro- 
mogenic, sporogen- 
ous, liquefying, 
readily stained by all 
methods but culti- 
vated with difficulty. 



THE MYCOSES 



1127 



Dermal 
lesion. 



affected. Pneumonia is a frequent complication, and the disease is fatal in 
from eight to ten days. 

Acute Farcy. — {Infection by the skin.) The symptoms are those of an 
acute septicemia following local phlegmon representing the site of inocula- 
tion, together with an acute lymphangitis characterized by subcutaneous 
nodules in the course of the lymphatics, which may suppurate and are called "Farcy buds.' 
"farcy buds." The urine may show the germs. Death usually ensues in 
from ten to fifteen davs. Both varieties of the disease show a chronic form chronic 

• t glanders. 

lasting for months or even years and occasionally terminating tn recovery. 

The inoculation of animals and cultural methods are often necessary for 
diagnosis. In all forms the occupation serves as a valuable suggestion and 
it is usually possible to find the source of infection in a diseased horse. 

THE MYCOSES. — Modern research has developed the fact that a great 
number of the coarse fungi are pathogenic for man. Most of these produce 
exclusively or predominantly lesions of the skin and find no place in this 
volume. 

Some of the more important of those producing internal symptoms will 
receive brief consideration. 

Aspergilloses. — Aspergillus fumigatus is the form usually found. The 
pulmonary form of aspergillomycosis has been discussed already in another 
section. While unusual this is of great interest to the diagnostician. 

Mucormycosis. — In rare cases of enteritis the chief part may be played 
by Mucor corymbifer. 

Trichophytia profunda, Trichophytia unguium, Trichophytia super ficialis, 
Epidermophytia cruris and Trichophytia tonsurans capillatii, represent the 
activity of Trichophyton tonsurans in producing respectively, parasitic sycosis, 
ringworm of the nail, ordinary ringworm, eczematous ringworm and "barber's 
itch." 

Pityriasis versicolor is caused by the Microsporon furfur, and " erythrasma" 
by microsporon minutissimum. 

Blastomycosis. — The blastomycetes are yeasts (budding fungi) and may 
or may not produce mycelium. 

The oidium albicans or "thrush" stomatitis is the best known and oftenest 
seen, but the same ailment may be caused by several other forms. 

Of these, Endomyces albicans is only less common than 0. albicans. 

SYSTEMIC BLASTOMYCOSIS.— This is a very important ailment, 
despite its rarity, by reason of the severity of its symptoms and its tendency 
to deceptive localization. 

Cause. — The Cryptococcus gilchristi is a budding fungus, which in pus or 
tissues appears as a single paired or budding cell varying in diameter between 
10 and 1 6fi and enclosed in a highly refractile membrane. 

Mode of Entrance. — It seems probable that inhalation implants the 
pathogenic organism. 

Symptoms. — The first effect is pulmonary, a bronchopneumonia develop- Misleading 
ing with a history of pain in the chest, perhaps chill, and evidences of severe symptoms - 
or primary bronchitis with blood-stained sputa. 



1128 



MEDICAL DIAGNOSIS 



Fever is present and with the coming of subcutaneous nodules, abscesses, 
single and successive or in crops, chiefly on the face and neck, together, 
usually, with ulceration, secondary, or even primary and independent of 
abscess sites, a chronic infection becomes established, which may assume the 
clinical form of an excessively chronic septicemia or pyemia. Ulcerating 
areas by fusion may cause large sluggish fungating areas. The joints may 
become very much enlarged in certain cases. The blood shows a moderate 
or high leucocytosis, but is otherwise not greatly affected unless the invasion 
of the medullary substance of the bones produces myelocytic forms. 




Fig. 544.— Disseminated, polymorphous, ulcerative sporotrichosis, simulating syphilis, 
tuberculosis, ecthyma, and furunculosis. {After C. H. Plant.) 

Diagnosis.— This depends primarily upon the physician's recollection that 
such a disease as systemic and dermal blastomycosis ("oidiomycosis") exists; 
secondly, upon the recovery of the fungus from the pus or, in some instances, 
from the sputum or urine, or even the blood. 

The spores are easily recognized if the pus is heated with 20 per cent, 
sodium hydrate solution or even with no preliminary mixing. A stain is 
neither necessary nor desirable. 

These cases are mistaken for other ailments and especially for tuberculosis 
of the skin, lung and bones unless the disease is held in mind as a possibility. 

The direct diagnosis is then so easy as to make unnecessary the specific 
tests for syphilis and tuberculosis. 

Coccidioidal granuloma must be excluded by examination of the fungus 
present in the discharges or tissues. 



COCCIDIOIDAL GRANULOMA — THE NOCARDOSES 



I 129 



This type of disease is quite different from blastomycosis, the course almost Prognosis, 
invariably being progressively and rapidly fatal. 

Both diseases may involve not only the skin, lungs, bones and joints, but 
also the kidneys, liver and spleen. 

COCCIDIOIDAL GRANULOMA.— As in blastomycosis this, an almost 
invariably rapidly fatal disease, presents dermal symptoms with evidences 
of overwhelming systemic infection. 

The disease is more rapid in progress, resists the iodides, in decided con- 
trast to its simulator, affects the lymph glands more decidedly and shows a 
very different form of fungus in the discharges or tissues. 

This is the O'idium coccidioide, which in simple preparations appears as 
spherical cells within a highly refractile membrane, but in a 48- or even 24- 
hour culture shows mycelial growth. It reproduces itself by endosporulation. 

SPOROTRICHOSIS.— This ailment was first reported by E. F. Schenck 
in 1896 who isolated its cause Sporotrichum schenckii. 

Symptoms. — The chief interest lies in the strong resemblance of the sporo- 
trichosis nodules to syphilitic gummata. These soften and break down into 
most obdurate and resistant ulcers resembling tuberculous lesions or ecthyma. 

Sore throat, eye involvement and sporotrichosis of bones and joints have 
been noted. 

Systemic symptoms are lacking, superficial closure of a discharging open- 
ing may take place before the abscess is healed within. 

Gougerot distinguishes three forms: 1st. That of disseminated gumma- 
like nodules which soften, break down and ulcerate. 

2d. A dominantly ulcerative type, the lesions resembling those of 
tuberculosis. 

3d. A hard, chancroid, localized, eroded lesion. 

Diagnosis. — This depends upon the recognition of the fungus. 

This is a short rod, large (3-5/* by 2-3 /x), oblong or ovoid, somewhat gran- 
ular, enclosed by an unrefractile membrane which refuses the ordinary stains. 

In cultures it shows mycelial growth and oval or round ectospores. 

THE NOCARDOSES.— The nocardoses (streptotrichoses) include true 
actinomycosis, elsewhere fully described. 

Practically the same processes may result from infection by the atypical 
actinomycoses, identical with the true form save that they lack the club-like 
swellings. 

Other nocardoses of importance are the members of the mycetoma group 
which are associated clinically and genetically with Madura foot, and the 
pseudo-actinomycosis group comprising several of the nocardia. 

Madura Foot {Mycetoma). — This curious ailment is most frequent in and 
near Madura, India, and is much less common in other portions of the 
Empire. 

It occurs as a widespread disease in northern Africa, and is occasionally 
reported from Greece, Italy, West Indies and the United States. 

Symptoms. — The foot alone (75 per cent.) or sometimes other parts of the 
body, become greatly swollen and the site of multiple discharging fistulae 



H3° 



MEDICAL DIAGNOSIS 



leading from the surface to deep-seated granulomatous areas, which prove to 
be casting off small granules similar to those present in true actinomycosis. 

As a rule but one form is present and, according to Stitt, this usually is the 
Nocardia madurce, showing pallid fish-roe like granules. Nocardia asteroides 
and others may be causative, and a discharge of black granules like gunpow- 
der grains indicates the presence of Madurella mycetomi, Aspergillus bouffardi, 
or Sporotrichum beurmanni. 

The disintegration of the tissues may be so great as to convert the foot 
into a mere "cheesy" mass, and an inflammatory edema is constant. 

Atrophy of the leg on the side affected serves to emphasize the deformity. 
Pain is slight or absent and relief is sought by the natives because of the 
burden imposed by the enormously enlarged useless member. 

Amputation is the only procedure of value, and cases are seldom seen in 
the earliest stage when there is a mere swelling of the sole. 




Fig. 545. — Madura hand. (After Carter.) 

Pseudotuberculosis Hominis Streptotricha. — As stated elsewhere the 
nocardoses may present a clinical picture almost indistinguishable from that 
of tuberculosis of the lungs, and cause pyorrhea, stomatitis, quinsy, enteritis, 
and even appendicitis in rare instances. 

The streptothrix is acid fast but less obdurate than the tubercle bacillus. 
It tends to branching forms and its units are longer and of equal length. 

In the stomach it may be taken for the Boas-Oppler bacillus. 

Another unpleasant quality is that of forming metastases in distant 
organs. 

In relation to this as to so many other of these rare conditions the diag- 
nosis depends chiefly upon remembrance of the fact that such causes of dis- 
ease exist and that the very terms "syphilis" and " tuberculosis,' ' especially, 
must carry with them the suggestion of the nocardoses and mycoses as 
rare possibilities. 

ACTINOMYCOSIS.— This disease which also belongs to the infective 
granulomata is caused by the Streptothrix actinomyces or "ray-fungus," and 



ACTINOMYCOSIS 



II3I 



constitutes the " lumpy jaw" of cattle. Successful cultivation and animal 
inoculation have proven the fungus, and the pus from the lesion shows charac- 
teristic opaque yellow granules from J£ to 2 mm. in diameter. Infection 
occurs, doubtless, through the entrance of the fungus into the mouth or air 
passages of man, and the disease is divisible into four forms according to the 
seat of the primary process. 

// the upper portion of digestive tract be involved, there may be swelling 
of the face, usually unilateral, but sometimes bilateral, closely simulating 
sarcoma or tertiary syphilis. The tongue may be affected or the disease 




"Lumpy jaw.' 



Characterise 

yellow 

granules. 



Fig. 546. — Madura foot. (After Carter.) 

may be found along the lower digestive tract where it may produce appen- 
dicitis, colitis, and even peritonitis, but the liver is rarely affected. 

Pulmonary actinomycosis is a chronic, wasting febrile disease with marked simulates 
pulmonary symptoms simulating chronic bronchitis, the usual pulmonary tuberculosis, 
abscess, disseminated tuberculosis, broncho-pneumonia, or tuberculosis asso- 
ciated with interstitial changes and cavities. 

In the digestive form the organism may be recovered from the stools, in the 
pulmonary form the presence of actinomycoses in the sputa and the absence of 
tubercle bacilli may sometimes make the diagnosis clear * 

Cutaneous actinomycosis closely simulates tuberculosis of the skin. Cere- 
bral actinomycosis yields symptoms of brain tumor or abscess. 

Diagnosis. — The disease so closely simulates a multitude of tumor 

* The author has encountered more closed than open cases and knows of no more 
obscure condition. 





1132 




MEDICAL DIAGNOSIS 








formations and inflammatory lesions that usually nothing short of the demon- 
stration of the specific organism suffices for diagnosis. 

LUPINOSIS (" ' Lathy r ism" " Chick-pea Disease"). — This ancient disease 
is due to the prolonged use of the common vetch or chick-pea as food and is 
common during times of famine in British India, France, Italy, and Algiers. 

Symptoms. — With gastrointestinal disturbance as a prodrome, the onset 
of pain with weakness and tremor is followed by spastic paralysis of the legs 
with exaggerated reflexes and normal sensation. Death occurs from inter- 
current disease. 

MEAT POISONING.— Whether due to the ingestion of poisonous sau- 
sage, pork, beef, veal, milk, or cheese, the symptoms are malaise, anorexia, 
and nausea or certain vague, pains, abdominal, cervical, or general. In 
some instances chilliness or rigor, vertigo or tremor precede the attack. The 
actual onset is characterized by acute gastrointestinal disturbance resembling 
cholera morbus, violent abdominal pain, marked prostration, sweating, severe 
headache and thirst. Fever varies from ioo° to io5°F., and the pulse is 
usually rapid. 

LACQUER POISONING.— This disease of lacquer workers strongly 
resembles the ivy (Rhus toxicodendron) poisoning of this country, differing 
only in the greater severity of its symptoms. The base of lacquer is the bal- 
sam of the Rhus vernicifera. 

THE CHIEF ANIMAL PARASITES 

RHIZOPODA. — Entameba histolytica is the chief member of this group 
and has already been discussed under "Amebic Dysentery." Other forms 
of ameba apparently non-pathogenic are occasionally encountered in the 
stools, urine, mouth (pyorrhea alveolaris) and lung cavities, the mode of in- 
troduction being little understood. 










iff;. 

St 




> 






Fig. 547- 
vaginalis. 

FLAG 

non-pathc 
omonas vo 
blunt end 
stituent oj 
entericum, 
a markec 
another p 


— Trlcho 
(After 

ELLAT 

>genic a 
,ginalis 

carries 
[ acid vj 

is 10 tc 
[ depre 
air spri 


monas Fig. 5 

Tyson.) entericum 

Schewiak 

A.. — The three var 
nd merit no exten 
is from 15 to 20 
a nucleus and th] 
iginal secretion, i 
> 2 1 micra long an 
ssion upon its an 
tiging from its poi 


48.— Me 
(Grt 
of) 

ieties oi 
ded des 
micra 1 
-ee or f < 
\nothei 
d 5 to ] 
terior s 
nted en 


gasioma Fig. 

issi and kominis 
testinalis 
Davaine. 

"dinarily encounte 
>cription. The pe 
ong, and 7 to 12 ] 
3ur flagellae. It is 
- pear-shaped orga 
.2 micra wide. F 
urface project thr 
d. 


549— < 

(Trickc 
). ' (Pr 
) 

red are 
ar-sha; 
iiicra 3 
> a con 
tiism, 1 
rom th 
ee paii 


Zercomonas 
monas in- 
ibram and 

probably 
Ded T 'rich- 
wide. Its 
imon con- 
Legastoma 
e edges of 
•s of -cilia, 



RHIZOPODA — FLAGELLATA — TREMATODA 



1*33 



The Cercomonas hominis or Trichomonas intestinalis , also pear-shaped, 
measures from 10 to 16 micra, carries two or three flagelke, and sometimes 
a visible nucleus. 

The Balantidium coli may or may not be pathogenic. It is a small oval 

ciliated organism and carries two nuclei, one spherical, the other reniform. 

Its blunt end shows a funnel-shaped opening. It has been found on and 

within the intestinal mucosa and submucosa, as well as free 

in the stools, and can cause an ulcerative dysenteric colitis. 

TREMATODA {Flukes).— -The most important of these 

organisms is the Bilharzia hematobia or Schistosomum hemato- 

binm which causes endemic hematuria prevalent in Egypt, 

North and South Africa, Arabia, Persia, and the West Coast 

of India. 

Only isolated imported cases are encountered in Europe 
and America. The accompanying illustration shows the 
peculiar relation of the sexes. The embryos are free swim- 
ming and the organism reaches the intestinal tract directly 
or indirectly through contaminated water. Once ingested, 
the organism is found chiefly in the portal veins, but ultimately in other 
portions of the body, especially the bladder and rectum. The eggs laid in 
tissues may also make their way to the bladder and intestines and escape 
with the urine and feces. In the tissues they may cause papillomata and 
fibroid processes or even form the nucleus of a vesical calculus. 




Fig. 550 — 
B alan ti dium 
coli. {After 
Malmslen and 
Leuckhardt.) 





Fig. 551. — Male {a) and female (6) of 
Bilharzia hemalobia. {After Looss.) 



Fig. 552. — Fasciola hepatica. 



Symptoms. — The foregoing description indicates the seat, diverse nature, 
and variety of symptoms, which are of course chiefly those of hematuria, 
abscesses, and irritation of the. urinary tract, dysenteric stools, rarely Glis- 
sonian cirrhosis and a varying degree of anemia. The diagnosis depends upon 
the finding of the characteristic eggs. 

The Fasciola hepatica or Distomum hepaticum of sheep, a small fluke, 



1 154 MEDICAL DIAGNOSIS 



measuring 20 to 30 mm. in length, carries fine spines, and is a rare source of 
infection in man. Its eggs measure 130 to 150 micra. 

The Distomum lanceatum (Dkrocoelium lanceatum or '"lancet fluke" is 
8 to 10 mm. in length and 1.5 to 2.5 mm. in width, and carries no spines. 
Infection in man is excessively rare, the intermediate host being the snail. 

The Opistorchis felineus measures 8 to 10 mm. in length, and 1.5 to 2 in 
breadth. It is a translucent yellowish-red parasite not uncommon in Siberia 
and occasionally found in Germany. 

The Opistlwrchis s Clonorchis endemicus) is like the preceding variety 

in size and color, its egg measuring, however, 20 to 35 by 15 to 21 micra. It 
is abundant in India, China and Japan, and is occasionally seen in America. 

In all probability the pathogenic effects ascribed to it formerly must be 
charged against Fasciolopsis buskii, a very large and common fluke, whose 
habitat, probably, is the upper intestine. 

The foregoing liver flukes may produce a chronic disease chiefly affecting 
children, often members of one family, and characterized by marked hepatic 
and gastrointestinal symptoms, chief among which are irregular diarrhea, 
becoming bloody, hepatic enlargement, slight fever, pain, intermittent 
jaundice, anemia, emaciation, and finally, general anasarca. 

The Paragonimus westermanni is a pulmonary fluke of a reddish-brown 
color and oval form, measuring 8 to 10 by 4 to 6 mm., its eggs measuring 56 
by 90 micra. It prevails widely in China. Formosa. Korea, and Japan and 
is occasionally found in the United States. The symptoms produced are 
repeated attacks of hemoptysis, trivial or severe, and chronic cough with 
rusty sputum. It should be remembered that all of the flukes found in man 
are flat, leaf-shaped bodies with ventrally placed suckers, and that all save 
the Bilharzia are hermaphrodite.* 

CESTODES [Tapeworms).— These are long, 
flattened, and segmented worms, each carrying 
both male and female sexual organs and lacking a 
digestive tract. The head or scolex carries suckers 
and in some varieties encircling hooks. Unless the 
head be removed, the worm mav continue its life T _ _ „ - 

x 1 g . 5 ^ 3. — 1 enta 
and growth by budding. Each and every segment saginata. (Mediocanel- 
carries sexual organs placed along the border in the ^^UM Pribram and 
teniae and in the median line in the bothriocephalus. 
The number of eggs is enormous and they may show a developed embryo. 

Tenia Saginata or Mediocanellata. — This is the common tapeworm of this 
country and Europe, sometimes called the " unarmed" or "beef- tapeworm'' 
because lacking the hooklets and often conveyed by beef. Its head is larger 
than that of the tenia solium, measuring 2 mm. or more in breadth. Its form 
is shown by the accompanying illustrations. Its segments measure from 17 
to 18 mm. by 8 to 10. The ova are not distinguishable from those of tenia 
solium. A length of 15 to 20 or even 30 ft. may be attained. 

* The measurements throughout this section for the most part follow the descriptions 
given by F. C. Wood, James Tyson and Pribram. 




CESTODES 



"35 




Fig. 554. — (a) Scolex, 
(b) egg and (c) of Tenia 
solium. {Pribram and 
Wood, modified segments.) 



Tenia Solium. — The tenia solium or pork tapeworm, is common in Europe 
or Asia, but infrequent in this country. It is shorter than the tenia saginata, 
seldom exceeding 12 feet in length. The head is 
smaller, rounder, and provided with double circlet or 
hooklets in addition to its suction discs, the neck is 
narrow and threadlike. The segments measure 1 cm. 
by 7 to 8 mm. The structure of the uterus and 
general form of the worm is shown in the accom- 
panying illustration. In man and pigs the ova de- 
velop and the free armed embryos pass to different 
parts of the body and develop as cysticerci. 

Dibothriocephalus latus. — This cestode, though 
largely confined to Switzerland and Japan and the 
coast of the Baltic, is occasionally encountered in 
immigrants and has recently been found in Minnesota 
in a number of cases reported by the late Frank F. 
Wesbrook. It is conveyed by the pike or other fish; 
the adult worm measures 25 or more feet in length, is 
unarmed and carries two lateral grooves upon its head. Among the other 
forms of cestodes may be mentioned the Diplogonoporus grandis or Krabbea 
grandis found in man only in Japan, the Dipy- 
lidium caninum common in the dog, very rare in 
man and also occurring in the canine and human 
flea and dog lice. The Hymenolepis nana or 
Tenia nana, a small worm but 5 to 45 mm. in 
length and 0.7 in breadth. This worm rarely 
found in man rinds its host in the rat, its habitat 
chiefly in Italy. Its head carries four suckers 
and a row of from 24 to 28 hooklets. The egg is 
oval or round and measures from 30 to 37 micra, the embryo carries six hooks. 
Hymenolepis diminuta or Tenia flavopuncta. This small worm measures 
30 to 60 cm. by 3.5 mm. The head (0.2 by 0.5 
mm.) is armed and oval. The eggs, 60 to 70 by 
70 to 80 micra, are yellowish and show faint radial 
stria tion. Butterflies, beetles, mice, and rats are 
its commoner hosts. 

Symptoms of Tapeworm Infection. — These may 
be those of anemia and slight gastrointestinal and 
nervous disturbances or an anemia undistinguish- 
able from pernicious anemia save by finding the 
parasite. The commonest and most significant 
grouping embraces the following symptoms: (a) 
Excessive or ravenous appetite, (b) Indigestion. 
(c) Oppression, fulness or actual pain over the 
abdomen. The symptoms may be present only in part, however, or almost 
wholly absent. 




Fig. 555 — Bothriocephalic 
latus. (a) head (magnified) , 
(b) egg, (c) head, neck and pro- 
glottides. 




Fig. 556. — Hymenolepis 
nana, (a) head (magnified), 
(b) egg, (c) hooklet, (d) head 
and proglottides. {After 
Braun, modified.) 



1 136 



MEDICAL DIAGNOSIS 



Davainea Madagascariensis is a rare parasite found in British Guiana, 
India, and Africa. It is but 30 cm. in length and has an armed head with 
90 hooks and four suckers. The ova measures from 6 to 8 micra, has two 
spikes and a double shell. 

TENIA ECHINOCOCCUS— This interesting tapeworm inhabits the dog 
which becomes its conveyer to man. Australia and Iceland are the chief 
sources of infection, nearly half the Australian dogs being affected and about 
one-third of those in Iceland. In other countries it is rare. The adult worm 
consists of about three or four members and measures about 2.5 to 6 mm. in 
length. The breadth of the head is 0.3 mm. It carries four suckers and is 
supported by a short neck. The head is armed with a double circle of from 
28 to 50 hooks. 

Mode of Infection.— Direct transfer from dog to man may result from 
close contact, especially in such countries as Iceland and Australia, where 
dogs are numerous and in close relation to their master and the family. Con- 
tamination of drinking water is also easily understood. If the small six 
hooked embryo is released by digestion of its shell, it passes through the 
intestinal mucosa to various portions of the body, chiefly, of course, the liver. 
Hydatid cysts. Wherever it lodges small double-walled cysts about 1 mm. develop, the hook- 
lets disappear, and a fibrous envelope results from the slight inflammatory 
I reaction. These primary cysts later develop secondary cysts through bud- 
ding from the inner layer and these daughter cysts are structurally identical 
I with the primary ones. Later they are released and a dozen or more may 
be found within the parent cyst. Each daughter cyst may itself reproduce 
by budding until the original cavity represents a long family line. Scolices 
develop carrying hooklets and sucking discs and representing the young 
worms. Thus a multitude may arise from a single cyst.. The fluid is pri- 
marily non-albuminous, limpid, and of a specific gravity from 1005 to 1010. 
The cysts may endure for many years, ordinarily undergoing a resorption and 
ultimate calcification, the hooks persisting even in obsolete cysts. Rupture 
is always possible, symptoms and danger depending upon the location. 
Suppuration is a serious but unusual event, most common in the liver. 

Distribution. — About 50 per cent, of echinococcus cysts occur in the liver, 
20 per cent, in other abdominal organs, some, less than 10 percent, each, in the 
pulmonary tract and nervous system. 

Symptoms.^-The size and location of the cysts determine the physical 
signs and subjective symptoms and the discovery of the hooklets in the feces, 
urine, sputum, etc., makes the diagnosis positive. Obscure symptoms refer- 
able to the organs most often affected are especially suggestive in Icelanders 
and Australians. The hydatid thrill is almost pathognomonic, but often 
absent even in relatively superficial cysts. It may be felt as a prolonged 
exquisitely fine vibration echoing the stroke of ordinary finger pleximeter per- 
cussion, but more clearly when the middle one of these pleximeter fingers is 
firmly percussed without the usual recoil of the percussion digit. In one case 
observed by the author the case was almost symptomless though evidently 
one of hepatic involvement, but the thrill at once solved the problem. 



"Daughter 
cysts." 



Misleading 
symptoms. 



Hydatid thrill. 



ASCARIS LUMBRICOIDES — OXYURIS VERMICULARIS 



I 137 



Aside from the foregoing points, a minute discussion of the host of symp- 
toms is futile, as there are none other than those of similar growths in different 
anatomic areas. Suppuration produces the picture of abscess, septicemia, 
or pyemia. A specific complement-fixation test is now established. 

Perforation may involve any adjacent structure and produce the symp- Perforation, 
toms peculiar to lesions of that organ. Urticaria is said to be a peculiar and 
frequent accompaniment of perforation. Multilocular elastic or fluctuat- 
ing tumors always suggest hydatids, especially when in the hepatic and 
renal regions, but as pulmonary phthisis and gangrene, all forms of abscess, 
pericardial effusion, cardiac dilatation, pleuritic effusion, hydronephrosis, 
renal calculus, pyelitis, a distended gallbladder, and even hepatic syphilis and 
carcinoma have been confounded with it, it is evident that exploratory 
puncture is often required. Hooklets are seldom absent in the fluid with- 
drawn. In the central nervous system the symptoms are those of tumor. 
Finally it should be emphatically stated that in many cases no symptoms of 
importance appear, that in general the impairment of health and nutrition is 
relatively slight in the absence of complications and that recovery under 
operation is the rule. 

Ascaris lumbricoides. — This, the most common intestinal parasite 
requires no intermediate host and infests the upper portion of the small 
intestine. The male measures 15 to 17 cm., the female 
20 to 25 cm.; it is earthworm-like in form. Being 
migratory, they are most frequently recovered from the 
stools, but may be found in the appendix, the bile ducts, 
in vomitus, or may even enter the pharynx, larynx, 
trachea, Eustachian tube, nasal passages, or lachrymal 
duct. Usually but from two to ten are present; but they 
may exist in quantities sufficient to cause intestinal 
obstruction. Rare cases of intestinal perforation are 
reported, but are probably instances in which the pres- 
ence of the worm is accidental rather than causative. 

Symptoms. — A few worms may be present without 
symptoms. Pallor, restlessness, irritability, nose rub- Largely gastro- 

1 • t • 1 • \ i -, 1 . 1. , • intestinal or 

bmg and picking, bad breath, anorexia, colicky pains, nervous, 
tympanites, malaise, impaired nutrition, disturbed sleep 
with teeth grinding, complex and misleading nervous j 
symptoms, such as epileptiform seizures, general con- 
vulsions, tetany, vertigo, aphasia, and even actual 
paralysis, localized or hemiplegia as well as recurrent 
febrile attacks, are among the symptoms attributed to this parasite. As a 
matter of fact, each and all are merely suggestive and the diagnosis can 
never be made unless the worms or their eggs are found. They are 
excessively rare in infancy and most common from the third to the 
tenth year. 

* Oxyuris Vermicularis. — The "pin" or "thread" worm measures 4 mm. 
for the male, 10 mm. for the female. These migratory parasites infest the 




Fig. 557. — Ascaris 
lumbricoides. (a) 
female, (b) male, (c) 
egg, (d) head. {Pri- 
bram.) 



Misleading 
symptoms. 



Not distinctive. 



n 3 8 



MEDICAL DIAGNOSIS 



Itching. 



Nervous 
symptoms. 



Underdone or 
raw pork. 



Prolific 
females. 



Muscle pain 
and tender- 
ness. 



Eosinophilia. 
Puffy eyes. 

Mortality. 



Direct 
diagnosis. 




Fig. 55 
Oxyuris vcrmi- 
cularis. (a) fe- 
male, (b) male. 



folds of the lowest bowel, seldom being found above the cecum, though rarely 
they migrate as far as the pharynx or perforate the intestine and form 
"verminous tubercles." In the stools they resemble bits of white thread 
and are readily dislodged by appropriate medication. The prominent symp- 
toms are genital and anal itching with nocturnal exacerbations and such other 
symptoms as have been described as associated with the round worm, save 
the nervous symptoms are less prominent and mucous colitis 
and such reflex irritation symptoms, frequent urination or 
incontinence, and balanitis, vaginitis, and perhaps masturba- 
tion are common. Here also the worm or its ova are essential 
to diagnosis, and are easily found, often indeed about the 
external genitals or anus. The worm is conveyed from person 
to person or by infected water or food. 

TRICHURIASIS. — In man trichiniasis depends upon the 
ingestion of infected raw or imperfectly cooked pork. Those 
suffer most who eat raw and underdone meat, and most of 
the cases encountered in this country have been Germans. It 
cannot be a rare condition as Williams reports 5 per cent, as 
showing infection in a series of 500 autopsies, but it is often 
unrecognized. The larvae require about seventy-two hours of residence in 
the intestines to become sexually mature and at the end of a week each 
female may have discharged into the lymph spaces or blood stream several 
hundred embryos. In due course these pass to the muscle fibers in which 
they create a reactive inflammation and become encapsulated. They may 
or may not so live for years. In man the appearance 
of an old cyst is that of "an opaque oat- shaped 
body" (Osier) owing to late calcification. 

Symptoms. — Assuming that a sufficient number 
of trichinae have been ingested, symptoms appear in 
about one week and are usually characterized by the 
conjunction of acute gastrointestinal disturbance, 
and fever, usually remittent or intermittent, followed 
by muscular pain and tenderness, limitation of move- 
ment, edema of the face, extremities and surface over 
affected areas, and a marked leucocytosis in which 
the eosinophiles often reach 50 to 70 per cent, of the 
total leucocytes. The attention should be fixed upon 
the muscle symptoms, swelling of the eyelids and eosino- 
philia, as the case may assume the typhoidal form, be 
complicated by albuminuria, pleurisy, pneumonia and 

dysphagia, aphonia, etc., etc. In other instances symptoms are of the 
scantest. The mortality is extremely variable (2 to 30 per cent.). The diet 
and the grouping of cases may also be suggestive, but oftentimes the muscles 
must be directly examined if the stools, ingested food, and other more avail- 
able material fail to show the organism. Harpooning the muscle is neither 
necessary nor proper if local anesthesia and a clean incision can be employed. 




Fig. 559. — Trichinella 
spiralis. (a) encysted 
in muscle, (b) male 
adult, (c) female adult, 
(personal observation) 
(d) male genital appa- 
ratus. 



TRICHINIASIS — UNCINARIASIS 



1139 



Many cases are mistaken for rheumatism 
in spite of the lack of joint involvement 
and the peculiar muscle symptoms. 

UNCINARIASIS (A nkylostomiasis, 

Egyptian Chlorosis, Hook-worm Disease). — 
Once regarded almost exclusively as a 
tropical disease, uncinariasis has been 
proven wide-spread and by no means 
limited to the tropics, though more widely 
prevalent in southern latitudes. It may be 
found in Egypt, England, Europe, Switzer- 
land, India, the Malayan Archipelago, the 
West Indies, and in our Southern States 
it is extensively distributed. Stiles has 
described an Uncinaria americana (Necator 
Americanus) differing slightly from the 
older form {Ankylostoma duodenale). 
The dimensions of both are for the male 7 
to n mm., for the female 10 to 18 mm. 
(see plates). No intermediate host is 
necessary, and the organism thrives in dirt 
and puddles. There are many reasons for 
believing that the skin may be a channel of 
infection. Adult worms may be found in 
any portion of the gastrointestinal tract, 
but chiefly in the duodenum and rarely in 
the stomach or colon. 

Symptoms. — There may be none in 
cases showing the worm in the feces, but 

ordinarily gastrointestinal symptoms co-exist with 

anemia, simple and mild, or so profound as to im- 
perfectly simulate pernicious anemia from which it 

is distinguished by normoblast predominance and a 

low color index. Stiles emphasizes the peculiar lack- 
luster stare and the muddy or waxy white skin. 

The remaining symptoms are those of profound 

anemia with anemic bruits, breathlessness, late 

edema, and a peculiar ascites. The characteristic 

feature of the anemia is the excess of eosinophile 

cells, both relative and absolute, most marked in 

early cases. The proportion of these cells to the 

whole leucocyte count varies from 4 to 50 per cent., 

the average being between 20 and 25 per cent. A 

rise in the count under treatment is a good omen, a 

low original count or a falling one is a bad one. 

Leucocytosis is present in a majority of the cases, but fi e d.) 
* Mental and physical retardation is commonly noted. 




Fig. 560. — Ankylostomiasis. Re- 
tarded development and typical fades 
in a young man.* (After Carter.) 




Fig. 561. — Uncinaria 
(ankylostoma) duoden- 
ale. (a) female, (b) male, 
(c) eggs, (d) male and 
female showing actual 
length but about one- 
third greater width than 
the actual specimens. 
(Pribram, slightly modi- 
fied.) 



Anemia. 



Eosinophilia. 



Color index 
low. « 



1 140 



MEDICAL DIAGNOSIS 



is seldom high, a count above 12,000 or 13,000 being exceptional. The 
more advanced the disease, the lower is the leucocyte count. The color 




Fig. 562. — Fatal case of ankylostomiasis. Erythrocytes 810,000, hemoglobin 15 per cent. 
Note marked edema {United States Naval Bulletin). (Stitt.) 

index is, as a rule, low, and in the tropical cases especially so, the same 
being true of the red cell count. Cell deformity is marked in the severer 
cases, but normoblasts predominate. 

FILARIASIS. — This extraordinary parasite includes 
three chief species. The Filaria bancrofti, also called 
nocturna, is found in the peripheral blood only at night 
; or during sleep, whereas the Filaria loa, or diurna, is 
found only during the waking hours or in daylight. The 
peculiar habits Filaria perstans is present day and night and is said to 
be present in from 50 to 90 per cent, of West African 
negroes, being apparently non-pathogenic. The Filaria 
demarquayi is found in the West Indies, persists day and 
night, and is actively motile. The Filaria ozzardi found 
in British Guiana, and a large species, the Filaria gigas, 
has been found at Sierra Leone. The first two forms, 
viz., nocturna and diurna, are the only ones of clinical 
importance. Filaria nocturna is found in all tropical and many subtropical 
countries. Most of those observed in the northern part of this country are 



Three chief 
forms. 



of parasite. 




Fig. 563. — Filaria 
nocturna in blood. 



FILARIASIS — ELEPHANTIASIS 



I 141 



imported cases. In certain tropical regions 70 per cent, of the population 
of certain villages may be affected. 

Morphology {Filaria nocturna). — The parent worm inhabits the lymph 
channels, the embryo the circulating blood, the body of the mosquito serving 
as intermediate host. The adult form is from 3 to 4 inches in length and of 
the thickness of a fine thread. The embryo is }£q inch in length and about 




Fig. 564^-Male (a) and female (b) of Filaria barter of ti. Natural size. (After Manson.) 

^000 incn broad, delicate and transparent, and enclosed in a transparent 
sheath. If the blood of a sleeping patient be examined day or night, or that 
of a waking patient by night, the microscopic findings are usually simple and 
definite. If a large drop, a broad smear, or a large wet preparation be taken, 
no staining is necessary and low-power lenses are sufficient. Both culex and 
anopheles may act as intermediate hosts. 




Fig. 565.— Filaria loa above; filaria Persians below. (After Fiilleborn.) 

Symptoms. — No symptoms appear in the majority of cases, the embryos 
indeed being innocuous. The parent worm produces at times either lym- 
phatic varix or edema from lymphatic obstruction, hence there are produced 
a group of symptomatic conditions of lymphatic origin, (a) Hematochyluria. 
Chylous urine always suggests filariasis. Its appearance is described else- 
where and its cause is a leakage of chyle, usually from the lymphatics around 



Often absent. 



1142 



MEDICAL DIAGNOSIS 



the kidney, pelvis or bladder. The urine coagulates on standing and the 
contracted white clot ultimately floats in the milky liquid. The condition 
is almost symptomless, though rarely clots may cause retention or loin 
weariness may exist, (b) Lymph scrotum is merely lymphatic varix of the 
scrotal channels, and painless soft tumors, usually in both groins, also occur 





Fig. 566. — Filar ia loa in the subcutaneous 
tissue twice normal size. (After Fulleborn.) 



Fig. 567. — Elephantiasis of the Feet. 
{After Castellani and Daniels.) 





-Elephantiasis of the labium. 
(After Scheube.) 



Fig. 569. — Elephantiasis of penis and 
scrotum. (Afer Hunt.) 



through varicose lymph glands. In either condition pain indicates lym- 
phangitis, (c) Elephantiasis and Elephantoid Fever. These conditions occur- 
ring in the tropics are no doubt generally due to the Filaria, but this is not true 
of the elephantiasis of the temperate zone. The symptoms are chill, high 
fever, heat, redness, and congestion over the area of lymphatic involvement 



DRACONTIASIS 



1 143 



with inflammatory induration which persists after the crisis. Abscess some- 
times occurs. The specific pathogenic activity of the Filaria diurna is not 
yet established. 

Dracontiasis {Guinea-worm Disease). — The Dracunculus or Filaria 
medinensis. The male worm is unknown, the female, cylindrical and smooth, 
measures 50 to 100 cm. by 2 to 3 mm., and carries a blunt hook on the head. 




Fig. 570. — Elephantiasis of scrotum. {After V. Schilling-Hannover .) 

The embryos are 500 to 750 micra by 25 to 30 and live in moist earth or muddy 
pools, finding an intermediate host in a small aquatic cyclops. It is found in 
India, Persia, Arabia, Africa, and Brazil. Rare cases have been reported 
in this country. Its preferred site is the subcutaneous tissue of the foot and 
leg, where it forms ulcers from which the head may protrude. Nevertheless 
the stomach is the portal of entrance, the worm penetrating the intestine and 
traveling downward to the lower extremity. If hot water be poured upon 



1 144 



MEDICAL DIAGNOSIS 



the ulcer the embryos may in part be discharged and after spontaneous 

parturition the worm may voluntarily come forth. 

Another method of gradual extraction is shown in our illustration. 

Trichuris trichiura {Whip-worm). 
This denizen of the cecum and 
colon measures from 40 to 50 
mm. and has a thread-like anterior 
and thicker hinder portion, conical 
and pointed in the female, obtuse 
and often coiled in the male. The 





Fig. 571. — Elephantiasis. Varicose glands 
and elephantiasis of genitals. 



Fig. 572. — Guinea worm (Filar ia medi- 
nensis). (b) female; (c) embryos; (0) mouth. 
(After R. Blanchard.) 



eggs, 0.05 mm. in length, carry a bud-like projection. The only pathogenic 
symptoms associated with it are anemia and enteritis, and these are rare. 




Fig. 



-Guinea worm. Rolled on a stick for gradual extraction. (See text.) 



Dicotophyme gigas or Eustrongylus gigas — This foot-long worm, usually 
seen only in animals, is occasionally found in the renal region of man. 

Strongyloides intestinalis. — This small worm measures 2 mm. by 0.06 
mm. It is frequent in southern China and has been found in Manila, 



TRYPANOSOMIASIS — SLEEPING SICKNESS 



I 145 



Germany, Italy, and America. If present in great numbers they cause 
enteritis and anemia. 

TRYPANOSOME FEVER AND THE SLEEPING SICKNESS.— The 

former is an irregular fever characterized by swelling of the spleen and lymph 
glands, weakness, and emaciation. The latter, its 
secondary stage, is a peculiarly latent and fatal disease 
native to Central and West Africa, and present in a 
peculiarly virulent form in Rhodesia (Trypanosoma 
rhodesiensi), is characterized by 
early apathy, mumbling, hesi- 
tant speech, tremor and difficult 
locomotion. The latent period 
may last five or more years, the 
increasing drowsiness becomes 
a deep and continuous sleep or 
coma, and the patient dies ordi- 
narily of septic meningitis. The 
disease is fatal, occasionally 
attacks Europeans, and usually 
lasts from three months to a 
year, dating from the commencement of active symptoms. 

The chain of proof is not complete, but it is certain that the trypanosomes 
are uniformly present in this disease and that they, respectively, can be car- 
ried and conveyed to man by the Glossina palp alls and Glossina morsitans, 




Fig. 5 74. — Strongy- 
loides intestinalis. (a) 
female, (b) rhabditiform 
larva, (c) filiform larva. 
{After Br ami.) 




Fig. 57 5. — Trypa- 
nosoma gambiensis. 
{Dutton and Laveran.) 




Limited range. 



Course. 



Tsetse fly. 



Fig. 576. — Ditterent forms of Trypanosoma rhodesiensi. {After Stevens and Fantham.) 

species of tsetse fly. The form of the organism is shown in the accompany- 
ing plate. It is small, actively motile, non-pigmented, and transparent, 
measures 10 to 20 micra and carries a curious rlagellum on one side of its Parasite, 
body. It is extra corpuscular and possesses an oval nucleus and a centro- 
some nearly opposite the attachment of the rlagellum. It apparently multi- 
plies by fission. 

Brazilian Trypanosomiasis. — This curious and interesting form chiefly 
affects children and produces its chief effect upon the thyroid gland or the 
brain. 



1 146 



MEDICAL DIAGNOSIS 



It is caused by Schizotrypanum cruzi, the carrier being a bug, Lamus 
megistus, and in infants the mortality rate is very great, the ailment pursuing 




Fig. 577. — Glossina morsitans. Tsetse fly. Transmitter of T. rhodesinsi. (Doflein.) 




Fig. 5 78. — Glossina palpalis. Tsetse fly. Transmitter of T. gambiense. (Doflein.) 




Fig. 579. — Sleeping sickness. Negro with the characteristic glandular swellings. (After 

Koch.) 

an acute, rapid course with high fever, enlargement of the spleen, liver and 
lymph nodes and evidences of acute myxedema. 



SCABIES — PEDICULOSIS 



1 147 



In the cerebral infantile form it is an equally fatal meningoencephalitis 
and those whom it does not kill it leaves hopelessly diseased. 

In adults and in older children it pursues a chronic course, interrupted 
in many cases by febrile exacerbations, during which the causative organisms 
may be recoverable from the blood. 

In this form the dominant symptoms may be cerebrospinal, those of myx- 
edema, or even of Addison's disease (Stitt). 




Fig. 580. — Terminal stage of sleeping sickness. (After B. Nocht.) 

SARCOPTES SCABLEI (A cams scabiei).—The female is the active agent, 
the male usually absent. The habitat is a burrow in the epidermis, often of 
the axilla or the front of the abdomen, and yet more commonly the finger 
webs and the lateral opposed surfaces of the digits. Characteristic scratch- 
marks and erosions direct attention to the burrows, which appear as short 
dark lines leading to a shining spot. The female, which may be seen with 
the naked eye, may be removed by passing a needle along the black line of 
egg deposit to the spot which indicates her presence. 






A. Male. B, Female. 



Fig. 582. — Pedicuhts 
capitis. 



Fig. 583.— Pedi- 
cuius pubis. 



Pediculus capitis. — This produces irritation chiefly about the posterior 
margin of the scalp and the eggs or nits indicate by their position in the hair 
the duration of the process. 

Pediculus corporis. — This should be sought in the seams of the clothing. 
The bites are dark, centered, hemorrhagic spots with a pale areola. Scratch- 
marks are, of course, common, chiefly over the upper back and shoulders. 
It is the chief conveyor of typhus fever. 



1 148 MEDICAL DIAGNOSIS 



Pediculus pubis. — This should be sought in and about the hair of the 
genital region, but is occasionally found in the axillae and the eyebrows. 

The maculce caeruleae (tache bleudtre) are subcutaneous bluish spots from 
5 to 10 mm. in diameter, upon the abdomen and thigh, and are due to the 
irritation of body lice. 

Vagabond's disease is a deep pigmentation resembling that of Addison's 
disease, but due to the constant irritation and scratching produced by the 
continuous presence of body lice. 

Cimex lectularius (bed-bug) and pulex irritans (flea) need no extended 
description. 

The sand flea or jigger (Pulex penetrans) is especially frequent in the 
West Indies and South America. It usually produces pustules or vesicles 
in the skin of the feet under which it grows and is considered more fully 
farther on. 

THE MYIASES AND DERMATOPHILIASIS, CUTANEOUS 

MYIASES 

The Screw- worm. — In the United States the most common affection due 
to the larvae of flies is caused by the screw-worm encountered in some of 
our Southern states. 

The fly, a blue-bottle Chrysomyia macillaria, lays her eggs in wounds 
showing an offensive discharge. The larvae cause a horrible destruction of 
the soft parts by burrowing into them and the mortality is large, 15-25 per 
cent, in 23 cases reported by Younts (quoted by Stitt), 18 of which were nasal. 

Ver Macaque Myiasis. — The name is that of the first larval stage of the 
gad-fly Dermatobia cyaniventris, a blue-bellied yellow-headed fly, common in 
Central and tropical South America. 

They are supposed to be deposited in the wounds made by the bite of a 
large tropical mosquito to which they have been found cemented. 

The gad-fly boils resulting are blind and extremely painful at first, breaking 
down later and discharging a purulent fluid. 

The timber fly disease of Africa presents almost identical symptoms. 

The Creeping Eruption. — This somewhat weird cutaneous manifestation 
results from the burrowing of fly larvae, as yet unidentified, which march daily 
a distance of from one to several inches raising the skin above them to form 
a pinkish line which marks their advance. 

They are found in Asia, Africa, South America and Southern Russia. 

Dermatophiliasis. — The chigoe or " jigger" flea (Dermatophilus penetrans) 
infests the dry sandy soil throughout nearly the whole tropical world, attack- 
ing man and lower animals alike. 

The site of election for the burrow of the impregnated female is the foot, 
and especially the lateral aspect of the toes near the nails. Other regions 
are frequently attacked, however, and hands, buttocks, scrotum, penis or 
labia may show the dark points within a tense, itching, white, pea-sized, or 
smaller, circle which -marks the presence of the insect. 



ACUTE RHEUMATISM 



1 149 



These points tend to ulcerate if the flea is not removed and the wound 
cavity sterilized with pure carbolic acid, followed by alcohol (Stitt). 

CERTAIN DISEASES OF THE JOINTS AND MUSCLES, OF PROVEN 
OR PROBABLE INFECTIOUS ORIGIN 

PRELIMINARY STATEMENT.— The present status of the commoner 
types of joint disease, no less than those of the muscles, is such as to strongly sug- 
gest that they are of infectious origin, none, however, save those of a tuberculous 
or gonorrheal character, may be said to be absolutely and finally proven as to the 
specific causative organism. On the other hand, the clinical and experimental 
evidence tending to establish their infectious origin is sufficient already to 
justify their entire removal from the older grouping and to refer some of them 
with considerable confidence to specific bacterial agencies. 

ACUTE RHEUMATISM 

Definition. — An acute febrile, non-suppurative inflammation of the 
joints, strongly suggesting an infection of the septic type, characterized by 
profuse acid sweats, the outpouring of an exudate within the synovial 
pouches and tendon sheaths of the joints affected, a peculiarly constant and 
significant relationship to antecedent and pharyngotonsillar infection, a 
decided tendency to recurrence and to the involvement of the endocardium, 
pericardium and myocardium during its course. 

PROBABLE PORTALS AND AGENTS OF INFECTION.— The infec- 
tious nature of this acute non-suppurative arthritis, while technically un- 
proven, is practically certain, and the older theories of perverted metabolism 
in which uric and lactic acid played so large a part must be regarded now 
as wholly obsolete. 

The peculiarly direct and almost constant relationship of acute rheu- 
matism to antecedent attacks of tonsillitis, the study of the bacterial flora of 
that . ailment, the almost constant recovery of Frederick Poynton's micro- 
coccus rheumaticus from the subserous connective tissue of the inflamed joints 
and the success attending the attempted experimental production of non- 
suppurative multiple arthritis, endocarditis, pericarditis and myocarditis in 
susceptible animals, by the use of pure cultures of this organism, are estab- 
lished facts of the utmost significance and importance. 

The pleomorphic micrococcus {streptococcus) rheumaticus is said to be 
merely a streptococcus strain lying between the streptococcus hemolyticus and 
streptococcus viridans, the two dominant organisms in acute and chronic ton- 
sillar infections of the ordinary type. Poynton has shown that the organism 
readily disappears from the circulating blood, is inconstant in the joint exudate, 
but relatively constant in the subserous periarticular connective tissue. 



Fever, sweats 
and arthritis. 



Antecedent 
tonsillitis. 



ii5o 



MEDICAL DIAGNOSIS 



Potent in 

causation. 



Incubators and 
transformers. 



Determine 
attacks. 



AH possible 
grades. 



Septic Foci. — The favorable results obtained in cases of recurrent acute or 
subacute rheumatism or even chronic (toxic) arthritis by the complete re- 
moval of the tonsils and, less often, by the elimination of other septic foci, peri- 
dental, antral, prostatic, cholecystic, appendiceal, and the like, together with 
the known streptococcic dominance in the bacterial flora of these conditions 
makes a strong case not alone for placing acute rheumatism under the head of 
infectious diseases, but for the specificity of the streptococcus strains lying 
between S. hemolyticus and S. viridans. 

Predisposing Factors.- — The existence of such chronically infected tonsils, 
carrying multiple strains of streptococci must now be considered as chief fac- 
tors in predisposition to, and in the causation of, acute rheumatism. 

The Tonsils. — Acute tonsillitis is an extremely common ailment and 
clinical experience justifies the belief that practically all persons so affected or 
at least those who have suffered repeated attacks, carry the potential causative 
factors of rheumatism and many other ailments in their throats. 

The tonsils are natural incubators and furnish the exact conditions, not only 
for persistence of growth, but for the peculiar nutritional variations, and grad- 
uated oxygen supply, necessary to streptococcic growth. 

Lowered Resistance. — The potency of poor nutrition, bad environment, 
fatigue, and exposure to cold and wet as predisposing factors is clinically well 
established, as is also the effect of local injury to a joint. 

Season and Climate. — The disease is most prevalent in cold, wet, change- 
able climates and its incidence falls chiefly upon the late winter and the spring 
months (75 to 80 per cent.). 

Age. — Maximum susceptibility is noted during the second and third 
decades of life, 75 per cent, of the adult cases occurring in males, though in 
childhood female preponderance is usual and occupation exercises a consider- 
able influence with respect to the subordinate predisposing factors. 

In infancy and old age it is rare; in children under ten, most trivial as to 
arthritis, and readily overlooked, but extremely prone to involve the endo- 
cardium, pericardium, and myocardium or all together {pancarditis). 

Frequency. — In hospitals located in the slum districts of London, the 
admissions under this head may reach 10 per cent, of the ward population. 

Heredity. — This apparently exercises a considerable influence in pre- 
disposition to streptococcic infection and therefore to acute rheumatism. 

Variability. — Acute rheumatism, whether occurring endemically or epidemic- 
ally, presents all possible variations in intensity. Furthermore a history of 
antecedent tonsillitis or pharyngitis in little children may be the only evidence of 
the disease, other than a slight tenderness of the joints often wholly overlooked 
even by the mother. 

The sore throat which precedes acute rheumatism may be present 
when the attack occurs, but usually precedes it by a period varying from 
several days to three weeks and usually is past when the polyarthritis occurs. 
The development of rheumatic fever in this respect presents the character- 
istics of "slow sepsis." 

SYMPTOMS. — The usual case presents an abrupt onset with moderate 



ACUTE RHEUMATISM 



"51 



Cases of 
universal 
involvement. 



Tenosynovitis. 



A fact of valui 



slight, or, in rare instances, excessively high fever, troublesome drenching sweats I striking 
of a peculiar and quite characteristic sour, musty odor and a polyarthritis. 

The larger joints are involved bilaterally in succession, usually beginning 
in one ankle or sometimes in some joint which may have been bruised or strained 
previously or represents that chiefly involved in occupational use, then passing 
to the corresponding joint of the opposite side. 

In many cases the joints of the knee, ankle, wrist, elbow, and shoulder 
ultimately all become inflamed, red, swollen, tense, exquisitely tender, and more 
or less defensively fixed. 

As suggested previously, any grade of involvement may be present 
from that of a single joint to an almost universal implication which does 
not even omit the spinal column, jaws, ribs, or the sacro-iliac or pubic 
articulations. 

It is a genuine arthritis in all severe cases, sparing neither tendons, bursa 
nor periarticular connective tissue, and according to the author's experience, 
some of the most persistent and viciously cardiac cases in adults begin and end 
as a rheumatic tenosynovitis. 

The condition of the victim of universal polyarthritis or the commoner 
multiple form constitutes one of the most pitiful of clinical pictures, but fortunately 
modern methods of treatment may prevent in most cases the extreme pain mani- 
fested under the older methods. 

In spite of the extreme degree of inflammation the joints do not suppurate nor 
become ankylosed in true rheumatic fever. 

FEVER. — The fever rises with every new invasion or complication whether 
arthritic or cardiac and falls decidedly with every sweat. 

Chilliness is common and due largely to the almost constant dampness 
of clothing and bedding alike, the frequent changes of which add greatly 
to the patient's discomfort, however skilful and gentle the nurse. 

The arthritis seldom persists in one joint for over one week and those first 
attacked may be wholly normal before the last afected show full development. 

Duration. — "The cure for severe rheumatic fever is six weeks in bed" 
is an old saying, not only true, but often an understatement if both patient 
and physician are wise, though the actual duration of the active arthritis may 
be relatively short under modern management. 

HEART COMPLICATIONS.—// is wholly improbable that any case of 
acute severe rheumatism wholly spares the heart, but undoubtedly the myocardium, 
pericardium, and, in certain instances, even the endocardium, may be involved 
in what may prove to be but a temporary and relatively slight lesion. 

The myocardium itself rarely, perhaps never, wholly escapes and doubtless 
we have little conception of the damage wrought as relating to future degeneration 
of the muscle, becoming manifest only after the lapse of many years. 

It is sometimes said that the danger is equally great in light and in 
severe forms, but it is probable that this is based largely upon the remarkable 
frequency of cardiac involvement in the acute rheumatism of young children 
showing slight articular lesions. According to the author's experience with 
the older children and with adults the danger of cardiac involvement is 



Temporary 

cardiac 

lesions. 



1152 



MEDICAL DIAGNOSIS 



Recurrences. 



Localization. 



Rapid 
deterioration. 



certainly graver in the severe attacks, though heart involvement may, and 
often does, occur in the case of slight monoarticular lesions. 

Frequency of Complications. — On the average at least one case in three 
will show a permanent residual endocarditis in a first attack and if one in- 
cludes the cases in which the endocardium apparently is affected, but seems 
to clear up with convalescence, the percentage is raised to James Mackenzie's 
figure, 58 per cent. In young children 80 per cent, is given by some authori- 
ties. 

Were cases watched, as they should be, always, for several months after 
apparent convalescence, we should raise our present figures by the inclusion of 
mitral stenosis and residual chronic myocarditis now largely overlooked on 
account of the slow development of definite physical signs. 

Errors of Omission. — The usual method of handling the rheumatic patient 
both during and after convalescence and the well-nigh universal failure to recognize 
the minor dilatations and the lesser signs of decompensation prevent, in many 
instances, a full recovery from the myocardial toxemias (90 -f- per cent, of the 
severe cases show demonstrable slight dilatation) or actual acute myocarditis (30 
per cent.), which conditions the author believes constitute the chief and most direct 
causes of the persistent physical weakness present in, and often persisting long 
after, the severe attacks {see "Minor Dilatations," etc.). 

Pericarditis is a very common complication (7 to 10 per cent, in adults and 
10 to 20 in children) and the physician must remember the frequency with which 
it runs a relatively painless course both during this intrinsically painful primary 
ailment and when itself dominating the field. He also must be careful to avoid 
the common error of mistaking a weak and widely dilated heart of myocarditic 
origin for pericarditis with effusion or vice versa. 

Universal Involvement of the Heart Tissues. — In children a severe pan- 
carditis is relatively common, and with each recurrence of acute rheumatism or 
tonsillitis the danger of cardiac involvement increases, and old lesions are likely 
to be relighted. 

When a persisting endocarditis does occur, between 90 and 95 per cent, 
of the cases will show mitral involvement which in many instances proves 
ultimately to be a double (stenotic and regurgitant) lesion. Isolated aortic 
lesions constitute 5 per cent.; mitral lesions alone, 72 per cent.; combined 
aortic and mitral lesions, 18 per cent.* 

The Right Heart. — The right heart largely, but not invariably, escapes 
permanent recognizable endocardial damage though almost invariably more 
or less dilated in severe attacks. The valves of the hardest worked side of 
the heart suffer most and oftenest. 

Blood. — As might be expected from the nature of the microorganisms 
apparently responsible for its occurrence, a rapidly induced anemia of a 
decided, but seldom extreme, grade, is a pronounced characteristic of acute 
rheumatism. It is of the secondary type, usually improves rapidly under 

* The latter figures are those of A. R. Edwards. It should be remembered that all 
available statistics represent ward cases in public hospitals. Private practice amongst well- 
to-do people should yield much lower figures. 



ACUTE RHEUMATISM 



"53 



treatment when the stage of convalescence is passed, but may be extreme or 
relatively intractable in some instances,* an occurrence which usually means 
the continued activity of a focal source of infection. A moderate leucocytosis is 
the ride. 

Blood Cultures. — Blood cultures are usually negative for the "Micrococcus 
{sen Streptococcus) rheumaticus" which does not reproduce itself in the blood or 
endure for long even in the joint exudate. Cultures from the exudate within the 
subserous periarticular connective tissue are said to be positive usually. 

Urine. — Albuminuria with an occasional cast and the usual findings 
characteristic of a urine of fever and toxemia are common, especially in the 
fully developed cases so largely represented in public hospital admissions. 

Skin. — Sitdamind. white or red or usually both, are extremely common. 

Rheumatic nodes seem to represent a subcutaneous expression of rheumatism 
running somewhat parallel in occurrence to endocarditis and pericarditis with 
which complications they are usually associated. Their embolic nature and 
structure are practically identical with that of the endocarditic vegetations .f 

Varying in size from that of a pin's head to that of a very large pea, or 
even an almond, they appear chiefly, though by no means exclusively, in 
children and during the third or fourth week of illness. They are localized 
usually over the region of the tendons, joint capsules or bony promi- 
nences almost everywhere. The wrists, fingers, elbows and spine are of tenest 
affected. Slightly stretching the skin over them makes them plainly visible 
by oblique light. Chronic cases often show them and in such cases 
some fibrosis is present. They may come and go within three or four 
days' time. 

They are hard and painless and must be carefully distinguished from the 
tender and painful cutaneous nodules of malignant recurrent endocarditis. 

Erythema multiforme and purpuric rashes are not uncommon. 

Gastrointestinal Tract. — Constipation is the rule and appetite is usually 
wholly lacking until convalescence is well under w T ay. 

Respiratory Tract. — Aside from the rare crico-arytenoid arthritis, the still 
rarer acute laryngeal edema, terminal pulmonary edema, and infarction aris- 
ing from complicating endocarditis or myocarditis, the only pulmonary com- 
plications are the pleurisies and pneumonias so frequently associated with 
rheumatic pericarditis and pancarditis. 

Nervous System. — Cerebral rheumatism is a rare and relatively fatal com- 
plication indicated by hyperpyrexia, delirium, convulsions and coma. The 
hyperpyrexia may be lacking in some cases. 

It may be preceded by vomiting, headache, delirium, excessive insomnia, 
cutaneous irritation or frequent micturition. It should be borne in mind 

* Jochmann quotes Grawitz as stating that in rheumatism the hemoglobin content, 
blood count, and specific gravity are usually unaffected. Such a statement is wholly out of 
accord with the findings of such careful investigators as Poynton and his co-workers and 
certainly opposed to the personal experience of the author. Furthermore, it is wholly out 
of harmony with the clinical type of the disease. 

t Poynton and Payne have shown sections of the nodules showing them to be the result 
of bacterial thrombi and resulting exudation necrosis. 
73 



Febrile 
albuminuria. 



Curious 
parallelism. 



Size and 
appearance 
of nodes. 



Distribution. 



Important 
distinction. 



Complications 
of a compli- 
cation. 



H54 



MEDICAL DIAGNOSIS 



Joint abscess. 



that, although it usually occurs in the third or fourth week, it may arise 
during apparent convalescence. About 50 per cent, of such cases die. 

Chorea is extremely common in children who have had rheumatism, 
especially so in those carrying a chronic endocarditic lesion. 

Poynton states that of 500 juvenile cases of heart disease reporting for 
treatment, 220 came "from chorea." Of these 220 cases, 122 had obvious 
organic heart disease (51 per cent.); "thirty-eight had dilatation with rheu- 
matic arthritis and pain" (17 per cent.); ten followed a sore throat (4 per 
cent.); four developed later demonstrable organic heart disease — 81 per cent, 
in all more or less directly showing a rheumatic association. 

DIFFERENTIAL DIAGNOSIS.— Septic arthritis is usually associated 
with rigors, a higher leucocyte count, the frequent existence of a known gross 
pyemic focus, a purulent joint exudate and lack of early recession. Theoret- 
ically, the differentiation may be difficult; practically, this is seldom the case. 

Pneumococcus Arthritis. — This is seldom polyarticular though two joints 
may be affected. The joint exudate may show the pneumococcus. 

Acute Tuberculous Arthritis. — In the acute stage tuberculous arthritis 
may be clinically undifferentiable, but it is usually actually or dominantly mono- 
articular and persistent, the onset is less sudden,* the fever less high; an active 
pulmonary focus may often be demonstrated, and the previous health and 
family history may be most suggestive. 

Certainly no mistake is likely to occur if the clinical history of acute 
rheumatic joint swelling is held in mind. 

Scarlatinal Rheumatism. — This is distinctly a serous or, less often, septic 
arthritic complication of a known case of scarlet fever (4 per cent.) and can seldom 
be called "out of its name. ,> It occurs usually during the second week of this 
disease and, according to Ker, almost invariably appears if the scarlatina victim 
previously has passed through an acute rheumatic arthritis. 

Miscellaneous Secondary Arthritides. — In many other diseases arthritis 
is a known complication, a more or less distinct possibility, or a recognized 
component, and the primary disease names the associated joint disturbance. 
Such are pneumonia^ cerebro-spinal meningitis (serous or septic), typhoid 
fever ("typhoid spine"), Malta fever, dengue, peliosis rheumatica, secondary 
syphilis, influenza, etc. 

Anterior Poliomyelitis. — In the early stage multiple joint pain may be 
present but every other sign of acute rheumatism is lacking. 

Osteomyelitis. — Every case of apparent joint inflammation in the child 
must raise the question of possible osteomyelitis, for mistakes are frequently 
made, too often without justification, for in most instances the swelling of 
osteomyelitis is unlike that of rheumatism in appearance, feel, and 
location. 

It is maximal at the epiphyses, local and constitutional symptoms are 
more intense, leucocytosis is usually high, blood cultures are often positive 
and rigors are common. 

* Unfortunately certain cases of juvenile rheumatism also develop slowly over several 
or many days. 



ARTHRITIS DEFORMANS 



"55 



Localization of the inflammatory focus and prompt operation are the chief 
requisites in osteomyelitis, and here an error in diagnosis usually costs a life. 

Acute Arthritis Deformans. — This cannot be differentiated with certainty 
from acute rheumatism by any means known to the author until its intractability 
to antirheumatic remedies of known potency and its persistent course become 
manifest. 

In the few cases seen by the author a significant persistence or unusually 
long duration of the individual joint swelling has been present. In these 
cases one might see all affected joints in full career for a considerable period, 
a condition quite contrary to the rule in acute rheumatism. Predilection for the 
wrist-, finger-, ankle-, and toe-joints often exists, but can only serve to 
arouse suspicion as such involvement may be decided in true rheumatic 
arthritis. 

Gonorrheal Arthritis. — A monoarticular arthritis affecting the wrist or 
knee alone is in itself sufficient to arouse suspicion, no less than its peculiar 
fixity or sluggishness, relative intractability and slight or absent response to 
anti-rheumatic remedies. 

When polyarticular it might confuse diagnosis, yet the persistence of the 
joint swelling is usually suggestive. 

Furthermore, any acute gonorrheal polyarthritis is almost certain to be 
associated with a readily demonstrable urethral or vaginal discharge. 

Direct detection of the causative coccus is then easy and the complement 
fixation test is definite. 

Recurrence in Acute Rheumatic Arthritis. — Unless the foci existing at Foci must be 

,..,. ,.., . ... eradicated. 

the portals of infection are eliminated, recurrence is common when the malign 
conjunction of excessive fatigue, exposure to cold and wet, and "sore throat," 
arises, and relapses may occur repeatedly and extend over several months. 

In the latter case one may be obliged to consider tonsillectomy or other 
necessary procedure even during the attack itself. 

The younger the individual once attacked, the greater is his vulnerability 
to renewed attacks and his danger from cardiac complications. 

PROGNOSIS. — The direct mortality is trivial ; the indirect, deferred and ultimate m r- 
remote death-rate is frightful. No disease outranks rheumatism in impor- 
tance and it kills almost wholly by the complications it induces. 

ARTHRITIS DEFORMANS.— Preliminary Comment.— Although the 
specific cause, of this formerly hopeless and progressively crippling ailment 
cannot be positively stated at the present time, it seems to be clearly shown to 
be the result of infection and to arise in most instances from chronic crypto- 
genetic foci containing streptococcic strains strikingly resembling or identical 
with the Streptococcus viridans. 

The gratifying results obtained in many instances and by many indi- 
viduals, including the author, by the institution of radical procedures in the 
removal of chronic foci of streptococcic infections have been both striking 
and illuminating, and it is altogether probable that within a reasonable time 
we may speak definitely as to the specific etiologic factors in relation to this 
disease. 



1156 



MEDICAL DIAGNOSIS 



Haygarth's 
nodosities. 



Heberden's 
nodes. 



'Poker spine. 



Acute form 
like rheuma- 
tism. - 



Exhaustion 
and malnu- 
trition. 



Pain variable 



Affects Women Chiefly. — This chronic and obscure disease of the joints 
chiefly affects women and in them is frequently associated with the meno- 
pause. It is most common between the ages of thirty and fifty, but not rare 
in younger persons, and differs from gout in the absence of arthritic deposits 
of sodium urate, and from so-called chronic rheumatism in its marked atro- 
phic or hypertrophic changes in the cartilages and bones. 

Three Types. — The three recognized types depend upon both pathologic and 
symptomatic differences and we recognize a predominance of changes in {a) the 
periarticular and synovial structures, (b) predominating atrophy of bone and 
cartilage, (c) hypertrophy. 

Osseous proliferations occurring at the joint margins are known as 
osteophytes, or, on the knuckles, Haygarth's nodosities. Any joint and even 
the whole spine may become ankylosed. Marked deformity and mus- 
cular atrophy and contractures are often associated with neuritis and atro- 
phic changes. The lateral nodules frequently seen on the distal phalanges 
are known as Heberden's nodes. They are seldom or never associated 
with cases involving the larger joints. Single joints may be involved, 
the spinal column, shoulders, hip, and knee being the common sites. This 
form is most common in men and at advanced ages. 

The spine alone may be involved (spondylitis deformans, "poker back") 
associated with ascending degeneration of the cord, and pain, muscular 
atrophy and anesthesia, due to involvement of the nerve roots. If the 
hip and shoulder joints are also involved [spondylose rhizomelique) the nervous 
symptoms are moderate or absent and the whole or only a part of the spine 
may be affected in certain instances. 

General Progressive Arthritis Deformans. — The onset of the acute form 
exactly simulates subacute rheumatism and differentiation is at first impos- 
sible. The absence of a complicating endocarditis and the persistence of the 
inflammation in the joints first affected, together with the lack of reaction or 
response to anti-rheumatic medication, are points of value, strengthened 
by the later development of fixation and crepitation. Mental depression and 
emaciation are marked and the attacks frequently bear a relation to lactation 
and child-bearing or other nutritionally depressing influences. 

The chronic form usually succeeds one or more acute attacks, and there is 
pain on movement, inflammatory swelling, and a variable amount of effusion. 
The tendency is to gradual progression and symmetrical involvement, the 
hands, knees, and feet being usually the earliest points of attack. 

The ordinary form of chronic, or subacute recurrent, rheumatism, asso- 
ciated with a history of previous rheumatic attacks and lacking, as a rule, 
any extreme deformity or ankylosis, is usually of relatively slight importance. 
In gouty arthritis there are deposits of sodium urate in the soft parts which He 
just beneath the skin and often perforate it, differing from the nodules of 
hypertrophic arthritis in their mobility. The apparent deformity is often 
very marked, the actual destruction relatively slight. 

Pain may be moderate or extreme and is of the neuritic type. Crepita- 
tion appears, there is marked deformity, and finally a firm ankylosis due to 



RECURRENT INFECTIOUS ARTHRITIS 



1157 



periarticular infiltration and adhesion. The muscular atrophy, usually 
that of disuse, is nevertheless marked and may be so rapid as to suggest a 
central cause, which presumption is strengthened by the glossy or pigmented 
skin, onychia, and paresthesia. The anemia may be marked and the disease 
may render the patient absolutely helpless. 

CHRONIC OR RECURRENT INFECTIOUS ARTHRITIS {Toxemic 
Arthritis, Chronic Rheumatism). — In the light of modern knowledge with 
respect to the etiologic factors active in cases of acute and subacute rheuma- 
tism, and noting the pronounced tendency to exacerbations evident in this 
formerly obscure ailment, together with their relationships to antecedent ton- 
sillar infection or the presence of cryptogenetic septic foci, one can hardly 
doubt the correctness of the old view that it represents chronic rheumatism, 
and is primarily of streptococcic origin* 

Foci of Infection. — The most astonishing results have followed the work 
of both dental and medical colleagues of the author in the hospitals of the 
University of Minnesota and in private ofiice practice following the radical 
removal of diseased tonsils, the cure of chronic sinusitis, the correction of peri- 
dental infection, and the establishment and maintenance of improved nutrition. 

It should be stated that in many of these cases, as in those of u arthritis 
deformans" many of which show a most decided and favorable response to 
the same measures of treatment, the disease may persist for several weeks or 
even months, usually in an attenuated form, even though actual progress 
may have ceased. It has seemed probable that in some of these cases a 
residual streptococciosis, of the rheumatic type in the former group, viridans 
in the latter, tended to persist and for a time undergo reproduction in 
the subserous synovial tissue. 

STILL'S DISEASE. — This is a chronic progressive arthritis especially 
affecting children during the first dentition, is insidious with respect to onset 
and course alike, appears first in the knees or wrists, rather than in the small 
joints as is the case with its congener in the adult, and is associated with 
leucocytosis, enlargement of the spleen, swelling of the glands tributary to the 
joints, subnutrition, and arrest of development in many instances. 

SYPHILITIC ARTHRITIS {Syphilitic Rheumatism) .—Luetic arthritis is 
never generalized and though the acute form involves several joints, more 
than three are seldom affected. The subacute form is usually monarticular. 
Beyond a mild remittent fever a variable amount of localized pain and ten- 
derness and its prompt response to properly applied specific treatment, the 
ailment offers nothing of special importance. The fact that it occurs usually 
at the time of onset of the secondary manifestations of syphilis makes oppor- 
tunities for error negligible. 

GONORRHEAL ARTHRITIS {Gonorrheal Rheumatism).— This trouble- 
some and persistent complication may result from infection of any mucous 
membrane with the gonococcus of Neisser and, as in the case of acute rheumatism 
any antecedent joint injury, strain or inflammation seems to invite arthritic 

* The author feels that as a title, recurring subacute arthritis would best suit the greater 
number of these cases. 



Crepitation 
and ankylosis. 



Trophic 
symptoms. 



n;8 



MEDICAL DIAGNOSIS 



A myth. 



Children. 



An aid to 

diagnosis. 



Unlike acute 
rheumatism. 



localization of the organism. In most instances an active urethral or vaginal dis- 
charge exists at the time of the onset of the arthritis, but if, as is commonly the case, 
relapses or recurrences arise, all such evidence of its true causation may be lacking. 

It was supposed formerly that male predominance was very marked, but 
this is not wholly true and, in large public clinics especially, Xeisserian 
arthritis is nearly as common in the female as in the male. Under the same 
conditions, it is astonishingly frequent in children and the specific infection 
is readily disseminated in public schools or other institutions of a similar 
type. In children the disease is frequently or generally polyarticular and 
may affect both the large and small joints. In the adult the knee-joint is 
primarily affected in about three-fourths of the cases. The active inflam- 
mation and pus formation are usually lacking and the joints may be either 
relatively painless or excessively tender. 

According to the author's experience the acute polyarticular cases are 
fortunately associated with an active visible or demonstrable genital infec- 
tion in nearly every instance. 

Incubation Period. — With respect to its onset in relation to the date of 
the primary infection, we rind that it is usually postponed for three or four 
weeks, but that it may occur during the first ten days. 

Mode of Onset. — Its onset is usually relatively gradual, associated with a 
moderate elevation of temperature and in most instances unattended by chill. 
Its duration is extremely variable but chronicity and relapse constitute the 
rule and a considerable degree of atrophy of disuse or actual deformity 
may result. 

Localization. — As previously stated, the disease is usually monarticular 
involves by preference the wrist or knee joint, but may also affect the shoul- 
der, wrist, hands, feet, hip, sacro-iliac joint, temporo-maxillary or even the 
sterno-clavicular articulations. 

Diagnosis. — The polyarticular cases are quite commonly mistaken for 
an acute rheumatism, especially if the examination is superficial or any 
active discharge from the urethra lacking. The ailment, however, varies 
strikingly from acute rheumatic arthritis in the behavior of the joints affected 
both as to acuteness of onset and relative promptness of recession on the part 
of individual joints. The superficial signs of inflammation are less marked. 
Tenderness usually but not always much less extreme. 

The diagnosis is usually made relatively easy by the recovery and staining 
of the gonococcus from an active or latent discharge and the complement- 
fixation test is positive. 

Complications. — Heart complications are fortunately rare but when they 
do occur may prove serious and intractable. 

STATIC AILMENTS.— Flat-foot, relaxed sacro-iliac joints, chronic bursal 
inflammations and the like call for no consideration in this volume but belong 
to the surgeon and the orthopedist. It may be stated incidentally that in 
many cases of sacro-iliac relaxation apparently responsible in some instances 
for persistent pain in the sacro or lower lumbar region are distinctly asso- 
ciated with the visceroptotic manifestations of universal congenital asthenia. 



MYOSITIS 



1159 



ACUTE NON-SUPPURATIVE POLYMYOSITIS 

(Dermatomyositis) 

Definition. — A rare febrile ailment representing an acute, progressive in- 
terstitial myositis combined with dermatitis and edema of the tissues overlying 
either the flexor or extensor surfaces of the muscles affected. 

Etiology. — The exact cause is unknown, but the entire course of the 
disease, together with recent investigations relating to its bacterial flora, 
indicate its infectious nature. No important predisposing factors are con- 
stant and the disease usually attacks persons in full health. 

Symptoms. — A sudden febrile onset, lacking chill, with general malaise, 
and considerable pain and tenderness over certain muscles, is the first indica- 
tion. This is followed by swelling and induration of the affected parts and 
associated with increased fever and usually a dermatitis and edema which 
destroys the normal contour of the region involved. 

In most instances the muscles are involved in succession and by groups, 
and to such an extent as ultimately to make the process practically universal. 
In certain cases, however, only a few groups are affected. The edema, 
on the other hand, usually involves at first only the extensor or flexor surfaces, 
giving the affected regions a peculiar and somewhat characteristic appear- 
ance. 'It was supposed formerly that the muscles of the eye, larynx and 
tongue were spared, but many cases are now reported in which these were 
affected as well as those of the pharynx, the latter complication often leading 
to a fatal termination through inability to take food. 

Speech may be affected by the involvement of the muscles of the tongue 
and in many cases severe and fatal asphyxia occurs from involvement of 
the muscles of respiration or the patient dies of broncho-pneumonia. 

The edema may not pit on pressure and as seen in the face and eyelids 
gives the skin a tense, alabaster-like immobility suggesting acute Bright's 
disease or trichinosis. 

Tenderness is usually extreme and the dermatitis may be associated with 
or substituted by bullae, eczema, erythema or urticaria, or strongly resemble 
true erysipelas. 

The nerves ordinarily are not involved though a certain form usually 
described under another name presents both neuritis and myositis, this 
conjunction being probably merely fortuitous. 

The proximal muscle groups are usually first involved and, fortunately, 
the wrist- and ankle-joints are ordinarily spared any excessive involvement. 
The disability and helplessness of the patient together with the pain which 
steadily increases makes a pitiable clinical picture. 

Duration. — The duration of the ailment is usually from two to eight 
weeks. In the subacute form it may be from four to nine months, or become 
chronic and endure from one to two years. 

The mortality is extremely high, even under modern treatment averaging about 
60 per cent. 

Differential Diagnosis. — Trichinosis presents a superficial resemblance 
in its muscle pain and disability as well as the swelling of the face, but is 



Extraordinary 
combination. 



Progresses by 
groups. 



Peculiar 
distribution. 



Serious 
complications. 



Misleading 
resemblance. 



"Neuromyo- 
sitis." 



Line 

of march. 



n6o 



MEDICAL DIAGNOSIS 



readily differentiated by the lack of trichinae in the excised muscle and in 
the stools no less than in the striking and somewhat characteristic outward 
symptoms present in this form of myositis and the high grade of eosinophilia 
invariably present in trichinosis. 

Primary suppurative myositis can hardly be confounded with the non- 
suppurative form because of its distinctly septic type of fever, profuse sweats, 
localized indurated swellings and its occurrence in one of three forms, 
each of which asserts its character at the outset, the one being multiple from 
the start, the other a single focus from which multiple areas of localized and 
circumscribed suppuration develop later, the third, infiltrating. The entire 
course is radically different from that of the non-suppurative myositis. 

Syphilitic myositis is usually discussed but in none of its forms does 
it bear any decided resemblance to the disease now under consideration. 

HEMORRHAGIC POLYMYOSITIS.— Definition— A disease of un- 
known origin affecting the muscles, resembling non-suppurative myositis, 
running an acute, subacute or chronic course and characterized by inter- 
stitial hemorrhage between the muscles, a tendency to a purpuric or morbilli- 
form exanthem, an almost invariable tendency to serious involvement of 
the myocardium, and frequent nephritic complications. 

Etiology. — No specific organism has been proven though staphylococci 
have been present in some cases. Nevertheless its infectious character cannot 
well be doubted, and it usually follows tonsillitis. 

Pathology. — The changes are primarily those of intermuscular hemor- 
rhages and degeneration of the muscle fibers succeeded, in the chronic stages, 
by an extensive production of connective tissue. 

Symptoms. — In general these are almost identical with those of non- 
suppurative acute primary myositis and the same tendency to involvement 
of muscle groups in progressive succession is shown. The pain is sharply 
circumscribed and definitely localized. The onset is more abrupt than in the 
non-hemorrhagic form and the fever somewhat lower. Symptoms of decided 
cardiac involvement appear early and collapse is a frequent occurrence. The 
peculiar skin eruption is striking and somewhat distinctive in its combi- 
nation with an unmistakable primary myositis. Hemorrhage may occur 
from mucous membranes and nephritis is extraordinarily frequent as a 
complication. 

Differential Diagnosis. — No confusion is possible if the striking and 
characteristic symptom-complex is held in mind. 

Prognosis. — Its mortality probably is about that of the acute non- 
suppurative myositis, viz., 60 per cent. 

ACUTE PRIMARY SUPPURATIVE MYOSITIS.— Definition.— An acute 
myositis presenting the clinical picture of an acute septic infection and un- 
questionably due to the action of pyogenic organisms. Presumably it is a 
secondary septic infection with a peculiarly specific localization . in most 
instances. 

Varieties. — It occurs in three chief forms: one, disseminated foci; two, the 
large isolated abscess; three, diffuse purulent infiltration. A large proportion 



MYOSITIS 



Il6l 



of the cases show but a single suppurative focus, and the pathologic changes 
described by various observers are only those that would be anticipated in an 
ailment of this peculiar character and localization. 

Symptoms. — The onset is abrupt and florid, an initial chill being followed 
by high fever, profuse sweating and the general malaise and aching character- 
istic of the toxemia of severe, acute infections. Pain, at first general, pro- 
gressively increases and becomes definitely localized in the muscle or muscles 
affected and these become the seat of tender, painful swelling involving the 
entire muscle and of an extremely indurated resistant character. Slight, 
overlying edema may be evident, the muscle is contracted and the part 
affected completely disabled. In nearly every instance the primary 
swelling undergoes the usual changes incident to abscess formation and 
demands prompt and radical surgical intervention which is usually followed 
by recession of symptoms and complete recovery after an interval of several 
weeks. If the abscess is neglected the usual dangers of general pyemia are 
encountered. Death may occur from this cause or from pneumonia but 
nearly all cases recover under proper treatment without permanent disability 
of the part or parts affected. 

SYPHILITIC MYOSITIS.— Luetic myositis may occur in any one of 
three different forms, two of which pertain to the secondary stage ; the third 
to its early tertiary period. The secondary forms are: (1) A peculiar swelling 
slowly becoming indurated; (2) a circumscribed or diffuse primary infiltration, 
painless and associated with no tenderness except at the point of insertion 
of the tendon of the muscle affected. 

In this latter form, or perhaps in both, fever may be present but is of a 
moderate grade and the disease shows a peculiar and characteristic predilec- 
tion for two muscles of the body, viz., the biceps and the rectus jemor is. 

Comment. — It is important that these secondary manifestations be borne 
in mind for in them as in the tertiary form of luetic myositis which is merely 
that of gummatous deposit, that which is a troublesome somewhat persistent 
and to some extent disabling lesion will vanish promptly under antisyphilitic 
medication. The tertiary syphilomata if promptly treated will recede usually 
without breaking down and forming scars. If not so treated they may soften 
and discharge outward. Inasmuch as the tongue together with the sterno- 
mastoid muscle are the favorite sites, considerable discomfort and humiliation 
may be avoided by prompt therapeutic measures. It is unnecessary to 
remind the reader that whatever the preferential location of such syphilitic 
lesions may be, any muscle may be affected. 

TUBERCULOUS MYOSITIS.— This exceedingly rare form of myositis 
may complicate a miliary tuberculosis and doubtless represents one variant 
of primary hematogenous tuberculous infection. It may involve one or many 
muscles, occurs in rare instances as a complication of chronic pulmonary 
tuberculosis and should be remembered as a remote but not unimportant 
clinical possibility. 

MYOSITIS FIBROSA.— This condition is one of pathological interest 
chiefly, wholly lacking constitutional symptoms and, usually, absolutely or 



Septic 

manifestations. 



Three forms. 



Responsive to 

specific 

medication. 



Excessively 
rare. 



A medical 
curiosity. 



Il62 



MEDICAL DIAGNOSIS 



"The ossified 
man." 



Primary and 

Secondary 

cases. 



Two etiologic 
types. 



Fatigue. 



Toxemia and 
vascular dis- 
orders. 



relatively painless, save in those cases in which an extensive transformation 
of muscles into fibrous tissue occurs as a result of months or years of develop- 
ment. 

Etiology. — It is said to be associated with chronic simple or septic inflam- 
matory changes in the muscles primarily or in neighboring joint structures 
and occasionally follows extensive, long-sustained skin ulcer or eczema. 

MYOSITIS OSSIFICANS.— Definition.— An extraordinary and exces- 
sively chronic disease constituting one of the curiosities of medicine and char- 
acterized by an excessively gradual transformation of the muscle fibers and 
interstitial connective tissue of the aponeuroses, tendons, and their sheaths 
into bony tissue following a stage of painful swelling of the affected structures. 

Varieties. — There are two chief forms: one, a spontaneous progressive 
polymyositis ossificans developing in youth or early adult life and primarily 
involving in most instances the muscles of the back and neck; second, a 
secondary form apparently owing its inception to chronic injuries or preexist- 
ing disease of the joints, excessive muscular strain or like conditions. The 
pitiable victim of this ailment often falls into the hands of the proprietors 
of side shows where he is shown as the "ossified man." 

MUSCULAR CRAMP. — This constitutes one of the most painful and 
distressing of the relatively common affections and would seem to fall into 
two groups with respect to etiology. First, the cases immediately or at least 
definitely attributable to excessive muscular activity, strain or exhaustion 
as affecting specific neuro-muscular units, conditions frequently seen in con- 
nection with forced marches, acute overexertion on the part of such as are 
unfit, or, the chronic fatigues of certain monotonous occupations demanding 
the persistent daily use of certain muscle groups. 

Second, the toxemic cramps associated with chronic nephritis, diabetes 
and many other ailments acute or chronic. 

Symptoms. — These represent merely an involuntary, extreme and, usually, 
excessively painful, spasmodic tonic contraction of the muscle group affected, 
this in the commoner form being the muscles of the calf of the leg. Such 
attacks may be brief or prolonged, recurrent, isolated, or, in certain occu- 
pational neuroses, may attain a definite chronicity of occurrence. 

MYALGIA (Muscular Rheumatism). — Preliminary Comment. — It is 
wholly probable that the term " muscular rheumatism" more accurately ex- 
presses the basic etiology of this formerly obscure and extremely common 
ailment than does the term "myalgia" Recent, investigations suggest 
that the causative factor in this excessively painful and troublesome ailment 
must be sought in the cryptogenetic foci so potent in relation to the causa- 
tion of acute rheumatism and many other less concrete ailments. Like 
rheumatism, this so-called myalgia occurs frequently as a sequel of tonsillitis 
and is peculiarly likely to develop after exposure to cold and wet under con- 
ditions of fatigue or overheating of the bod}". 

Preferential Sites. — Myalgia usually takes the form of lumbago, torti- 
collis or so-called pleurodynia, though almost any muscle group may be 
involved if the predisposing or determining factors mentioned are present. 



DIABETES MELLITUS 



1 163 



Symptoms. — Save in the case of pleurodynia the amount of pain present 
in this ailment is dependent chiefly upon the voluntary use of the muscle 
group affected. In the former, movement is obligatory, but, in general, 
spontaneous pain is relatively slight or wholly absent, though localized tender- 
ness may be extreme. 

Diagnosis. — The presence of tenderness over the muscles involved and 
the prompt pain response to movement make the diagnosis. Care must be j 
taken lest a persisting torticollis due to organic disease be mistaken for Torticollis, 
myalgia, which is ordinarily of but a few days duration, and pleurodynia must 
never be accepted as genuine without a careful examination of the heart, lung, 
and pleura. Furthermore, a strikingly similar pain of true intercostal Pleurodynia, 
neuralgia characterized by tenderness along the course of the nerves affected, 
paroxysmal pain independent of movement and definite points of maximal 
tenderness must be borne in mind. Another condition of which the pre- 
ceding ailment may be the precursor is il herpes zoster" one of the most "Shingles.' 
excruciatingly painful of all minor afflictions and characterized by its long- 
deferred declaration of identity in the form of multiple herpetic vesicles at 
the known points of superficial, cutaneous, intercostal distribution. 



CERTAIN IMPORTANT CONDITIONS OF UNKNOWN CAUSATION 
OR LACKING A PROPER DESIGNATION 

DIABETES MELLITUS 

Definition. — A disease of general metabolism of unknown causation char- 
acterized by a permanent inadequacy on the part of those organs or tissues Endocrin dis- 
normally charged directly or indirectly with the storage, fixation, consumption 
or orderly release and proper distribution of grape-sugar; such inadequacy being 
manifested invariably by an excess of sugar in the circulating blood, by resultant 
glycosuria, and, in the established and advanced disease, by a ketone acidosis. 

A Modern Hypothesis. — The pancreas is functionally a gland of both 
internal and external secretion and in its so-called "islands of Langerhans" Sisiai 
it possesses tissue elements embryologically and functionally distinct from 
that of its glandular acini which are concerned with the production of its 
external secretion and strikingly resistant to many adverse conditions which 
cripple or destroy the body of the pancreas. 

These islands, the so-called "insular apparatus," are believed at present 
to produce normally a hormone which is essential to the adequate control of Hormone 
glycogenesis and the formation and elimination of acetone (ketone) bodies 
in the human organism, and to be in great measure independent of the 
pancreatic tissues concerned in external secretion. 



Langerhans. 



A proper balance between the action of this pancreatic hormone and Balanced 
adrenalin is thought to be indispensable, the former building up glycogen j 
in the fiver and muscular system; the latter breaking it down and accelerating 
its transformation into sugar. 

The old experiment of Claude Bernard, who produced glycosuria by 



1 1 64 



MEDICAL DIAGNOSIS 



Action of 

pancreatic 

hormone. 



Neurogenous 
diabetes. 



Glucose. 



Cli.nicai 
glycosuria. 



Intermittent 
cases. 



puncture of the floor of the fourth ventricle, in all probability depended upon 
the production thereby of a splanchnic stimulus to the chromaffin tissues 
which resulted in the unloading of an excess of adrenalin and a dominance of 
the adrenalin influence over that of the insular pancreatic hormone devoted 
to conservation and supply. 

Falta summarizes the subject admirably in the following words: 

" The pancreatic hormone is an exquisitely assimilatory hormone, and governs glycogenesis 
in the liver and muscles. In the light grades of insufficiency the disturbance in carbohydrate 
metabolism occurs only when there are instituted great demands on glycogenesis in the liver 
{alimentary overloading with carbohydrates). In the severer disturbances there occurs, in 
addition to the disturbance in anabolism, a marked increase in catabolic processes and thereby 
a faulty decomposition of higher and lower fatty acids (keionuria)" 

Diabetes does not depend wholly upon a disturbance of function or 
anatomic integrity of the pancreas. 

It would appear that two distinct elements enter into clinical diabetes 
mellitus; one, the disturbance in storage, proper distribution, and assimila- 
tion preliminary to properly regulated combustion; the other, to an excessive 
and illy-regulated transformation of the alimentary intake into sugar. 

Associated with the former there is an imperfect transformation of albu- 
min and fats which results in the excessive formation of acetone bodies 
(acidosis). 

The introduction of Allen's methods of treatment makes the prognosis 
better than ever before. Carbohydrate tolerance can now be accurately 
and scientifically determined and fewer patients die from faulty dieting. 

It is evident that the adrenals and the chromaffin system may play a 
chief part in some instances and so-called "neurogenous diabetes" is thought 
to be the result of persistent stimulation of the chromaffin system, these 
originating in the higher centers and acting through the splanchnic and many 
glands other than those mentioned may play a part. 

The scope of this volume permits no further advance into this fascinating 
realm and we must turn to the more prosaic clinical aspects of diabetes 
mellitus. 

Clinical Definition. — In a purely clinical sense glycosuria comprises all 
conditions under which the urine contains grape-sugar (glucose) in sufficient 
quantity to respond to the ordinary tests. In short, all diabetics have gly- 
cosuria, but all who have glycosuria are not diabetics* Sugars of various kinds 
may be found in the urine, but glucose is the one of especial interest to the 
physician. Normal urine contains it, as it does albumin, but not to an extent 
that can produce any confusion in clinical work; hence any urine that shows 
sugar, when tested according to methods here recommended, is abnormal. 

Furthermore, glucose or dextrose may appear either persistently or in- 
termittently in the urine of apparently healthy persons and no sharp line 
separates the benign from the pathologic condition, save that suggested by 
Stengel, who says that all cases fall under one of two classes, viz.: First, 

* It must be remembered that in diabetes sugar may be elaborated from substances 
other than carbohydrates. 



DIABETES MELLITUS 



Il6' 



recession. 



marked. 



those easily controlled {simple glycosuria); second, those that are relatively in- 
tractable {diabetes mellitus). The urine of one who takes into a fasting 
stomach phloridzin or large quantities of glucose, a woman recently delivered, 
or the man with a brain injury may temporarily contain sugar. The stout 
high-living individual may carry such a condition for many years (lipogenic 
diabetes) without serious impairment of health; but lapse of time alone suffices 
to prove the benign nature of any given case. Glycosuria may entirely disappear Temporary 
for long periods, only to recur, and, not infrequently, to assume a malignant 
form. Such periods of latency cannot be justly estimated, and the very 
causes that are assigned for benign glycosuria are quite commonly associated 
with the development of diabetes mellitus. The conditions under which 
pathologic glycosuria develops are in brief the following: 

Age. — It occurs at all ages, but chiefly in obese individuals in their fifth 
and sixth decades. Its prognosis is inversely as the age of the individual. 
Children rarely recover save when the disease onset is mild, recognition 
prompt and treatment early rational and efficient, and in them the course 
may be astonishingly acute. 

Sex. — Eighty per cent, of the cases occur in males. 

Race. — Certain races suffer greatly from disease. In Tunis and in Malta 
its ravages are comparable to those of tuberculosis in European countries, influence 
This, however, applies chiefly to city dwellers. Hebrews are especially 
liable to the disease. An enormous increase has been noted in certain cities 
during the last three decades. In Danish cities and in Paris, for example, 
the mortality is said to have quadrupled during that period. Due allowance 
must be made for improved diagnostic methods. 

Heredity is very marked. Schmitz reports that diabetes has occurred in 
the blood relations of 998 of the 21 15 individuals whose cases he had inves- 
tigated, fourteen cases having been reported in one family. It is said to be 
present in 20 per cent, of all cases. 

Diet. — Alimentary glycosuria is under certain conditions quite unim- 
portant. A definite limit may be placed to the amount of sugar that should 
be disposed of under normal conditions, without producing glycosuria, and 
various writers have suggested a test amount varying from 100 to 250 grams, 
this to be taken at one sitting, and on a fasting stomach. If sugar then 
appears in the urine, the individual is a suspect. 

A simple rule provides that one who can take 50 grams of grape-sugar 
on a fasting stomach and show no reaction in the urine is absolutely normal. 
If not more than 1 per cent, is demonstrable, he may be held as merely 
functionally inadequate unless it be found that carbohydrates alone cause 
glycosuria. 

Exercise. — There can be little doubt that a rich diet, associated with 
sedentary habits and great mental activity, are potent predisposing factors 
in causation. 

Gout. — Gout is distinctly associated with diabetes, though it is claimed 
that the arthritic form is comparatively benign. The reason for such an Arthritic 
association is evident, the same habits of life and hereditary elements being 



Test of 
tolerance. 



glycosuria. 



n66 



MEDICAL DIAGNOSIS 



Lipogenic. 



present in both diseases. It should be noted, however, that the consumption 
of alcohol is not often a prominent factor in the causation of glycosuria. 

Antecedent or Complicating Diseases. — Aside from those mentioned 
in the opening paragraph, gout, tuberculosis and nephritis are occa- 
sionally associated with diabetes, the two latter being usually secondary 
conditions. 

Obesity. — A large number of glycosurics are obese, and this lipogenic 
form is ordinarily easily controllable and often curable: nevertheless, many 
cases apparently benign at the outset become true diabetes. 

Pancreatic Disease and Sclerosis of the Spinal Cord. — It is probable that 
a large proportion of the cases of diabetes are pancreatic in origin. Sclerosis 
of the cord may be secondary or primary, and the relationship of the two 
The three P's. conditions has not been sufficiently worked out. 

SYMPTOMS. — The so-called '''three P"s." polyuria, polyphagia, poly- 
dipsia, represent the fundamental symptoms as seen in a typical case and the 
thirst, increased frequency of urination, and large amount of urine, are usu- 
ally the first symptoms noticed. An excessive appetite is seen in nearly all 
advanced cases. Rapid loss of weight and strength is marked in true diabetes 
and often prominent in the benign forms. The Skin. The skin is dry. 
eczema, boils, carbuncles are common and gangrene is often a ter mi nal 
complication. The Eye. Xeuro-retinitis, hemorrhage and cataract are often 
seen. Muscles. Besides pronounced weakness, muscle cramps are common 
in advanced cases. Sexual Organs. Impotence, amenorrhea, pruritus vulvae 
and balanitis occur and pregnant women are likely to abort. Xenons 

;tem. Neuritis, headache, mental irritability or depression, drowsiness 
or insomnia may occur, true melancholia may develop, and in 50 per cent. 
of the severe cases the knee-jerks are absent unilaterally or bilaterally. 
Lungs. Pulmonary tuberculosis is a common terminal event. 

Coma. — Diabetic coma may be the first recognized symptom of the dis- 
ease. The author recalls a casual meeting on the street which led to the 
recognition of unsuspected advanced diabetes in the infant child of a friend, 
the babe dying a few hours later in diabetic coma. In this case the breath 
had the peculiar aromatic sweetness present in all cases of threatening coma 
and presumed to be due to the presence of acetone. Other premonitory 
symptoms are headache, drowsiness, nausea, vomiting, dyspnea and rapid 
pulse, the dyspnea is a definite air hunger, the term accurately describing the 
symptom. Constipation is often marked and symptoms of mild or severe 
indigestion may be present. In actual coma the breathing may be slow and 
deep, sighing, superficial, or Cheyne-Stokes. Certain cases are characterized 
by profound collapse, and in others ataxic symptoms are prominent. 

Precautionary Measures. — The discovery of a definite acetonuria de- 
mands immediate action on the part of the physician. 

One would depend upon the administration of added amounts of carbo- 
hydrates and if deemed necessary the internal administration of sodium bi- 
carbonate 30-40 gm. daily until neutralization of alkalinity of the urine was 
attained. 



"Fruirv" 
breath. 



Carbohydrate 
increase. 



Alkalis. 



DIABETES MELLITUS 



1167 



In the severer cases or those suggesting an impending coma, this treatment 
would be pushed rapidly (2 gm. every 20-30 minutes). 

In beginning coma or the established condition, sodium bicarbonate would 
be given intravenously, never subcutaneously (one liter 4 per cent, solution). 

Hitherto, acting upon the established fact that starvation of the normal 
individual produces an acidosis, we have feared it for diabetic patients, but 
Allen claims that occasional recoveries from prolonged diabetic coma 
are due to the clearing of the blood as a result of starvation, that the 
treatment for acidosis is fasting, the use of alkalis being proper but of 
doubtful efficacy. 

Intermittent fasting, when scientifically, rationally and intelligently 
applied is without doubt the best means of controlling glycosuria and pre- 
venting acidosis. 

Every medical man should be familiar with the technic of this procedure 
and its important limitations and safeguards. 

The sudden radical withdrawal of sugar and starches is an invitation 
to acidosis, a complication responsible for two-thirds of the deaths from this 
ailment. 

The non-withdrawal, or strict limitation of fats constitutes another 
important source of danger from the same cause. 

The Blood. — Bremer's test may be valuable in coma if for any reason a 
specimen of urine is unattainable. Two smears, one of diabetic blood, the 
other of normal blood are made in the ordinary manner. Tehse are fixed by 
heat and stained for two minutes in a 1 per cent, aqueous solution of congo- 
red. The diabetic smear remains unstained or shows a pale or greenish- 
yellow. The control smear of normal blood is stained red. If methylene 
blue is used the diabetic smear takes a yellowish-green; the normal, blue. On 
the other hand, a solution of Biebrich-scarlet stains the diabetic smear scarlet 
and does not affect the normal blood. The reaction is not caused directly 
by glucose itself, but by some unknown substance present in the blood of 
diabetics. 

Glycemia. — Normal blood contains sugar in an amount varying between 
0.060 and 0.120 per cent., the average content being 0.085 P er cent. 

If the blood sugar content is increased to about 0.170 grams per 100 
cu.cm. the " threshold of retention" is passed and glycosuria becomes 
manifest. 

On the other hand even though the diabetic patient's urine may have 
been rendered sugar-free, the blood may continue to show an excess above 
the normal though insufficient in quantity to cross the threshold and appear 
in the urine. The amount shown in the blood of diabetics varies from 0.130 
to 0.400 per cent, and in coma may rise to 1 per cent. 

\ Einstein's modification of Benedict's method for the estimation of the 
sugar content of the blood is given on page 120 and is the simplest and most 
rapid process known to the author. 

Hyperglycemia in Conditions other than Diabetes. — An excess of sugar in 
the blood may follow the ingestion of an excess of starches and sugars, precede 



Starvation. 



Bremer's test. 



Glycemia. 



n6S 



MEDICAL DIAGNOSIS 



;.. : . ;;.:alcase. 



Removable 
sugar. 



Low specific 
gravities, etc 



I — ; ::: = -: 

t s. c : : r 5 . 



and accompany the menstrual period, accompany pregnancy, or attend 
cerebral hemorrhage, brain tumors, skull fractures, or severe concussion. 

Emotional shock has been known for long to be a competent cause, and 
diseases : :he liver, pancreas, or endocrine glands, and carcinoma of the 
viscera may be associated with a markedly high degree of glycemia. 

Ether anesthesia and major surgical operations often bring about a 
marked temporary increase, and in Graves' disease it maintains a relatively 
high level. 

The Urine. — Total quantity increased, the amount sometimes reaching 
or exceeding 20,000 c.c. The specific gravity is high, varying from 1030 to 
1060. Sugar varies from a mere trace to 8 or 12 per cent, in extreme cases. 

Important Variations. — It must be remembered that in glycosuria as in 
albuminuria the abnormal constituent of the urine may be totally absent 
for considerable periods, may be lacking at one time of the day and present 
at another, and may be wholly removed by careful dieting or fasting, thus 
making it possible for a glycosuric to pass a life insurance examination. 
Furthermore, the specific gravity is not always high, and a specific gravity of 
1010 does not justify the omission of the test for sugar, as is so generally believed. 
Xo one of the cardinal symptoms is absolute. Polyuria is not an invariable 
symptom and, as might be inferred, both polyphagia and polydipsia may 
be absent and even in true diabetes long periods of latency may occur. 

Diacetic Acid and Acetone. — See under Urinalysis.) 

Prognosis. — The prognosis in glycosuria depends primarily upon the 
decision as to whether one is dealing with true diabetes or simple glycosuria. 
In the former, the prognosis is always grave: in the latter, it is favorable. In 
youth, the disease is almost invariably rapidly fatal, cures being extremely 
rare. The thin offer a more serious prognosis than the fat. The presence of 
diacetic acid is a danger signal. Apoplexy, carbuncles, tuberculosis,, gan- 
grene and coma are distinctly terminal events. 

Heredity is of great importance. Age is a cardinal factor, for children 
under ten all die and even young adults (under twenty-five seldom recover. 
At and above forty the prospect of control and life prolongation is good 
and many cases representing the preceding decade yield favorable results. 

Cases of acute diabetes are described but the author has not encountered 
an impeccable one as yet in the adult. 

DIABETES INSIPIDUS. — This curious ailment, occurring usually during 
the first three decades of life, and more frequently in the male., may be in- 
duced by head injuries, violent emotions, acute infections, tuberculous 
meningitis, sunstroke, cerebral syphilis or tumor {especially, of the hypoph 
and diseases of the abdominal viscera, including aneurysm. Heredity is 
sometimes evident and it may be congenital. 

Involvement of the hypophysis cerebri (pituitary body is relatively 
common and. possibly, constant, in these cases of idiopathic (true) diabetes 
insipidus. 

The diuretic action of the internal secretion of the pars intermedia of 
this gland is well established. 



GOUT 



1 169 



The characteristic feature of diabetes insipidus of the idiopathic type is 
the peculiar response of the kidneys to increased sodium chloride or protein 
ingestion. 

In the normal individual and in cases of primary polydipsia ("symptom- 
atic diabetes insipidus") this response manifests itself chiefly or wholly, in an 
increased concentration of the urine, i.e., heightened specific gravity, increased 
total solids. 

In diabetes insipidus also the increase of total solids is obtained, but only by 
the passage of an increased total amount of urine, the specific gravity remaining 
unchanged. 

Morbid Anatomy. — The lesions consist merely of congestion and dilatation 
of the kidney and ureters, and hypertrophy of the bladder. Various lesions 
of the nervous system have been reported but none specific save as above. 

Symptoms. — Excessive or unusual thirst, striking emaciation and a dry 
skin coexist with the passage of enormous quantities of pale, faintly acid or 
neutral urine (5000 to 20,000 c.c.) during the twenty-four hours. The specific 
gravity is extremely low (1001 to 1005), total solids for the twenty-four 
hours normal. Albumin and casts if present at all are scant and of no signifi- 
cance and the sediment is negative ordinarily. 

Differential Diagnosis. — The disease is most commonly confused with 
interstitial nephritis but the mistake can seldom occur if the total solids 
are estimated as should invariably be done, an increase being the rare excep- 
tion in the latter disease. Furthermore, the cardiovascular symptoms of 
nephritis, in any case likely to be confounded with diabetes insipidus, usually 
would be marked. 

Prognosis. — If associated with cerebral tumor or organic disease in any 
part of the body it is bad. Many of the hereditary cases recover or live 
with their ailment to a ripe old age. 



GOUT 

(Arthrosia podagra) 

Definition. — An ailment of unknown specific etiology chiefly affecting 
11 well-to-do" individuals, appearing in acute, subacute, chronic, or, peculiar 
larval forms and characterized by an hereditary or acquired inability on the part 
of the affected individual to elaborate and maintain sufficiently active specific 
ferments and nucleases (oxydases) to secure to the individual organism such 
chemical changes in the purin bases as are essential to normal metabolism. 

Etiology. — The true cause of gout remains still unknown though the work 
of recent years has greatly enlarged and enriched our knowledge of its meta- 
bolic disturbances and of the ferments which are deficient or lacking in 
victims of this disease. It would appear that in the discussion of its etiology, 
we are still dealing largely with secondary factors. 

Inheritance. — This constitutes one of the most interesting and striking 
features in connection with gout and though a prominent English clinician 
74 



Unvarying 

specific 

gravity. 



Great quantity 
of light urine. 



Basic cause is 
unknown. 



1 170 



MEDICAL DIAGNOSIS 



The wine 
cellar. 



Extraordinary 
figures. 



Mode of life. 



Remarkable 
prevalence. 



Possible 
source of error. 



Alternatives. 



Peculiarities 
of trans- 
mission. 



Unusual in 
youth. 



Irreconcilable 
figures* 



of wide experience has said that the inheritance of gout is largely the inheritance 
of a good wine cellar, we must, nevertheless, recognize the fact that a special 
predisposition to perverted and deficient metabolism exists in the descen- 
dants of gouty individuals and occasionally becomes apparent at a relatively 
early age. 

In Great Britain, which includes the area of greatest prevalence of this 
ailment, from 75 to 80 per cent, of the cases are said to suggest an hereditary 
taint and even in the public services of the London hospitals the hereditary 
element is said to exceed 50 per cent.; nevertheless, one may easily overesti- 
mate the importance of such figures if he fails to take into consideration its 
wide prevalence and the habits of life, with respect to a generous dietary 
and the use of heavy ales and wines, which have prevailed throughout that 
country. 

There can be no doubt that a very considerable proportion of the popu- 
lation of England is tainted with a more or less attentuated gout and the 
inheritance may take the form either of the main disease or some of its many 
so-called alternatives such as arteriosclerosis, chronic nephritis, eczema, 
certain forms of diabetes and chronic gastric intestinal diseases. 

In a malarial country a marked tendency exists always to charge to that 
disease an enormous number of ailments which in a non-malarial country 
would be dignified by a separate clinical title and specific and individualized 
treatment. No doubt the same statement is true to some extent with respect 
to gout in its alternative forms and this fact further vitiates our statistical 
information. 

Any or all of the diseases mentioned as gout alternatives are merely expres- 
sions of toxemia occurring also in countries relatively gout-free. 

It is said by English authorities that transmission from a grandparent 
through the mother, herself unaffected, is more evilly effective than trans- 
mission from father to spn. The fact that women are relatively immune 
to the disease, even though descendants of gouty fathers and grand- 
fathers, would lead one to attribute much of this immunity to their lesser 
indulgence in the pleasures of the table and wine cellar, and still further 
diminish one's belief in the present astonishing figures relating to the fre- 
quency of gouty inheritance. 

Age {Juvenile Gout).— In proven cases or typical forms, this is undoubtedly 
unusual and the disease is essentially one of middle age, incidence rarely 
occurring under thirty. It shows a suggestive tendency also to subside after 
the age of sixty when in most individuals the habits of life are greatly 
modified. 

Lead Poisoning. — The frequency of lead poisoning in association with 
gout is so great as to raise serious doubts as to the true meaning of the figures 
offered. Garrod, for example, reports not less than 33 per cent, of gouty 
patients appearing in his public services as showing evidence of an ante- 
cedent saturnism; on the other hand, Frerich of Berlin failed to find one case 
of gout among the 163 cases of lead poisoning which he specially investigated. 

Habits. — Habitual heavy eating and the consumption of large amounts 



GOUT 



II7I 



of animal food and highly spiced rich dishes, especially when combined with 
a persistent indulgence in alcoholics, even though the daily allowance may 
not be actually excessive, and especially an habitual indulgence in the 
heavier wines and ales, would seem to be commonest factors in the produc- 
tion of cases of proven gout. 

Certainly the most important element in the treatment of chronic gout lies 
in the imposition of restrictions with relation to such habitual indulgence. 

One might consider also the effect of excessive worry, mental strain and 
exhausting labor under adverse conditions, the first being not uncommon 
contributory factors in the gout of the well-to-do, the last a frequent element 
in "poor man's gout" occasionally encountered by the author in British 
clinics. 

Occupation. — In general, gout is a disease of the well-to-do and of the 
classes of relative or absolute leisure. Workers in lead, butchers, those em- 
ployed in breweries, public houses and the like are doubtless predisposed 
through occupation, yet manifestations of the disease even in them are usu- 
ally associated with a history of heavy eating and steady, even if moderate, 
drinking. 

Climate and Race. — Some curious differences in racial predisposition exist 
and to what extent climate may play a part seems to be undetermined. 
With relation to the incidence of gout among the people, England leads the 
world, France and Holland come next, and Swedes, Norwegians, Russians, 
Italians, Spaniards and Germans show comparative immunity. " Normandy 
is said by Charcot to be especially affected as compared with the rest of 
France, and Scotland and Ireland suffer far less than England." 

The foregoing statement certainly offers food for speculation and an 
opportunity for some practical statistician. 

Essential Factors. — The investigations of the last decade have thrown 
a flood of light upon the disturbed metabolic processes associated with gout, 
and added much to our knowledge of its dietetic management. Nevertheless, 
much remains to be explained and its basic cause is wholly undetermined. 

The changes wrought in the purin group through the action of oxygen 
on the one hand and NH 2 on the other evidently dominate the deficient 
metabolism characteristic of this disease. 

These purin bodies derived from ingested nuclein-rich food, as well as 
those of the body tissue themselves (nucleins and nucleo-proteids), become 
of first importance in the modern view of gout. 

Uric acid belongs to the "purin group" which contains also adenin, 
guanin, hypoxanthin, xanthin, and caffein. 

Purin is represented by the formula 



N- CH 



HC 



N- C.N 



C.NH 



Basic in 
predisposition. 



Poor man's 
gout. 



Predisposing 
occupations. 



Strange 
differences. 



Exogenous and 

endogenous 

purins. 



IIJ2 



MEDICAL DIAGNOSIS 



Characteristic 
variation. 



By the introduction of oxygen or NH 2 , or both, the oxypurins, hypo- 
xanthin, xanthin, and uric acid, or the aminopurins, adenin and guanin, 
are formed. 

The source of the purin bodies is nuclein, and their elaboration depends 
upon the presence of a sufficient amount of active ferments {nucleases, desamidases f 
and oxydases) in the human body. 

11 Under normal conditions the greater the nuciein content of the ingested food 
the more marked is the excretion of uric acid in the urine, and in the normal 
individual the uric acid excretion curve is singularly constant for like conditions 
of diet, activity, and body weight, though varying considerably in different 
individuals" (Ltitje). 

In gouty individuals the excretion of both endogenous and exogenous 
uric acid is markedly diminished save during an acute seizure. 

Clinical Characteristics. — The most characteristic clinical features of gout 
are: 

i. The persistence of uric acid in the blood even under a purin-free diet 
(i.e., eggs, cream, milk, cheese, olive oil, and other fats). 

2. That under such a diet the excretion of endogenous uric acid (that not 
derived from food rich in nucleins but from the patient's own tissues) is abnormally 



3. That during an attack of gout the urinary uric acid content rises sharply 
and promptly falls below normal at its close. 

4.*That victims of gout placed upon a diet rich in purin bodies (thymus, 
pancreas, liver, etc.) fail to show the marked increase of exogenous uric acid 
excretion by the urine found in the normal individual. 

5. The tendency to uratic deposits in the joint tissues in chronic cases and 
the formation of tophaceous deposits there and elsewhere. 

6. The tendency of the disease to attack metatarso-phalangeal joints and, in 
acute seizures, that of the great toe, with peculiar frequency. 

7. The frequency of larval and irregular gout of peculiarly protean and 
baffling symptomatology. 

8. The tendency of the disease to change its form and pass from the stage 
of acute seizures followed by wholly symptom-free intervals, to that chronic form 
associated with permanent changes in the joints and other organs (kidneys, 
stomach, intestines, heart, and blood vessels), with greater or less impairment 
of health and strength. 

9. The tendency of the disease to develop its severer manifestations after the 
third decade of life. 

SYMPTOMS. — The classical symptoms of acute gout are : 
(a)' Agonizing vise-like pain in a metatarso-phalangeal articulation, usually 
that of the great toe. 

(b) Dusky redness of the affected area. 

(c) Swelling, with tense, hot, glistening, overlying skin, and ultimately a 
slight superficial edema. 

(d) Exquisite tenderness. 

(e) Fever, rarely exceeding 102 to io^F. 



gout 1 1 73 



(J) Moderate leucocytosis — 14,000, 20,000. 

(g) An excess of uric acid in both urine and blood (Garrod's thread test) 
at the height of the attack. 

Onset. — The attacks come on suddenly, usually in the early morning 
hours, but are commonly preceded by premonitory symptoms sufficient to 
warn any patient who has previously experienced such seizures. 

Such premonitory symptoms are: 

(a) Loss of appetite or dyspepsia, with acid eructations. 

(b) Bronchitis. 

(c) Unusual restlessness, nervous instability, or attacks of mental 
depression. 

(d) Fleeting pains in the smaller joints. 

(e) Headache, insomnia, or unrefreshing sleep. 
(J) Moderate leucocytosis — 14,000, 20,000. 

The pain usually abates in the morning, only to reappear on succeeding 
nights with added intensity. One joint only may be affected, or the disease 
may appear in other articulations. An attack usually lasts for a week or 
more, gradually subsiding with desquamation and local itching, leaving 
behind it a tender swollen joint, which in most instances persists for at 
least a week and often much longer. Walking may be difficult for several 
weeks. 

Transient albuminuria may occur even in the absence of established renal 
disease. As has been stated, the urine is scanty and the output of uric acid, 
markedly increased during the acute seizure, promptly shrinks as the attack 
subsides, and is markedly diminished during the free periods. 

Cardiovascular Lesions and Gouty Kidney. — As is well known, the gouty 
habit and inheritance alike predispose to cardiovascular changes. 

Arteriosclerosis is the usual accompaniment. It is usually widespread 
and frequently associated either with a true contracted kidney or with that 
of the arteriosclerotic type. 

Glycosuria. — Gouty diabetes is well known as a complication. It is 
usually mild, essentially chronic in its course, and readily controlled by 
proper dietetic restrictions. 

That such a condition should occur as a complication of gout is extremely 
interesting in its relation to the imperfect or perverted ferment production 
and activity which he at the root of the symptomatic expressions. 

Exciting Causes. — The factors precipitating a gouty seizure are often 
undiscoverable, but local joint injury, strains, and exposure to cold and wet 
are often the apparent causes; and fits of anger, psychic shock, or acute 
worry are undoubtedly sufficient to determine the explosion. 

Retrocedent Gout. — This faulty term covers cases in which the symptoms 
relating to the brain, gastrointestinal tract, or heart are unusually severe. 

Delirium, stupor, coma, and apoplectiform attacks, excessive purging, 
and persistent or intractable vomiting are alarming symptoms which fortu- 
nately seldom occur. Precordial pain, rapid, irregular pulse, and severe 
dyspnea are likewise of an alarming nature and serious import, but these 



ii74 



MEDICAL DIAGNOSIS 



Not a concrete 
ailment. 



A basic error. 



symptoms of severe toxemia furnish us with no adequate ground for assuming 
a separate type of the disease. 

Futcher rightly states that most of these individuals are uremic, and to 
this statement one may add that the cardiovascular changes of long- 
established cases are sufficient in themselves to account for nearly all of 
the symptoms. 

Acute gout presents no serious diagnostic problems in differentiation. 

Chronic Gout. — The seats of predilection in chronic gout are, in order of 
frequency, as follows: the great toe, tarsus, ankle, knee, hand, and carpus. 

As the disease progresses in its chronic form the joints become thickened 
and deformed. Bursal inflammations are common, especially in the region 
of the olecranon and patella, and the chronic painful course is frequently 
interrupted by acute or subacute seizures with or without fever. 

The tophi may form masses as large as a plum, but the "Heberden's 
nodosities" so frequently encountered in clinics, are rare in gout and more 
often seen in connection with arthritis deformans of the hypertrophic type. 
These occur commonly about the terminal finger joints, seldom exceed 
a pea in size, are painless, and show no tendency to ulceration. They 
occur most commonly in women and during or after the menopause. Un- 
doubtedly most cases of chronic painful multiple arthritis occurring in the 
male, and in gout-ridden countries, are due to gout, and this is especially 
true of such cases as are associated with marked arteriosclerosis or renal 
disease. 

It is probable that the disease is on the increase in America, but good 
wine cellars, heavy ales, excessive meat-eating and lives of relative leisure, 
are still relatively uncommon in the United States, and, in consequence, 
gout is relatively rare and in many regions almost unknown. 

The chronic arthritis of women is more likely to represent arthritis de- 
formans, or the rarer genuine chronic rheumatism, both of which are probably 
due to chronic infections. 

Irregular Gout. — This comprises that vast group of symptoms arising 
in the case of tainted individuals who have escaped the acute manifestations 
of inherited or acquired gout. 

The term "lithemia" has served in the past to cloak every diagnostic sin in 
the catalogue of human ills, but at present is falling into disuse, as is also the 
term "gouty diathesis," which falls so pleasantly upon the ear of those hypo- 
chondriacal victims of gastric neuroses and the like, who feel that at last a safe 
anchorage is found in the snug but ample diagnostic harbor represented by an 
aristocratic ailment. 

"irregular gout" is a perfectly proper term, and the ailment merits most 
careful consideration. Its presence should not be predicated upon the mere 
presence of an apparent excess of uric acid in the urine, as is so frequently 
done, for, in true gout, the uric acid curve runs below the normal and only 
by the most elaborate analyses based upon a carefully controlled dietary 
can one determine the endogenous and exogenous uric acid curve of the 
individual. 



GOUT 



"75 



Hence, the absolute diagnosis of irregular larval gout is surrounded by too 
many technical difficulties to render it available for most practitioners. The 
tentative or probable diagnosis is only justified when the family history or habits 
clearly indicate the tendency in the individual. 

The symptoms ascribed to it cover almost every variety of gastro- 
intestinal disturbance, eczemas, herpes zoster, headaches, including migraine, 
and too. often a mere psychasthenia* or some of the many disorders reflect- 
ing the "congenital universal asthenia" of Stiller. 

The treatment so often prescribed is therefore poorly adapted to many 
of the ailments so often sheltered by this too ample diagnostic cloak, and 
quite generally the diagnosis of "lithemia" is applied to cases which are of 
a nature directly opposite to gout in etiology and in therapeutic require- 
ments, or, to serious organic disease, needing both correct diagnosis and 
selective treatment. 

RICKETS. f — An infantile disease characterized by general impairment of 
nutrition and peculiar changes in the bones. 

Etiology. — The etiology remains unknown and it cannot as yet be classed 
with deficiency diseases. Improper food, calcium deficit in the osseous struc- 
tures, and insanitary environment, quite frequently associated with a 
syphilitic or tuberculous hereditary taint. The disease is relatively rare 
in breast-fed children. 

Symptoms. — The child appears delicate superficially and structurally, 
with small bones, less rigid than normal and shows at the epiphyses, especially 
of the wrists and ankles, characteristic swellings associated with imperfect ossi- 
fication processes. In the parieto-occipital region the bone may yield to finger 
pressure and in certain areas there may be parchment-like crackling (cranio- 
tabes). The broad forehead carries prominent frontal bosses due to hyperos- 
tosis, the ribs show the peculiar and characteristic beading at the chrondro-costal 
junction (the rickety rosary), the clavicles appear short and abnormally 
curved, and there is frequent pigeon breast (pectus carinatus). The abdo- 
men is prominent, the liver and spleen are usually enlarged and autopsy may 
show changes in the mesenteric glands. Such a child shows either an. in- 
ability to walk or creep about or if walking may suddenly develop apparent 
weakness or disinclination. There may be slight fever, the child is tender 
when touched or moved and extremely restless at night, the pillow being soaked 
with perspiration and the hair often rubbed away at the occiput. As might 
be expected gross rickety deformities are common. Spinal curvature, usually 
but not always antero-posterior, appears and bow-legs of the most extreme 
type may be encountered. 

Persistence of the fontanelles is a common symptom. The diagnosis is 
not likely to be missed in well-marked cases, but the slighter varieties occur- 
ring under unexpected conditions may cause trouble. 

Prognosis. — The disease may indirectly cause a large mortality by 
weakening the child's resistance to other diseases, but there is no direct 

* The term is used throughout in its literal sense. 

f Included here for the sake of convenience rather than correctness of classification. 



Correct diag- 
nosis difficult. 



Bizarre and 
incoherent 
symptoma- 
tology. 



Basic cause 
unknown. 



Epiphyseal 
swellings. 



"Cranio-tabes' 
and "bosses." 



"Rickety 
rosary" and 
"pigeon 
breast." 



1176 



MEDICAL DIAGNOSIS 



Its very exis- 
tence doubtful. 



A melange of 
symptoms. 



mortality. The development may be long delayed and permanent lack of 
resisting power and various deformities be left behind. 

Many cases are encountered which lack the classic symptom group in greater 
or less degree. 

NEURASTHENIA 

{"Nervous Prostration" "Nervous Exhaustion") 

Definition. — A term applied loosely to a large and heterogeneous group of 
symptoms indicative of instability and excessive lability, both mental and physical, 




Fig. 584. — A remarkable case of cardiovascular syphilis with aneurysm and an enormous 
heart presenting typical "neurasthenic" symptoms. No murmurs were present. 

such as occur also individually or collectively in a great number of organic dis- 
eases and known constitutional defects. 

Whether the syndrome ever exists as a primary and independent condition 
or as a concrete and definite symptom-complex is, at present, doubtful. 

Preliminary Comment. — To deal satisfactorily with a condition totally 
lacking demonstrable specific pathology and presenting only a melange of 



NEURASTHENIA 



1177 



symptoms, individually and collectively such as may represent the commonest 
and most logical results of a great number of chronic and acute diseases, 
would seem to be, and undoubtedly is, a hopeless undertaking. 

Like those archaic terms " heart trouble," "stomach trouble," and 
"liver trouble," the term neurasthenia has not only served as a cloak for 
our own diagnostic insufficiency, but as a standing invitation to loose methods a euphemism t 




Fig. 585. — A case of cardiorenal disease with. marked cardiac enlargement and decided 
hypertension. No murmurs were present. The symptoms of ''neurasthenia" had proven 
most misleading. 

in diagnosis, offering a too ready relief from some of the most vexing problems 
encountered in medicine. If it were only on this ground it would seem that 
the term should either be dropped wholly, restricted to the few cases which 
may possibly be entitled to such a designation, or strictly limited as to its 
use to the description of true psychasthenia, using that term in its literal 
sense. 

Greatly Attenuated by Modern Diagnostic Methods. — To the author it 
would appear that if we were to deduct from the cases of so-called "neurasthenia" 



117S 



MEDICAL DIAGNOSIS 



those proving under thorough and scientific methods of investigation to be ex- 
amples of organic disease of the heart, kidneys and nervous system, chronic 
cryptogenic septic infection, chronic anemia, drug-habit, incipient insanity, 
hyper-, hypo- and dys-pituitarism or dys-thyroidism, larval syphilis and, espe- 
cially, active obscure tuberculosis and chronic subnutrition, the residue would 
closely approximate zero.* 




Fig. 586. — A case of frank mitral stenosis and regurgitation in relation to which the 
obtrusive symptoms of "neurasthenia'' had been accepted at face value. 



* To such of us as have doubted for years the very existence of a primary "neurasthenia 1 ' 
and chafed under the universal tendency to retain and employ this unfortunate designation 
in lieu of the specific terminology applicable to the ailments which underlie it, it is refresh- 
ing to read the recent statement of an eminent neurologist to this effect, viz., "The diag- 
nosis of neurasthenia is becoming more rare as the methods of study improve, as our 
knowledge of the chemistry of disease grows, and as we examine patients with greater and 
greater thoroughness." 

Chas W. Burr: Osier's "Modern Medicine," vol. v. p. 624, Second Edition, 1915. 
Dr. Burr believes nevertheless in its "infrequent'" existence as a primary disease. 



M I R ASTHENIA 



1179 



Larval organic 
diseases. 



Keystone of 
neurasthenic 
arch. 



A confusing 
factor. 



There are no symptoms or symptom groups peculiar to "neurasthenia** 
in the light of modern knowledge and its continued existence seems to 
depend upon the fact that in some instances a genuine scientific diagnosis is 
unattainable, 

This obviously constitutes an uncertain tenure, especially as the syn- 
drome reflects apparently a distinct toxemia or subnutrition of the centers, 
conditions which must often arise from cryptogenetic foci of infection, 
minor circulatory defects, faults of internal secretion, or renal permeability 
such as may be obscure or quite beyond detection for a time, but frankly 
manifested later. 

To a remarkable degree its manifestations depend upon depressed general a. basic factor. 
nutrition associated with structural deficiencies of the type of u universal 
congenital asthenia." 

This condition, originally described by Berthold Stiller, of Budapest, and 
elsewhere considered is now becoming recognized at home and abroad as the 
condition basic in manifold disturbances of function, inadequacies of structure 
and predisposition and vulnerability to infection. 

It explains fully that frequent inadequacy to sustain the normal amount of 
stress, incidental to life and life's work, which, heretofore, has been regarded 
as the keystone of the "neurasthenic" arch. 

Much confusion has arisen from a tendency to place certain obstinate or 
inveterate psychic deviations under "neurasthenia" or "neurasthenic 
psychoneuroses." 

Some of the many thus classified in a recent work on nervous diseases 
are the following: 

(a) Agoraphobia. The fear of crossing open spaces. 

(b) Claustrophobia. The fear of any enclosed space. 

(c) Morbid doubt and indecision of an excessive type. 

(d) Obsessions. Even kleptomania and morbid impulses to kill. 

(e) Morbid lack of will power. Associated with inability to perform 
certain simple acts save in complicated ways or the utter lack of power to 
step over a slight obstruction, etc. 

With all of these are included those states of morbid anxiety combined 
with perfect lucidity of thought. * 

Such fixed or inveterate obsessions, phobias and "anxiety neuroses" 
would seem better dealt with as states apart even from mere psychasthenia, 
which well might be used in its literal sense. There is unquestionably such 
a thing as "brain-fag," though it is astonishingly difficult to produce by 
mere brain-work or even by shock, grief or other emotional crises in per- 
fectly sound, otherwise healthy and well-nourished individuals. 

Hypochondria must be carefully distinguished from the perfectly natural 
mental depression, discouragement and anxiety so often present at the out- 
set of treatment in many chronic conditions associated with illness of the 
most varied character. 

* Headache, slight defects of memory, irritability, temperamental instability, readily 
induced fatigue, mental and physical, vertigo, etc., etc. 



n8o 



MEDICAL DIAGNOSIS 



The great danger to the patient involved in the present unfortunate freedom 
of employment of the term "neurasthenia " as representing a primary ailment, 
is best illustrated by enumerating some of the many organic diseases coming 
under the author's notice, in which the primary diagnosis was ''neurasthenia." 
Only those diseases are mentioned in relation to which diagnostic error has been 
represented in many instances. 

These are: (a) Dilated, insufficient hearts both of the "drop" type and 
those of the primary myocardial or endocarditic -myocardial type (a host of 
them). 

(b) Renal impermeability and even nephritis of the interstitial or arterio- 
sclerotic type (a multitude). 

(c) Carcinoma of the stomach or bowels. 

(d) Gastric and duodenal ulcer. 

(e) Early and even advanced cerebral arteriosclerosis. (Nearly all of 
the precocious or middle-aged cases.) 

(/) Chronic cholecystitis. 

(g) Insanity. 

(h) Hysteria. 

(i) Thoracic aneurysm. 

(J) Brain tumor. 

(k) Cerebral syphilis. 

(/) ^Addison's disease. 

(m) Active but obscure tuberculosis of the lungs (a great number). 

(n) Tuberculous meningitis. 

(o) Tuberculosis of the kidney. 

(p) Paretic dementia. 

(q) Drug habit (nearly all of the private cases). 

(r) Atypical hyperthyroidism (great numbers of them). 

(s) Atypical myxedema (the greater part of the thyroid u insufficiencies). ,, 

(t) Cryptogenetic sepsis (probably one of the commonest of overlooked 
conditions). 

(u) Chronic malaria. 

(v) Secondary and even pernicious anemia. 

(w) Leukemia. 

(x) Chronic appendicitis. 

(y) Locomotor ataxia. 

(z) Lead poisoning and various other toxemias of a similar sort including 
concealed chronic alcoholism.* 

Many more could be named and it is obvious that in most instances the 
primary diagnostic failure was simply the result of grasping the most obvious 
diagnostic solution, under the honest belief that asthenic and psychasthenic symp- 
toms represent a common clinical entity and a common ailment, viz. neuras- 
thenia. 

The primary assumption should be that symptoms of asthenia and psychas- 
thenia constitute the commonest of the indications of obscure infections and toxe- 
* To this list "endocarditis lenta" should be added. 



NEURASTHENIA 



IlSl 



mias, of incipient, partially or fully established organic disease and of nutritional 
deficit usually associated with visceroptoses. 

Symptoms. — These are so numerous and varied as to preclude a full 
enumeration and description but apart from certain instances wherein direct 
cerebral or spinal damage occurs, as in larval cerebral syphilis or the early 
stages of general paresis and multiple sclerosis, are alike in their reflection of 
lability and instability of the circulation, of body nutrition, and of the psyche 
of the patient, no less than in their tendency to persist until an adequate 
circulation is reestablished and the nutritional level raised. 

A general failure to grasp these fundamental truths is responsible for 
the extreme chronicity of the phases of psychic and functional depression 
which makes the so-called "neurasthenic" the bane of the general practitioner 
and the chief pillar and support of the innumerable Spas of Europe and 
the United States alike. 

With respect to the mental state and deceptive localization of symptoms, 
the so-called "nervous dyspeptics" furnish the typical example. This is 
the commonest form of ambulatory invalidism or semi-invalidism, a lure 
for the unwise among surgeons, as is too often indicated by the multiple 
scars of futile operative procedure, and a constant source of therapeutic fail- 
ure and consequent discredit to the family physician. The patient may be 
seen in any stage, but in its more extreme forms it makes a deplorable clinical 
picture clearly setting forth the minor but troublesome types of psychic in- 
stability which result from poisoning of the centers whether this is but a part 
of general tissue starvation, of deficient cardiac power and reserve, or the 
toxins of acute or chronic infections and dyscrasias. 

Deficient endurance, submerged response, or excessive perverted or ill-con- 
trolled reaction must result. 

This finds its expression in readily induced fatigue, psychic, physical, or 
both combined, in vagaries of, gastrointestinal secretion and motility, in the 
decided dominance of symptoms in one local field or another, often excessive, 
because of the summation of persistent or recurrent defects of reaction to 
initial stimuli.. 

The patient tends to become self-centered and morbidly introspective; 
his moods are variable, but quite naturally he may become irritable and 
despondent. Every symptom becomes magnified; the pathways for pain 
and discomfort are better and better defined as they are the more 
persistently traveled, while morbid anticipation and expectation beckon 
them on. 

The trifling ache or pain, the trivial flatulence, the disinclination or mere 
hesitation of the bowels to adhere to a strict schedule, all minor events such 
as occur to a majority of healthy men from time to time, unheeded, come to 
be of vast importance to the nervous dyspeptic or to any psychasthenic 
individual. 

At his worst he is the man with the notebook, and in this is jotted down 
from day to day a multitude of interrogatories and finically noted trivial 
events for the consideration of the physician. 



Diverse 
symptoms. 



Introspection. 



Exaggeration. 



A man of in- 
finite detail. 



Il82 



MEDICAL DIAGNOSIS 



Finical about 
food. 



A haunter of 
"Spas." 



Curability. 



Futile 
surgery. 



An unfortunate 
tendency. 



In his pocket is a wallet full of carefully preserved prescriptions, urinary 
examination records, differential blood counts, stomach analyses and the like. 

Every particle of food taken is admitted under the honor system, so to 
speak, for each article has long since been tried and measurably proven. 

If he is well-to-do he may have visited every "Spa," tried every fad 
from the dietetic zero, through the grape cure, the exclusive chopped or 
scraped meat diet, to the "molken Kur" and is more than ready and willing 
to discuss with the physician or any fellow sufferer each and any therapeutic 
system, individual diet, mineral water, or drug. 

Such is the extreme but very common picture which leads one of the 
foremost of Swiss clinicians to pronounce the psychasthenic dyspeptics an 
"incurable group" (diese unheilbare Krankengruppe") , an expression which 
doubtless drew a heartfelt "amen" from the great body of practicing 
physicians; yet nearly all of these patients are curable, sometimes very easily, 
oftener only by the expenditure of several months of time and an amount of 
money sufficient to pay for residence in a hospital, a selected trained nurse, 
and a doctor. 

Diverse Localization of Symptoms. — Practically every organ in the body 
may be the apparent focus and source of the disease and the fountain-head 
of selected symptoms, but too often misinterpreted as surgical conditions. 

This is especially true of the female pelvic organs and the abdominal 
viscera proper, which are chief sources of symptomatic expressions. 

It is appalling to think of the amount of surgery which has been undertaken 
in cases lacking any organic lesion of a gravity sufficient to demand it, and of the 
almost invariable results, i.e., temporary improvement, ultimate increase of 
disability, and, not rarely, totally unexpected death either "upon the table" or 
within a few days following the operative procedure. 

In these cases, above all others, radical surgical intervention must be 
based upon genuine need and definite fin dings. and, when emergency is lacking, 
undertaken only when properly directed medical treatment has failed to 
relieve the condition, or the patient is so circumstanced that he must hazard 
the more direct method. 

Unfortunately these structurally deficient, almost invariably visceroptotic 
and functionally unstable, individuals seek operative relief joyously, usually 
to their own harm and the surgeon's discomfiture. 

A detailed presentation of symptoms is quite unnecessary, but it should 
be remembered that cases of all grades of intensity are encountered; that 
in many instances the condition is temporary and recurs only when nutrition 
is brought below a certain level; and that, however decided the psychic 
symptoms may be, they do not often exhibit the characteristics of a true 
psychosis. 

They usually are natural and logical results of the conditions present and 
of the peculiar handicaps of the individual. 

In nearly all of the active cases the hallmark of congenital universal as- 
thenia will be found, to which a more or less decided impairment of nutrition 
or loss of weight is usually added. 



NEURASTHENIA 



1 18 3 



When these are absent a source of reflex irritation, often found to lie 
in the sexual apparatus, cryptogenetic foci of infection, incipient disease 
of the brain or spinal cord, drug habit or other source of symptoms must be 
sought. 

The most striking psychic symptoms are those expressing readily induced 
or persisting ''brain fag"' or excessive irritability, and in many instances, 
the sense of physical fatigue is of psychic origin though this is oftener an 
expression of anatomic and temporarily inadequate myocardium (and the 
poor nutrition of the patient . 

Failure of concentration or of the capacity for sustained mental effort, 
and defective memory, are extremely common. Restlessness, moodiness 
and irritability are natural results of the conditions present. 

Vasomotor relaxation, troublesome throbbing of the abdominal aorta. 
a visible capillary pulse, and vagus arrhythmias, no less than those due to 
associated or causative minor cardiac decompensation or overstrain are 
occasionally present and may be so intensified subjectively by the patient's 
abnormal reactivity, as to become extremely troublesome. 

This tendency to over-reaction is also accountable for the increased 
sensibility to pain and the hyperesthesia, so often evident. 

In some instances sexual excesses and perversions lie at the root of the 
ailment or need correction before any measures of treatment can prove 
successful. Misleading testicular and ovarian tenderness occur and an exag- 
gerated symptom-response on the part of a ptotic uterus, though wholly 
removed in many instances by treatment directed to the general improve- 
ment of nutrition (the ptosis persisting unchanged, , often lead to operation 
and to repeated examinations and persistent local applications which tend 
to focus the patient's introspection upon the reproductive organs. 

Sexual hyperexcitability, on the one hand, and nervous or fatigue impo- 
tence upon the other, are not rare. 

Vertigo is a relatively uncommon symptom and a tendency to syncope 
may sometimes be observed. 

The deep reflexes are normal or. oftener, exaggerated, the pupils may or 
may not be dilated but react normally to light and accommodation, and read- 
ily induced ocular fatigue is quite common. 

Peculiar areas of anesthesia, hysterogenetic zones, and a lack of bilateral 
symmetry on the part of the superficial reflexes, indicate, not neurasthenia but 
hysteria, a thing apart, wrapped in its oivn veil of mystery. 

Diagnosis. — Inasmuch as a genuine primary " neurasthenia" must at 
most be barely "'within the limits of visibility," it would be superfluous to 
do more than assert the absolute necessity for a thorough investigation in 
every case, directed to the detection of the actual underlying cause of any 
psychic and motor disturbances present. 

Primarily the question of recent or existing infection should be determined 
and that of recent weight loss or persistent poor nutrition decided. Organic 
disease must be excluded or, if manifest, properly evaluated, and the stig- 
mata of congenital universal asthenia sought. In this connection especially. 



Misinterpreted 
"fatigue." 



" Brain fag. 



Sources of 
discomfort. 



Sexual 
causes. 



Misleading 
tenderness. 



Be thorough. 



Procedure 
recom- 
mended. 



n84 



MEDICAL DIAGNOSIS 



Basic 
assumption 



but in every case, the condition of the heart itself should be determined, 
for each and every symptom of " neurasthenia" may be wholly or in large 
measure due to minor cardiac incompensation. 

Sources of reflex disturbance must be considered, together with the habits 
and mode of life of the individual. 

Drug habit, luetic infection, and larval or active defects of internal secre- 
tion are potent in causation and hysteria and incipient insanity must be 
given thought in otherwise clouded histories. 

A common source of error lies in the presence of unsuspected larval hyper- 
thyroidism or its opposite larval myxedema. The former may be strongly 
suspected if the blood shows a relative lymphocytosis and indeed in all cases 
of persistent and excessive pulse acceleration coexisting with even slight 
thyroid enlargement and a pseudo-Corrigan pulse. The latter condition 
may demand test doses of the thyroid substance. 

Paretic dementia is very generally called " neurasthenia " in its earlier 
stages and the same statement applies to other forms of cerebral syphilis and 
disseminated sclerosis. 

The cryptogenetic septic foci represented by chronically infected tonsils 
or accessory sinuses, peridental abscesses and the like may be of cardinal 
importance as causative or perpetuating factors. 

Finally the author would repeat and emphasize the statement that only by 
the primary assumption that so-called "neurasthenia" even in its clearest classi- 
cal expressions represents almost wholly a mere symptom complex of an under- 
lying, constitutional and demonstrable structural or nutritional defect, with or 
without any one of many organic diseases or toxemic states, can we hope to avoid 
serious error. 

SEA-SICKNESS AND CAR-SICKNESS.— These interesting and com- 
mon conditions still remain unexplained. We know that the vestibular 
apparatus is to some degree responsible and that to some extent the abdom- 
inal sympathetic system participates. 

With many people, however, the condition may be absent at one time 
and present at some other, presenting perhaps far less of the pitching 
and " writhing" motion of which such sufferers chiefly complain. Many 
are wholly free in recumbency or even in the open air, with others a failure 
to take a brisk cathartic before a voyage proves disastrous. 

Fortunately, of itself, it seldom or never kills, but in no other condition, 
known to the author is there more complete temporary change of disposition, 
greater hopelessness, more profound depression, or even obscuration of 
niceties of life. 

Even old sailors are not immune. One of the sickest of sea-sick individ- 
uals ever seen by the author was a Gloucester fisherman who for punishment 
was kept aloft in a heavy head sea off Cape Horn and forced to continuously 
slush down the masts. 



DISEASES OF THE NERVOUS SYSTEM 



I I 



DISEASES OF THE NERVOUS SYSTEM 

Scope of Section. — The extreme complexity of this department of medicine 
renders its adequate discussion impossible save in works wholly devoted to the 
specialty it represents. 

Nothing beyond a helpful resume or synopsis is attempted in this volume. 
The realm of the alienist is not invaded, nor is any serious attempt made to 
set forth in detail the complicated anatomy of the nervous system, a thorough 
knowledge of which, based upon special study and dissections, must be as- 
sumed as already possessed by the reader. 

There is absolutely no "royal road" or " short cut" to the acquisition of 
knowledge with respect to the anatomy and physiology of the nervous 
system. 

The Neuron Theory. — Though incomplete, the prevailing theory con- 
cerning the histologic structure and functional activity of the nervous system 
has the merits of simplicity and ready adaptation to known symptomatology. 

As now conceived, the nervous system is an aggregation of like units, 
each consisting of an excitable ganglion cell and a cellulifugally conducting 
axis cylinder process of variable length (axon, neurit), which running naked, 
or becoming ensheathed as a medullated nerve fiber, gives off lateral branches 
(collaterals) which, like its terminal, split ultimately into fine fibrillae known 
as end brushes or arborizations. The cell also has cellulipetally conducting 
protoplasmic processes known as dendrites or dendrons. 

With relation to the cell these represent respectively the transmission and 
reception of outgoing and incoming impulses. 

Although the terminal axon arborizations of one neuron are intimately 
related to the dendrites of another, it is probable that there is no actual con- 
nection, but rather mere contact or contiguity. The function of. the basic 
plasma is unknown, but in the cell body are compact coils of fibrillae which 
are regarded as the true conducting elements and certain basophilic granule 
groups known as Nissl's tigroid substance, which are so modified or dimin- 
ished under conditions of cell fatigue or disease as to suggest a trophic 
function. 

Mode of Action. — If one assume an afferent (sensory) impulse orig- 
inating in any of the peripheral special sense organs (sensory dendrites) and 
considers the nature of the conducting mechanism, he can readily appreciate 
the facility of transmission from one set of neurons to another until a reflex 
or voluntary center is reached and the equal readiness with which its efferent 
(motor) fiber carries the message. This marvelous telegraphy is the basis 
of all acts, reflex, voluntary, or automatic, and involves a maze of compli- 
cated pathways and substations which relate to the orderly association and 
interaction of sensation, movement, and intellection necessary to human 
life and normal activity. 

Regional distribution and function are both conserved by the grouping 
of cells and fibers to form sensory and motor tracts, reflex pathways, trophic 
centres, and primary governing centers. 
75 



Scope of 
section. 



Ganglion cells. 
Axis cylinder. 



End brushes. 
Dendrites. 



Fibrillae. 



Chromophilic 
granules. 



Conduction 
and trans- 
mission. 



Regional 
grouping. 



u86 



MEDICAL DIAGNOSIS 



Motor 
impulses. 



Sensory 
impulses. 



Parenthetic 
neurons. 



Centrifugal 
vs. Centri- 
petal impulses. 



Cortex. 



Corona 

radiata, 



Internal cap- 
sule, pons and 
medulla 



CONDUCTION IN MOTOR AND SENSORY AREAS.— Motor impulses 
originating in the pyramidal cells of the cortex pass through their axons to a 
terminal arborization in the anterior horn of the spinal cord or to a cranial 
nerve nucleus where they are received by the dendrites of the related neurons 
and through their axons conveyed to the periphery. The sensory impulse 
requires in addition to these central and peripheral neurons certain " paren- 
thetic" neurons. For example, a pain impulse from the skin passes through 
the dendrites of the peripheral neuron to the spinal ganglion and through its 
axon to the cells of the cord or medulla oblongata, and from these cells, 
acting as parenthetic neurons, to the cortical center, hence in general, " cen- 
trifugal" corresponds to motor and "centripetal" to sensory impulses. 



PYRAMIDAL Ctn. 

OF CEHEBRAl. 

CORTEX ' 



CBResELl.AH 
CORTEX 




MOTOR 
NUCLEI 



Fig. 587. — Showing course of sensory and motor fibers in the cord and the formation of a 
spinal nerve. {After Keillcr, Gerrish and Dana. Slightly modified.) 

THE MOTOR TRACTS.— The Direct Motor Tract arises in the cortical 
cells constituting the motor areas (see Fig. 513), and its neuraxons pass through 
the corona radiata and are gathered into a narrow band occupying most of the 
posterior segment of the internal capsule; thence they pass through the crura 
cerebri to the pons variolii and medulla, giving of in the latter collaterals which, 
with the exception of the sixth nerve, cross the median line to the nuclei of the 
motor cranial nerves of the opposite side. 



TRACTS AND FUNCTIONS 



1187 



The main bundle in passing through the medulla sends nine-tenths of its 
fibers across the median line at its lower portion to form the motor decussation 
and the anterior pyramids. Thus the original bundle is divided into uncrossed 
and crossed columns. 

The crossed fibers enter the lateral column of the spinal cord to form the 
crossed pyramidal tract which descending, diminishes in size as it yields fibers 
at different levels (spinal segments) to form the spinal motor nerves, in each 
case ending in a terminal arborization about an anterior horn cell which trans- 
mits the impulse through its own neuraxons (spinal nerves). 





CEREBELLUM 



Fig. 588. — The direct (voluntary) motor 
tract. (After Van Gehuchten.) 



Fig. 589.— The indirect (involuntary) 
motor tract. {After Van Gehuchten.) 



The uncrossed tract forms the " columns of Tiirck" ("direct pyramida 
tract") and its fibers cross in the anterior commissure at the different levels, to 
participate in the formation of the spinal motor nerves through an arboriza- 
tion around the anterior horn cells, exactly as in the case of the crossed pyra- 
midal tract fibers. 

The "indirect motor tracts " follow primarily much the same course but 
after giving off terminal arborizations to the pons-nuclei cross the median line 
in the middle cerebellar peduncle, thence they pass to the cerebellar cortex, 
and thence, after arborization, to the lateral fundamental column and anterioi 
horns. They are related to coordination and higher reflex and automatic 
movements. 

DIRECT SENSORY TRACT.— From the skin the impulse passes along 
the peripheral nerve and to its cell in the posterior spinal ganglion, thence 
to cells in the posterior horns which receive the stimulus and for the most 
part transmit it by their neuraxons across the cord through the anterior 
commissure to the opposite antero-lateral ascending tract, and through the 
medulla and pons to the optic thalamus where another cell receives and by its 
neuraxon transmits it to the cortex. 



Decussation. 



Crossed tract. 



Direct tract. 



Motor nerves.. 



n88 



MEDICAL DIAGNOSIS 



Equilibrium. 
Gower's tract. 

Tiffs*" 

Goll's tract. 



THE INDIRECT SENSORY TRACT.— This conveys stimuli from 
muscles, joints and the viscera through the posterior root ganglia and thence 
along the sensory roots to the cord where a part enters directly, and ascends 
in the posterior column of the cord of the same side as far as the nuclei of 
the columns of Burdach and Goll {nucleus cuneatus and nucleus gracilis) 
in the medulla, from which centers the neuraxons (internal arcuate fibers) 
cross in the sensory decussation. Some go thence to the cerebellar cortex, 
whence they are transmitted by cells of that area through the superior cere- 
bellar peduncles to the optic thalamus and red nuclei, and thence by yet 





Fig. 590. — Direct sensory tract. Course 
of fibers and general arrangement of neu- 
rons. {After Van Gehuchlen.) 



Fig. 591. — Indirect sensory tract. 
{After Van Gehuchten.) 



another neuraxon to the central convolutions. Other impulses pass from 
the sensory root to the cells of Clark's column, and pass up the direct 
cerebellar tract to the cerebellum, thence to the optic thalamus, red nuclei, 
and cerebral cortex. 

FUNCTIONS OF THE TRACTS OF THE SPINAL CORD.— The func- 
tions of the various tracts of the cord are, so far as known, the following: — 
The direct pyramidal tract is purely motor and its fibers cross at the level of 
the nerve emergence. 

The crossed pyramidal tract is the chief motor area of the cord represent- 
ing the fibers which cross in the lower portion of the medulla. The per- 
ipheral nerves of both tracts are dependent upon the trophic influence of 
the anterior horn cells. 

The direct cerebellar tract represents chiefly visceral sensation and is 
concerned with equilibrium. 

The antero-lateral ascending tract {Gower's tract) is concerned with sen- 
sations of pain, temperature and touch, conveyed from the opposite side 
through the anterior commissure. GolVs tract conducts sensation from the 



DISEASES OF THE CEREBROSPINAL SYSTEM 



L I 



joints, tendons and muscles of the same side while in the cord, its fibers cross- 
ing in the medulla. It is therefore associated with ataxia, deficient orien- 
tation and muscle sense in general, under conditions of disease. 

Burdach's tract conveys tactile sensations from the opposite side, con- 
tains many associating fibers and is crossed by afferent sensory fibers con- 
veying reflex, painful, articular or muscular stimuli, hence if diseased there 
may be anesthesia, ataxia, more or less pain and interrupted (lost) reflexes. 

The fundamental columns are related to association of different cord 
levels with each other and with the brain stem and cortex and contain both 
sensory and motor fibers. The cells of the anterior horns are trophic in 
function, constitute the nutrient cells of the lower motor neurons, and if 
diseased produce atrophy, R.D.,* and paralysis, (flaccid paralysis) and loss 



dorsointer.mediate 
fissure: 



POSITION OF 
DORSAL ROOTS 



DORSOLATERAL 




Fig. 592. — Diagrammatic transverse section of spinal cord. {After Gerrish.) 

of the deep reflexes. The anterior horns are essentially motor, the pos- 
terior sensory. The cells at the posterior angle of the posterior commis- 
sure are probably automatic centers; others in the immediate neighborhood 
may be trophic, sensory, and vasomotor. 

Functions of the Sensory Tract. — The direct sensory tracts represent 
chiefly pain, touch and temperature sense, the indirect sensory and motor tracts 
being intimately connected with coordinate movement, voluntary or involun- 
tary and, of course with visceral sensation. These wonderful tracts govern 
the automatic and psycho-reflex acts of the human organism. 

CAUSES OF DISEASE OF THE CEREBRO -SPINAL SYSTEM.— 
These may be both direct or indirect, primary or secondary, and though the 
greater number of nervous diseases proper are distinctly related to structural 
alterations of the nervous system, the clinician must always hold in mind the 

*The electrical reaction of degeneration. 



Anterior 
horn cells. 



Anterior vs. 

posterior 

horns. 

Automatic 
centers. 



Pain, touch, 
temperature 
sense. 



Visceral sensa- 
tion and 
coordination. 



Remote ail- 
ments as 
causes. 



1 190 MEDICAL DIAGNOSIS 



fact that remote disease may find its ultimate and perhaps chief and terminal 
expression in the brain, cord, or peripheral nerve. 

For example, arteriosclerosis and nephritis are responsible for most cases 
of cerebral hemorrhage and thrombosis, as is left-sided valvulitis for cerebral 
embolus. A peripheral neuritis may be traced to lead or alcohol poisoning, 
and in such cases, reasoning from effect to specific cause, one reaches a definite 
and potent therapeusis. We may consider, therefore, without separating 
primary from secondary lesions, the following etiologic factors: 

(a) Toxemias and Direct Bacterial Activity. — Arsenic, lead, alcohol, and 
carbon bisulphid serve as the type of one form; diphtheria, erysipelas, syphilis,* 
and typhoid of another; nephritis, diabetes, and chronic auto-intoxication , 
severe anemias, and the cachexias, yet another. In most instances such poisons 
produce changes in the peripheral nerves or the spinal cord, i.e., polyneuritis, 
acute poliomyelitis, Landry's paralysis, locomotor ataxia, etc., the peripheral 
nerves being oftenest affected. 

(b) Secondary (metastatic) tuberculous, malignant, or septic foci. 

(c) Affections of the heart and blood vessels, i.e., valvular lesions, arterio- 
sclerosis, degenerative diseases of the heart muscles, etc. 

(d) Tumors. — Under this we include gummata, sarcoma, carcinomata, 
tuberculous growths, cysticercus cysts, etc. 

(e) Traumatism, and its sequelae, including scar formation. 

(f) Meningeal inflammation, acute or chronic, suppurative or non-sup- 
purative. 

(g) Caries, gumma, osteomyelitis. 

(h) Developmental defects and diseases of a distinctly hereditary type. 

(i) Certain unexplained nervous disorders denominated functional, such 
as epilepsy. 

(j) Certain changes of a purely senile type, often premature in occurrence, 
and in general, degenerative and atrophic in type. 

(k) Hereditary and acquired predisposition, habits, and environment, hold 
a prominent place. 

DEGENERATION. — Injury to the parent cell causes degeneration of its 
processes, and division of these leads to their death peripherally, but may not 
entirely destroy the function of the cell. 

It is interesting to note that secondary degeneration is limited to the 
neuron involved and that a lesser amount of atrophy may occur in a fiber 
not directly or exclusively connected with the affected cell. 

There are three chief forms of degeneration: (1) Primary. (2) Sec- 
ondary or Wallerian. (3) Toxic. 

The first occurs in the cachexias, locomotor ataxia, and in senile processes. 

The second is characterized by a degeneration chiefly affecting the per- 
ipheral segment and is a relatively rapid process, being complete within from 
two to four weeks. 

* Vascular syphilis has assumed enormous importance in diseases of the nervous system 
as an etiologic factor, since the discovery of Treponema pallidum and the introduction of the 
Wassermann tests. (See Cardiovascular Syphilis" for discussion.) 



GENERAL SYMPTOMATOLOGY 



II9I 



As a rule, the degeneration follows the direction of normal impulse con- 
duction, though in association or commissural fibers it is only partial and, as 
the trophic center of the sensory nerve is the spinal ganglion, if the injury or 
section be between the ganglion and the cord the peripheral nerves do not 
suffer. The cells of the anterior horns are trophic for motor nerves and injury 
to them as to the peripheral nerve itself means outwardly progressing 
degeneration. 

The third type, toxic degeneration, is segmental but follows the laws of 
Wallerian degeneration. 

Regeneration. — Nerve cells cannot be reproduced if destroyed, but nerve 
fibers can regenerate though only as to the peripheral fibers, and this process, 
moreover, demands that the trophic center be sound. 

CLASSIFICATION.— Whatever be the cause of organic disease of the 
nervous system, we distinguish those of the general or irregular distribution 
from those which chiefly or perhaps exclusively affect a definite tract or 
neuronic chain ("system disease"). 

In "focal" disease a certain portion of the brain or spinal cord may be 
involved together with all contained structures. If two or more definite 
conduction paths are involved, one speaks of a "combined, system" 
disease. 

The distinction cannot be exact, but is convenient and conforms to 
known disease types, as in pernicious anemia. In grosser lesions, such as 
those of hemorrhage, thrombosis, and abscess, one finds a tendency to more 
or less rapid necrosis of tissue resulting in cyst formation, which may show 
gradual occlusion by contraction and scar formation. 

SEQUENCE OF DEGENERATIVE CHANGES.— These may be thus 
summarized:* 

Spinal Cord Lesions. — Ascending degeneration of sensory pathways, de- 
scending degeneration of motor tracts. 

Region of the Mesencephalon. — Degeneration of the optic tracts and 
red nucleus, atrophy of the brachia, corpus dentatum of the cerebellum, 
pontine ganglia, etc., and both ascending and descending degeneration of 
the fillet. 

Cerebellar Lesions. — Atrophy of the opposite red nucleus and the 
brachia; degeneration of the median cerebellar peduncle, restiform body, 
lower olive, etc. 

Cortical Lesions. — Atrophy of such related structures as the red nucleus, 
fillet, opposite brachium, and the subthalamic region, with degeneration 
of the optic thalamus, all directly related projection fibers and partial de- 
generation of those of association. In young children Wallerian degenera- 
tion results in arrested growth of the parts involved as is well illustrated by 
those adults who have had infantile spinal palsy. 

GENERAL RELATION OF PATHOLOGIC CHANGES TO SYMP- 
TOMATOLOGY. — The following summary will suffice to show the direct 
and indirect results of (a) irritation, or (b) destruction of the motor and 

* Following Jakob's classification. 



Focal lesions. 



1192 



MEDICAL DIAGNOSIS 



A sharp 
contrast. 



Absent' 
response. 



Flaccid 
paralysis. 

Site of lesion. 



Lost reflexes 
atrophy and 
R.D. 



Prognosis. 
Spastic type. 



Neither R.D. 
nor atrophy. 



Reflexes 
increased. 



Flaccidity and 
anesthesia. 



sensory cells and pathways. In the former instance we find morbid activity, 
in the latter loss of function. 

SENSORY AREAS. — Irritation. — (a) Increased response to peripheral 
stimuli, i.e., hyperesthesia or actual pain (hyperalgesia, violent neuralgic 
pains). 

(b) Subjective sensations, such as tinnitus aurium, hallucinations, both 
visual and aural, and various paresthesias, such as numbness, tingling, or for- 
mication, according to the regions involved. 

Destruction. — Entire or partial loss of sensory response to peripheral 
stimuli or of certain special sensations only (i.e., anesthesia, thermo-anes- 
thesia, analgesia, etc.), and partial or complete ataxia. 

MOTOR LESIONS.— (^4) Peripheral or lower motor neuron (i.e., an- 
terior horn cells, or cranial nuclei, to periphery). — Paralysis is flaccid, usually 
bilateral* (if unilateral on same side as lesion), and must be due to a lesion 
involving (a) the cells of the anterior cornua, (b) the cranial nuclei, or (c) the 
peripheral nerves, cranial or spinal as the case may be. 

Fibrillary twitching may be present but there is neither contracture nor 
rigidity, and by interrupting both the reflex arc and the trophic stimulus it 
involves a loss of the reflexes together with the supervention of marked muscular 
atrophy and the electric reaction of degeneration. Not only does the presence 
of reaction of degeneration conclusively prove such a paralysis to be one of the 
peripheral neuron, but its entire absence after several days means early 
recovery. In general, the prognosis is good in inverse proportion to the degree 
of R. D. 

(B) Central Motor Neuron (i.e., cortical centers to cranial nuclei or 
anterior horn cell but not including them). — On the side opposite an intracranial 
lesion there is spastic paralysis (rigidity) with secondary contractures, whereas 
marked true atrophy (aside from that of disease) is lacking, R. D. absent and 
lendon reflexes increased by removal of cerebral inhibition. 

Irritative lesions affecting motor areas of the cortex may cause tonic, 
clonic or epileptiform spasms, athetoid, choreic or wholly irregular movements 
and muscular twitching. 

Unilateral Spinal Cord Lesions ("Brown-Sequard paralysis' 7 ). — Loss 
of power is complete on the side of the lesion with anesthesia on the opposite 
side save for a zone corresponding to the level of the lesion and on the same side. 
Muscle sense is impaired on the paralyzed side, retained on the opposite 
(anesthetic) side, and the type of paralysis is spastic save at the level of the 
lesion where the destruction of the anterior horn cells may produce a, flaccid 
paralysis in the limited area represented by their trophic influence. 

Complete Transverse Spinal Cord Lesions. — Symptoms. — If the trans- 
verse lesion be complete there is complete flaccid paralysis and anesthesia 
below the lesion with lost deep reflexes, atrophy, and R. D. Any spastic 
paralysis indicates an incomplete lesion. 

* Cord lesions are usually bilateral; cortical lesions crossed monoplegic; lesions of the 
region below the cortex and above the motor decussation in medulla, crossed hemiplegic. 



SPECIAL REFLEXES 



1 193 



REFLEXES 

. .4 reflex consists in the transmission of an impulse along a sensory neuron 
to the reflex center, and thence along the motor axon to the muscle*] It requires 
therefore, an unbroken chain from the periphery to the center and back to 
the periphery, and excessive activity is prevented by a cortical governing 
(inhibition center). A reflex may be localized and coordinate, in that the 
primary stimulus produces movement in a single muscle or in a limited group 




Fig. 593.— Diagrammatic representation of the reflex arc. Normal on left, inter- 
rupted on right. It will be noted that the arc proper extends from the percussion hammer 
(sensory stimulus) through the peripheralsensory nerve, through the ganglion of the posterior 
root, through the posterior to the anterior horn where the sensory impulse is translated 
into a motor response which in turn is modified by the inhibitory cortical fibers. It is 
evident that a lesion interrupting the arc at either c, d, g, h, or f, will abolish the reflex, and 
produce flaccid paralysis if the nerves themselves or the cells of the anterior horn are seriously 
involved. Spastic paralysis results, if the lesion be at e or a with consequent exaggera- 
tion of reflexes through loss of cerebral control (lateral sclerosis, cortical lesions). Lesions 
at c and d cause loss of knee jerk and, associated with a lesion at b, represent the usual 
seat of locomotor ataxia. (After Gowers, Butler, Herter, et al.) 

of muscles, or incoordinate ar spasmodic, and either general or confined to 
certain muscle groups. Such are seen in general convulsions from various 
causes or a reflex spasm associated with certain diseases, and yet another 
form of reflex may be both coordinate and purposeful. Reflex centers exist 

* It is primarily a centripetal sensory impulse conveyed to the reflex center and there 
converted into a centrifugal or motor stimulus. 

t In general the presence of normal superficial reflexes is much more important than their 
absence. 



Coordinate vs 
incoordinate. 



1 194 



MEDICAL DIAGNOSIS 



Automatic 
activity. 



May precede 
loss of knee- 
jerk. 



Reenforce- 

ment. 



Increased 
knee-jerks. 



in the spinal cord, pons varolii and medulla, the former being largely related 
to muscular action, the latter to the vital but unconscious and automatic 
vital functions, i.e., cardiac, respiratory, etc. 

THE MORE IMPORTANT SPECIAL REFLEXES.— Ciliospinal Re- 
flex. — Stimulation of the cervical sympathetic by pinching the skin of the 
neck dilates the pupil and its absence indicates a lesion of that nerve. 

Conjunctival Reflex. — Complete anesthesia, deep stupor, or coma usually 
abolish the well-known spasm of the orbicularis palpebrarum following 
conjunctival irritation. 

Palate and Pharynx Reflex. — The latter is absent in most hysterias. 

Jaw-jerk. — (A contraction of the muscles of mastication). — Percuss the 
chin firmly by the mediate method while the mouth is moderately open. 
Inconstant in health, marked if reflex excitability is increased. 

Supinator-jerk. — Tap supinator tendon just above styloid insertion. 
Usually absent in health (fifth cervical segment). 

Triceps-jerk. — Support the arm at the elbow, carrying it outward at a 
right angle to the body, let the forearm hang vertically downward and tap 
strongly the triceps tendon just above the olecranon (fifth, sixth, and seventh 
cervical segments) . It is absent or slight in health. 

Biceps-jerk. — Flex elbow at right angles, strike forearm near lower end 
of radius. Biceps contraction occurs only in disease (fifth cervical segment). 

Achilles-jerk. — Put the tendon Achilles slightly on the stretch by extend- 
ing the leg and dorsiflexing the foot, or, have the patient kneel on a chair 
with the foot unsupported; tap the tendon sharply and in health a contrac- 
tion of the calf muscles follows. Its early disappearance in locomotor ataxia 
is an important diagnostic sign (fifth lumbar and first sacral segment). 

It may show a clonus just as in the case of the patellar reflex to be de- 
scribed. 

Scapular Reflex.- — Contraction of scapular muscles on stroking inter- 
scapular region (fifth, sixth, seventh and eighth cervical and first dorsal segments). 

The Patellar Reflex* (Knee-jerk). — This is best obtained by having the 
patient cross one knee over the other or better sometimes, if he passes his 
own arm under the knee of the member to be tested over the opposite knee, 
in such manner as permits the leg to hang free and relaxed across the wrist. 

Then the patient is told to close the eyes, join his own hands and pull 
when the word is given (reenforcement), coincidently the tendon, just below 
the patellar margin, is sharply tapped with the side of the hand, the edge of a 
book or a percussion hammer, f 

The forward jerk of the leg and foot or visible contraction of the muscle 
varies greatly in health and may be markedly increased in certain conditions 
of impaired nutrition associated with nervous instability, hysteria, tetanus, 

* Tendon Reflexes. (Deep reflexes.) It will be noted that all of the tendon reflexes 
require that the tendon involved be slightly on the stretch. 

t Usually the jerk can be obtained without reenforcement, but it saves time to carry 
out the entire procedure. In bed-ridden patients the same procedure can be carried out 
by utilizing one's own arm and the flexed opposite knee as points of support. 



SPECIAL REFLEXES 



H95 



strychnin poisoning, rheumatoid arthritis or after sexual excesses and drink- 
ing bouts, and is pathologically increased in any disease which cuts off the 
cerebral inhibition fibers. Such are cortical hemiplegias and sclerosis (lateral 
or amyotrophic) of the lateral columns. 

For clinical purposes one may assume that it is invariably present in 



health. Its absence 

7T< 




employed 



Fig. 594. 

1. Knee-jerk elicitation. 

Method sometimes 
by author. 

2. Simple method. 

3. A common method. 

4. Ordinary reenforcement method. 

5. Method of obtaining Achilles- jerk. 

6. Method of eliciting ankle clonus. 

7. Method of obtaining triceps -jerk. 

8. Method of obtaining jaw-jerk. 



Westphal's Sign," indicates a lesion interrupting the Lost 

n . ...,.,' knee-jerk. 

reflex arc, viz., a lesion involving the 
sensory or motor fibers (neuritis), the 
posterior roots or columns, the anterior 
cells or even the motorial end plates. 

Hence it is lost in locomotor ataxia, 
anterior poliomyelitis, transverse myelitis 
of the second and third lumbar segments 
(seat of reflex), Landry's paralysis, Fried- 
reich's ataxia and sometimes in chorea, 
diabetes and severe toxemias such as 
diphtheria. Cases of pathologic exaggera- 
tion may yield a series of "jerk," on tap- 
ping the quadriceps tendon. In such 
cases especially "ankle clonus" should be 
sought.* 

Patellar clonus is elicited by grasping 
the knee-cap firmly with the thumb and 
forefinger and pushing suddenly downward 
and hold momentarily. 

Crossed Adductor Reflex. — This is an 
adduction of the opposite thigh following 
the tap upon the patellar tendon. 

Ankle Clonus. — The knee is very slightly 
flexed, the heel rests in the palm of the 
examiner's left hand, his right grasps, ex- 
tends and suddenly dorsiflexes the foot upon 
the leg. An initial series of clonic invol- 
untary contractions of the muscles of the 
calf repeated under sustained pressure of the 
flexing hand constitutes clonus. 

True clonus has the same significance 
as exaggerated knee-jerks in its relation 
to organic disease, being most common in 



lateral and disseminated sclerosis. If con- 
tractions appear before the degree of foot flexion exceeds a right angle and 
are evidently voluntary, irregular and fleeting, one is dealing with spurious 
clonus, usually hysterical {second and third lumbar segments). Tonic con- 
traction of the anterior tibial group may occur. 

* The real test symptom is contraction of the quadriceps muscle rather than actual 
movement of the foot. Hence the examiner's free hand should be placed upon the muscle. 



True clonus 
prolonged. 



Pseudoclonus, 
transient, 
irregular and 
voluntary. 



1 196 



MEDICAL DIAGNOSIS 



Wrist-jerk. — Let the hand drop at the wrist (which is supported), strike 
the extensor tendons of the dorsum just proximal to the wrist-joint. (Usually 
absent or slight in health.) 

Epigastric. — Retraction of epigastrium following downward stroking of 
chest in nipple line. A continuation of this line of stroking from the costal 
margin downward produces contraction of the abdominal muscles. It is 
of little importance or clinical value {fourth, fifth, sixth and seventh dorsal 
segments) . 

Abdominal Reflex. — Elicited by stroking outer side of abdomen at various 
levels, {eighth, ninth, tenth, eleventh and twelfth dorsal and first lumbar segments) . 

Gluteal Reflex. — This consists in contraction of 
the glutei on vertical stroking of the buttocks {fourth 
and fifth lumbar segments). 

Cremasteric Reflex.- — Quick retraction of testicle 
upon stroking inner and upper part of thigh. (Not 
dartos contraction.) 

Caution. — All reflexes are best elicited when the 
patient's attention and vision are diverted. The super- 
ficial reflexes merely prove the integrity of the region 
governing them. 

Babinski' s Toe Reflex. — This consists in deliberate 
dorso-extension and separation of the toes and 
especially of the great toe, followed by dorsiflexion 
of the ankle-joint, when the sole is gently or firmly 
stroked with a quill point, finger-nail, etc. It is 
usually associated with disease involving the pyra- 
midal tracts and in any event is pathologic. It is 
said that in healthy young children not yet able to 
walk a similar but more rapid response is obtainable. 

Oppenheim's Reflex. — This is a Babinski reaction 
elicited by forcibly stroking the inner or median border 
of the tibia. Gordon applies deep pressure to the calf 
muscles (Gordon's paradoxical flexor reflex). 

Plantar Reflex. — The chief value of this sign lies in its constancy in health, 
its frequent absence in hysteria, and its reversed form constituting the Babinski 
sign. If the sole of the foot, thoroughly dried, be stroked, the patient's 
attention being diverted, his position supine, the knee and thigh semiflexed 
with the leg in outward rotation, plantar flexion of the toes beginning with 
the four outer, and dorsiflexion of the ankle result {second and third sacral 
segments) . 

Adductor-jerk. — Abduct thigh and tap adductor magnus tendon. 
Adductor contraction may occur on both sides in conditions of high reflex 
irritability. 

Organic Reflexes. — These involve chiefly respiration, deglutition, mic- 
turition, and defecation, and a full consideration of their complicated 
mechanism is out of the question in a volume on medical diagnosis. 




Fig. 595. — Plantar re- 
flex. Upper plate shows 
normal reflex plantar 
flexion. Lower: — Dorsi- 
flexion of great toe. 
(Babinski's sign.) 



SPECIAL REFLEXES 1197 



They are best considered in relation to the symptomatology of the individual 
diseases. 

Defecation. — To test the action of the rectal sphincter a digital examina- 
tion is necessary, the strength of the resistant or grasping contraction being 
noted. In health contraction follows a prick of the anal region. 

Rectal incontinence may be met with in all conditions associated with 
coma or profound toxemia, such as typhoid, as well as in certain organic 
nervous diseases. There is sometimes a true reflex spasmodic incon- 
tinence. 

Micturition. — Dribbling of urine usually means overfilling of the bladder 
and calls for the use of the catheter. A true reflex incontinence may exist 
such as seen in young children. Both rectal and vesical centers are in the 
lower lumbar (fourth and fifth) and upper sacral (first, second, third) portion 
of the cord. 

SYNKINESIAS OF DIAGNOSTIC VALUE (Uninhibitable Associated 
Movements). — These represent a limited return from the dissociation of 
training to fetal pathways of association, through the effects of disease and 
may be illustrated by several phenomena of clinical interest. The term 
"reflex" is not fully explanatory of them. 

BrudzinskPs Signs. Collateral Reflex. — In meningitis and cerebral dis- 
ease, passive flexion of one leg may cause involuntary flexion of its opposite 
(" identical collateral reflex"). If extension occurs instead, it constitutes 
the reciprocal collateral reflex. 

Neck Sign. — The patient being in the dorsal recumbent position the head 
is flexed on the chest; flexion of the thighs and of the knees resulting. This 
is a valuable sign in meningitis. 

Striimpell's Tibial Phenomenon.- — In lesions of the upper motor neuron 
the simultaneous making of pressure upon the thigh, light pressure upon the 
dorsum of the foot of that side, and an effort on the part of the dorsally 
recumbent patient to raise the thigh forcibly may result in strong contraction 
of the tibialis anticus muscle. 

The Oppenheim-Babinski Hip-flexion sign is of interest but of slight 
clinical importance. It consists merely in an uninhibitable flexion of the 
thigh of a spastic paralyzed lower extremity upon attempting the exchange, 
the flat dorsal-recumbent for the sitting posture. 

Grasset's sign or phenomenon is of some value in hysterical simulation 
of partial organic hemiplegia or simulation by the malingerer. 

In full recumbency with arms crossed in front and legs separated (as 
should be done in the Oppenheim-Babinski maneuver), the patient finds it 
impossible to lift both lower extremities simultaneously though each may be 
raised separately. The trap for the simulator is obvious. 

Hoover's Sign. — This has essentially the same differential value as the 
preceding maneuver. 

In the partial dorsally recumbent "hemiplegic" and the normal person 
alike, the attempt to raise one leg alone involves downward pressure by the 
opposite extremity in a degree proportional to its strength. 



1 198 



MEDICAL DIAGNOSIS 




THE MOTOR POINTS OF ERB 



1 199 



A. Anterior surface of 


arm, shoulder and hand. 


1. Deltoid. 




16. Flexor longus pollicis. 


2. Musculo-cutaneous n. 




17. Pronator quadratus. 


3. Biceps. 




18. Median n. 


4. Musculo-spiral n. 




19. Abductor pollicis. 


5. Brachialis anticus. 




20. Opponens pollicis. 


6 & 7. Median (the ulnar lies just 1 


nternal 


21. Flexor brevis pollicis. 


to 6). 




22. Adductor pollicis. 


8. Pronator radii teres. 




23. Lumbricales. 


g. Supinator longus. 




24. Ulnar n. 


10. Palmaris longus. 




25. Palmaris brevis. 


11. Flexor carpi ulnaris. 




26. Adductor minimi digiti. 


12. Flexor carpi radialis. 




27. Flexor brevis minimi digiti. 


13. Flexor profundus digitorum. 




28. Opponens minimi digiti. 


14. Flexor sublimis digitorum. 




29. Palmar interossei. 


15. Same (second and third digits). 






B. Posterior surface of arm, shoulder and hand. 


1. Deltoid. 




9. Supinator brevis. 


2. Triceps (long head). 




10. Extensor carpi ulnaris. 


3. Triceps (external head). 




11. Extensor indicis. 


4. Musculo-spiral nerve. 




12. Abductor longus pollicis and extensor 


5. Supinator longus. 




brevis pollicis. 


6. Extensor carpi radialis longior. 




13. Extensor longus pollicis. 


7. Extensor carpi radialis brevior. 




14. Abductor minimi digiti. 


8. Extensor communis digitorum. 




15. Dorsal interossei. 


C. Motor points on 


the head and neck. 


1. Temporalis. 




.1.7. Anterior thoracic nerve (pectoralis 


2. Middle branch. (Facial) two 


lower 


major). 


(branch of upper above). 




18. Phrenic nerve. 


3. Occipitalis. 




19. Omohyoid. 


4. Retrahens aurem. 




20. Sternothyroid. 


5. Upper facial. 




21. Frontalis. 


6. Facial trunk. 




22. Corrugator supercilii. 


7. Posterior auricular nerve. 




23. Orbicularis palpebrarum. 


8. Masseter. 




24. Xasal muscles. 


9. Splenius. 




25. Levator labii superioris. 


10. Spinal accessory nerve. 




26. Zygomaticus major. 


11. Sternocleidomastoid. 




27. Orbicularis oris. 


12. Trapezius. 




28. Hypoglossal nerve. 


13. Long thoracic nerve (serratus 


mag- 


29. Levator labii inferioris. 


nus). 




30. Depressor labii inferioris. 


14. Circumflex nerve (deltoid). 




31. Depressor anguli oris. 


15. Brachial plexus. 




32. Lower branch of facial. 


16. Erb's point (deltoid, biceps, br£ 


chialis 


33. Platysma. 


anticus, supinator longus.) 




34. Sternohyoid. 


D. Motor points 


on the anterior aspect of the leg. 


1. Anterior crural nerve. 




12. Vastus externus. 


2. Tensor fasciae latse. 




13. Vastus internus. 


3. Sartorius. 




14. External popliteal nerve. 


4. Obturator nerve. 




15. Peroneus longus. 


5. Quadriceps (common point). 




16. Extensor longus digitorum. 


6. Pectineus. 




17. Tibialis anticus. 


7. Rectus femoris. 




18. Peroneus brevis. 


8. Adductor longus. 




19. Extensor- hallucis longus. 


9. Adductor magnus. 




20. Extensor brevis digitorum. 


10. Gracilis. 




21. Dorsal interossei. 


11. Crureus. 






E. Motor points on the posterior aspect of the leg. 


1. Gluteus maximus. 




9. Internal popliteal nerve. 


2. Sciatic nerve. 




10. External popliteal nerve. 


3. Adductor magnus. 




11. Gastrocnemius (outer head). 


4. Semitendinosus. 




12. Gastrocnemius (inner head). 


5. Gracilis. 




13. Soleus. 


6. Semimembranosus. 




14. Flexor longus digitorum. 


7. Biceps (long head). 




15. Flexor longus hallucis. 


8. Biceps (short head). 




16. Posterior tibial nerve. 



1200 



MEDICAL DIAGNOSIS 



Lack of tone. 



Loss of power. 



Faradic test. 



In malingering and hysterical paralysis the strength of the downward 
pressure of the pseudo-paralyzed member is approximately or actually normal. 

THE EXAMINATION OF THE MUSCLES.— The tests for paralysis 
are suggested by the defects noted under "Segmental Lesions," or under 
the discussion of the special nerves involved. 

A peculiar lack of tone is noticeable in a completely paralyzed limb even 
though the patient be unconscious and any existing muscular atrophy is readily 
detected by observation, careful measurement, and palpation. With this should 
be considered the question of power and electrical reactions, as in certain diseases 
a spurious hypertrophy appears. 

The Reaction of Degeneration.- — Faradic and galvanic batteries are re- 
quired together with the usual appliances for controlling and applying the 
current. 

The Faradic Current. — The muscles should first be tested for faradic ex- 
citability. Having wet both electrodes with salt water, a weak current is 
applied, and with the indifferent electrode over the sternum or between the 
scapulae, the smaller electrode is applied successively to the motor points of 
Erb and the resulting tonic muscular contraction and the increase of current 
necessary to produce it is noticed. Corresponding points on opposite sides 
of the body should be tested in alternation. 

The Galvanic Current. — The indifferent electrode (the larger) should be 
positive, the normal electrode negative. These are applied as in the faradic 
test and the current is first closed and after a moment again opened, gradually 
increasing the current until muscular contraction follows the closure of the 
circuit, this last constituting cathodal closure contraction (CaCC). The 
switch is then thrown to change the direction of the current, the intensity 
of which must remain the same and the test repeated, when any muscular 
contraction will represent anodal closure contraction (ACC). The com- 
parative promptness and strength of contraction must be carefully noted. 
Further tests are not necessary, but the opening contractions may be noted 
in the same manner. 

Significance of Electrical Reactions. — Normally the response should be 
prompt and decided to either electrode of the faradic current and shoidd continue 
during its passage. If the contraction be sluggish or absent, if it diminishes 
or disappears, it indicates disease. 

In the case of the galvanic current, the reaction following cathodal closure 
should occur with a less current than is required for anodal closure contraction, 
but no tonic contraction should occur while the current is passing. Similarly 
AnCC exceeds, normally, AnOC and this in turn CaOC. 

The reaction of degeneration is represented by an AnCC which equals or 
exceeds CaCC. Furthermore, in the case of the galvanic as in the faradic, 
contraction may be delayed, sluggish, vermiform, or entirely absent. 

R. D. signifies a loss of nutrition in the motor nerve due either to disease of a 
trophic center or the nerve itself and is a prominent symptom of the flaccid palsies 
whether affecting cranial or spinal nerves. When R. D. is present the faradic 
excitability is lost. 



Galvanic test. 



Cathodal 
closure- 
contraction. 



Anodal closure- 
contraction. 



Promptness of 
reaction. 



CaCOAnCC 
is the normal. 



R.D. 



Sluggish 
response. 



Significance of 
R.D. 



CERTAIN PSYCHIC DERANGEMENTS 1201 



CERTAIN PSYCHIC DERANGEMENTS 

Disorders of Memory. — The patient's memory should be noted in the 
preliminaries of case taking by questions relating to his birthday; the num- 
ber, names and ages of children, date and place, etc. 

Loss of Memory (Amnesia). — This may be circumscribed — when only 
certain things and for a certain space of time cannot be remembered — or 
general. Any disease which impairs the nutrition of the brain, or especially 
that of the cortex, may result in loss of memory. 

It may fail in relation to recent events and remain clear for those of the 
remote past and both phases must be tested. 

It may follow acute infectious diseases, injuries producing mental shock 
and may be due to organic lesions of the brain, such as apoplexy, tumor, 
thrombosis, embolism, meningitis, senile degeneration or scleroses, insanity 
and frequently neurasthenia. 

Complete loss of memory is chiefly observed in insanities (dementias) 
chronic alcoholism and neurasthenia. 

Hypermnesia. — An exaltation of memory occurs in some cases of chronic 
delusional insanity. 

Paramnesia. — This is a peculiar illusion of memory in which events 
which never happened in the experience of the individual are in his belief 
remembered, occurs in some cases of paranoia and is closely allied to the (nor- 
mal) conviction that one is repeating at some certain time a former experience. 

Defective moral sense, when occurring in an individual whose previous 
moral status has been above reproach, should excite suspicion of degenera- 
tive brain disease, especially dementia paralytica. 

Illusions are faulty interpretations of actual visual impressions and are 
actually visual paresthesias. For example, a strap lying on the floor may 
be seen as a snake. Illusions are common to nearly all forms of delirium. 

Hallucinations are sensory impressions lacking any objective basis. A 
patient may see a snake on the floor when in reality there is nothing which 
could be mistaken for a snake. Hallucinations are met with in most all 
forms of insanity. 

Delusions are false beliefs and may be either sane or insane — an indi- 
vidual believing that today is Monday when in reality it is Tuesday may be 
said to have a delusion, or false belief, but it is significant only in so far that 
he is mistaken. Insane delusions, on the other hand, are not only absolutely 
contrary to facts, but they cannot be corrected by an appeal to reason and l 
are entirely out of harmony with the patient's education and surroundings. 

Insane delusions are either fixed, i.e., when the insane belief is persisted 
in, or changeable when one belief is constantly being replaced by another, as 
occurs in delirium. 

A delusion is said to be systematized when it enters into combinations with 
other facts of consciousness, as occurs in true paranoias, or unsystematized, 
when it is not associated with other facts of conscious experience (delirium, 
dementia paralytica). 
76 



1202 



MEDICAL DIAGNOSIS 



Loss of consciousness occurs as a frequent symptom of organic disease 
of the brain, but may be a symptom of many conditions depending on nutri- 
tional disturbances of the cortex. The degree of unconsciousness varies 
considerably. The term "stupor" is used when the patient can be roused 
temporarily from his sleep, whereas, if all ordinary stimuli, such as slapping, 
rubbing, etc., fail to rouse the patient and unconsciousness persists for some 
time it is termed "coma." (See under "Coma"). 

Sudden loss of consciousness is usual in syncope, apoplexy, cerebral hem- 
orrhage, embolism or thrombosis of a cerebral artery or may result from con- 
cussion of the brain. In epilepsy a temporary loss of consciousness occurs. 
Uremia, diabetes and cholemia by the production of toxic substances may 
produce a loss of consciousness, while among the more common and important 
poisons doing so are alcohol, opium and chloral. 

Delirium. — In itself this is divisible into active (wild or maniacal), pas- 
sive (low, muttering). Furthermore, a delirium may be wholly nocturnal 
and in all acute diseases tends to assume that form or merge gradually into 
it during convalescence. Delirium tremens and the fully developed cases of 
typhoid fever illustrate, respectively, the active and passive type. Delirium, 
aside from brain lesions, indicates chiefly toxemia or extreme exhaustion, but 
may be seen in hysteria and occasionally in epilepsy. 

Disturbances of Sleep. — Insomnia may occur in acute and chronic dis- 
eases, whether cerebral or general, or in neurasthenia or simple overwork. 
Early waking or frequent waking is quite general in old persons and certain 
cardiopaths, night terrors and transient somnambulism are common in young 
children. Tea, coffee, tobacco, cerebral excitement, old age, cardiovascular 
weakness, and fatigue are common causes of sleeplessness at night. 

Drowsiness during the day or when attempting to do brain-work is a very 
common symptom of cardiovascular inadequacy in middle aged and elderly 
people especially. 

Because of the close relation of dreams to delusions and to psychoneu- 
rotic symptoms, their painstaking and laborious analysis is believed by 
Freud to be very important for the interpretation of these symptoms. 

The Chief Disturbances of Speech. — Normal speech depends upon the 
normal interaction of the senses of sight, touch, smell, taste, sound and muscle 
sense, together with intact association fibers, a normal memory and an intact 
motor mechanism. 

If any link in this chain be lacking a defect in speech results, often taking 
the form which corresponds to the particular function or subfunction which 
is deficient. Thus anarthria or dysarthria may result from a defective motor 
tract or from the lack of power to perform the coordinate movement neces- 
sary to word formation. This is characterized by imperfect articulation of 
the linguals 1 and t if the tongue be involved, or of the labials b, p and n, 
which are replaced by f and v if the lips are affected. Palatal paralysis causes 
explosive p's and b's and makes the voice itself nasal. 

Changes in Rhythm. — Syllabic speech (division of words into their sylla- 
bles), scanning and staccato speech (explosive word utterance) is another form 



CERTAIN SPEECH DEFECTS 



I203 



frequently observed in multiple sclerosis and occasionally in other conditions. 
Opposed to this is the confluent speech usually bulbar in origin. 

In general one may say that lesions involving the tongue and lips give rise 
to anarthria or dysarthria, whereas speech defects of an entirely different type in 
which the perceptive centers and higher and more complex degrees of coordination 
are involved are referable to the cerebrum. The lower mechanism is of course 
dependent upon and subservient to the higher. 

Disturbances of Speech of Cerebral Origin. — Such are included under the 
general term aphasia which is divided into motor and sensory types, the 
former representing the higher emissive mechanism, the latter the power of 
receiving and reviving speech concepts, being largely dependent upon sight 
and hearing (auditory and visual centers). 

The motor speech center (Broca's center) in the inferior third left frontal 
convolution, and the articulation center in the inferior anterior central convolu- 
tion, govern motor speech and either may be affected independently of the other. 

A lesion of the left motor speech center causes entire loss of voluntary 
speech, i. e., true motor aphasia, in right-handed persons, but does not affect 
automatic and emotional speech, the center for which exists in both hemi- 
spheres. It is evident that motor aphasia logically includes the loss of 
power to utter given words (aphemia), to write words (agraphia), to use : 
gestures (amimia) and the loss of power of musical expression, vocal or 
written (motor amusia and musical agraphia).* 

In sensory aphasia the inability to perceive and interpret language is 
fundamental and therefore there must be an auditory aphasia or word deaf- 
ness (loss of power to recognize spoken words), visual aphasia or alexia 
(failure to recognize or understand written or printed words, word blind- 
ness), and subdivisions of exactly the same sort as were referred to under 
"Motor Aphasia." In paraphasia, word repetition, misuse and incoherence 
are the chief features, and paragraphia represents the graphic form of the 
same subdivision. 

Mind blindness and mind deafness represent an entire loss of visual or 
auditory memory not only of words, but of common objects and the faces 
even of near relatives, or in the second variety, all power to recognize musical 
or other sounds disappears. Here again we find subdivisions, such as 
apraxia, or inability to recognize the use of objects, and alexia, representing 
a failure of comprehension in reading. f Amnesic aphasia expresses the 
difficulty in recalling voluntarily special words or classes of words. 

The Lesions Affecting Speech. — Motor aphasia — third left frontal con- 
volution in the right-handed or a subcortical lesion underlying Broca's center. 
Visual speech — left angular and supramarginal convolutions. Auditory 

* "Ataxic aphasia" covers error in form without articulation defects or any evidence of 
sensory aphasia beyond slight or marked errors in the pronunciation of words, and is a form 
of aphasia usually seen in attacks that are partial, or, during the process of recovery. The 
term is sometimes applied to motor aphasia in general. 

f Another rare subdivision known as dyslexia covers a peculiar mental fatigue accom- 
panying reading, even for short periods unassociated with visual defects or pain. 



Causative 

lesions. 



Motor vs. 
Sensory. 



Broca's center. 



Automatic 
centers. 



Amimia and 
agraphia. 



Word deafness 
and word 
blindness. 



Apraxia and 
alexia. 



Amnesic 
aphasia. 



Localization. 



1204 



MEDICAL DIAGNOSIS 



aphasia— first temporal convolution, auditory speech center or afferent 
tracts. 

Lesions of the association fibers are frequently combined with others, as in 
apraxia. Anarthria may result from lesions in any portion of the tract 
interrupting stimuli from the higher centres to the motor cranial nerves or 
affecting the essential nuclei in the medulla and pons. 

Method of Examination. — Tests for sight and hearing should precede 
the examination for the detection of the following speech defects: (a) 
Motor aphasia (aphemia). — The patient cannot speak voluntarily, read 
aloud, or repeat words. If he cannot write voluntarily or by dictation or 
copy, he has agraphia. If in speaking or writing he uses wrong words or is 
strikingly incoherent there is paraphasia or paragraphia. 

(b) Sensory Aphasia. — The. patient cannot recognize words written or 
printed and read them silently even, or, he cannot read them intelligently or 
correctly. This is determined by writing direct simple questions to be 
answered by the patient. If he cannot hear spoken words or understand 
them as indicated by his failure to perform some ordinary action at command, 
he has auditory aphasia. 

Mind Blindness and Mind Deafness. — For testing the former one should 
use common objects, such as a pencil, pen, pocket-knife or coin, and ask the 
patient to use them, i.e., to write, to open the knife, to open a book, etc. 
Mind deafness should be tested by the slamming of a door, ringing a bell, 
coughing, etc., etc.* 

INVESTIGATION OF SENSORY FUNCTIONS.— The eyes of the patient 
should be bandaged and one should test: (i) General sensation. (2) Pain. 
(3) Temperature sense. (4) Muscle sense. 

Touch. — The tip of a pen, quill, toothpick, or pencil point and a lightly 
rolled bit of cotton, a feather or a camel's-hair brush are necessary for 
determining variations in sensibility, the latter articles serving to eliminate 
the element of pressure. The patient must be instructed to immediately 
say " touch" when any stimulus is perceived and he must be frequently 
checked by omitting the touch though putting the question. Exactly similar 
areas on both sides should be systematically followed to avoid bungling and 
time-consuming repetition. He should also be made to indicate with his 
finger the exact points tested, or distinguish between normal, diminished 
(hypesthesia), absent (anesthesia), and excessive (hyperesthesia) response. 
Such changes may be unilateral (hemianesthesia), bilateral or even general 
or limited to a single member. As regards perception of stimuli they may 
be prompt or delayed, and finally we have to deal with various forms of 
perverted sensory perception (paresthesia) , among which are many of special 
sense and the so-called "aura" of epilepsy. A failure to correctly localize 
sensations is common in disease and subjective transference to the opposite 
side is called " allochiria." 

* The discussion of this topic is reduced to its most elementary terms. The reader 
should consult some extended treatise if he desires to enter into the infinite complexities 
involved. 



TACTILE SENSE — MUSCLE SENSE 



Long saphenous 



Anterior tibial 



Internal plantar 



External plantar 

Fig. 597. 



1205 




External plantar 
(Br. post, tibial) 




Internal plantar Internal saphenous 

(Br. post, tibial) 

Fig. 598. 



Anterior tibial 




Internal plantar 



Fig. 599. 



Long saphenous 



Posterior tibial 



External saphenous 



External plantar 




Long saphenous 



Musculocutaneous 
(Br. ext. popliteal) 



Posterior tibial 
Anterior tibial 
Internal plantar 



Fig. 600. 

Figs <Q7 S98, 599, 600.— Distribution of sensory nerves of the skin of the foot. 
• ay/, oy , oyy, R Butler>) 



I206 



MEDICAL DIAGNOSIS 



Tactile Sense. — This may be tested by the esthesiometer or lacking that 
an ordinary hairpin or pair of blunted or guarded compasses. In this both 
pressure and contact are included and the two points should be separated 
according to the part examined and in conformity to the summary of nor- 
mal perception given below,* inasmuch as one point may be felt when two are 
applied or vice versa. The distances necessary for the sensation of two 
points in actual contact may be abnormally increased. In testing contact 
or touch the pressure may be determined by placing articles of different 
weight upon different portions of the body, always seeing that they are sup- 
ported. Localization is readily tested by having the patient place his own 



Small sciatic 



Internal cutaneous 
branch of anterior crural) 



Internal saphenous 




External cutaneous (from 2d 
and 3d lumbar nerve) 



External popliteal 



External saphenous 



Fig. 601. — Distribution of the sensory nerves of the skin of the leg, posterior aspect. 

(G. R. Butler.) 

finger upon any spot touched and the pain sense is determined by using a pen 
or pin. Temperature sense is tested most conveniently with test-tubes con- 
taining warm and cold water. Any of the varieties of sensation above 
described may be increased and diminished, absent or misinterpreted. 

Muscle Sense. — For proper testing, articles of various weight but of 
similar form should be used, the portion of the body tested being unsup- 
ported. The tendinous or articular sense is tested by having the patient imitate 

* lips, 3 mm. (H inch). Tip of toes, cheeks, eyelids, temple, 12 mm. (3^ inch). Tip 
of tongue, 1 mm. (3^5 inch). Tip of fingers, 2 mm. (3^2 men). Tip of nose, 8 mm. (^ 
inch). Back of hands, 30 mm. (1^ inches). Forearm, leg, dorsum of foot, 40 mm. 
{1% inches). Back, 60 to 80 mm. {2% to 3^ inches). Arm and thigh, 80 mm. (3^ inches). 



ATAXIA — ANESTHESIA 



I207 



any movements of extension or flexion or unusual position in which the other 
leg is placed and further have him assume positions as described. 

Ataxia is chiefly dependent upon the articular and muscle sense but also 
involves sight, touch and other factors necessary to the harmonious action 
of muscle groups. It may affect either station, gait or other voluntary move- 
ments. 

The Test. — The patient should be asked to touch the lobe of the ear of the 
opposite side, the tip of the nose, a certain finger of the opposite hand, or, 
in the lower extremities, different points of the opposite members with the 
great toe. He should then be required to stand with heels and toes together; 



Supraclavicular 
Circumflex 

Musculo-spiral 



Musculo-cutaneous 




Intercosto-humeral 



Wrisberg 



Internal cutaneous 



Fig. 602.- 



Median 



■Distribution of the sensory nerves of the skin of the arm, anterior aspect. 
(G. R. Butler.) 



marked swaying or a fall indicating " static ataxia" {Romberg's sign). If 
with the eyes open he cannot walk a straight line, he has " motor (dynamic) 
ataxia." If his gait is reeling and drunken (titubating), he has u cerebellar 
ataxia" and in this form the patient shows normal muscle sense and coordina- 
tion if recumbent, the difficulty being one of equilibration. 

If his dyscoordination is associated with motor weakness he may show 
''paretic ataxia" or spastic ataxia according to the type of motor defect 
present. Even the "dynamic ataxia" may be found extremely complex if one 
analyzes the several factors which enter into or intensify it, e.g., lost cen- 



Static ataxia. 



Motor ataxia. 



Cerebellar 
ataxia. 



I208 



MEDICAL DIAGNOSIS 



tripetal of deep sensory impulses from the muscles, bones and joints, cutan- 
eous anesthesia and impaired muscle- tonus being most important. 

Ordinary ataxia indicates cortical lesions or those of the pons crura and 
corpora quadrigemina, locomotor ataxia, transverse spinal lesions, ataxic 
paraplegia, Friedreich's disease or syringomyelia. 

Stereognosis. — The inability to recognize familiar objects by touch 
(parietal lobe) usually suggests a lesion of the parietal lobe. 

Significance of Sensory Disturbance. — Hemianesthesia of hysterical origin 
commonly affects the left side, is sharply defined and frequently complete 
even as to the special senses. 



Supraclavicular 
Circumflex 



Intercosto-humeral 



Wrisberg 



Internal cutaneous 




Musculo-spiral 



Musculocutaneous 



Ulnar 



Radial portion 
Musculo-spiral 



Median 



Fig. 603. 



-Distribution of the sensory nerves of the skin of the arm, posterior aspect. 
{G. R. Butler.) 



Cortical hemianesthesia is combined with hemiplegia and usually incom- 
plete unless associated with an unusually large lesion or involving the optic 
thalamus. 

Crossed hemianesthesia associated with hemiplegia of the opposite side has 
been referred to as present in unilateral lesions of the cord (Brown-Sequard 
paralysis). 

Hemianesthesia and hemiplegia with crossed oculo-motor paralysis indicates 
a lesion of the crus, and finally, combined hemianesthesia and hemiplegia may 
occur as the result of a lesion of the internal capsule. 

Anesthesias of patchy distribution suggest hysteria or neuritis and as between 



CORTEX LESIONS 



1209 



those mono anesthesias due to a spinal lesion and the rare cerebral form the 
former presents a sharp boundary line, the latter an anesthesia diminishing as 
the trunk is approached. As between hysteria. and neuritis the former tends to | 
disregard both segmental and individual nerve distribution. 

Bilateral anesthesia without motor paralysis usually affects the lower por- 
tion of the body and is particularly common in traumatic neuroses and 
hysteria. // the latter, it spares usually the skin of the genitals and a portion of 
the sacrum, if from the spinal cord it would almost invariably be associated 
with paralysis or other evidence of cord disease. 

Hyperesthesia and Hyperalgesia. — The well-known hysterogenic zones 
of hysteria furnish the best examples.* They may also be encountered in 
rickets, in brain tumor, as a zone above the anesthetic level in unilateral 
spinal hemiplegia, or be associated with meningitis, neuralgia and various 
toxic disturbances of the nerves. 

Anesthesia dolorosa is encountered in compression of the spinal cord 
in which it co-exists with analgesia, but is associated with extreme pain. 
Analgesia and hypalgesia may be encountered, the former suggesting hysteria 
or syringomyelia. 

TOPICAL DIAGNOSIS 

CERTAIN CEREBRAL CENTERS.— Certain areas in the cerebral cortex 
controlling certain bodily functions are known as centers. These, in many 
instances, cannot be sharply circumscribed and must be looked upon as 
physiological rather than anatomical units. 

The Motor Centers. — These lie in the ascending frontal gyrus, the fissure 
of Rolando and the paracentral lobule. From these the functions of the 
muscles of the opposite side of the body are controlled and a fairly clean-cut 
differentiation between individual centers, as, for example, that of the arm 
and that of the leg, can be elicited by electrical excitation.' Stimulation of 
such centers produces contractions in the muscles controlled, while destruc- 
tion of them is followed by definite muscle group paralysis. The control of 
certain muscles which have a bilateral symmetrical action, such as the mus- 
cles of mastication and of the larynx, is not merely unilateral, but is undoubt- 
edly exhibited by both cerebral hemispheres. 

The part played by subcortical motor centers, though presumably of 
major importance, remains largely indeterminate. 

As stated, the center for speech is situated in the inferior frontal and 
superior temporal gyri. The posterior portion of the left inferior frontal 
convolution forms the area of Br oca, the motor speech center in the right- 
handed. 

The Cortical Center for Sight is contained in the calcarine fissure and 
cuneus of the occipital lobe. The cortical center for the sense of hearing lies 
in the superior convolution of the temporal lobe. In the hippocampal gyrus 
of the temporal lobe is most probably situated the cortical center for the 
sense of smell. In the performance of the higher intellectual functions the 

* These are chiefly, the breast, ovaries (deep pressure), groin, spinal column, and patella 



Neuritis and 
hysteria. 



Traumatic 
neuroses and 
hysteria. 



Associated 
lesions. 



Cord 
compression. 



I2IO 



MEDICAL DIAGNOSIS 



part played by the cortex of the frontal lobes in particular may be accepted 
with a fair degree of certainty. 

CORTEX. — In disease certain cerebral tracts are silent {symptomless) or 
vield only psychic reactions, others permit direct localizing diagnosis. 

Monoplegia is the type which permits most exact localization. The 
result of a lesion may be limited to the head, an extremity, or, in the case of 
the former, be confined to a single organ. 

On the other hand, the close proximity of motor areas may produce associated 
monoplegias such as those of arm, leg, or face and arm, or incomplete hemi- 
plegias, but usually with primary or ultimate predominate involvement of one 
area. Complete cortical hemiplegia is possible, but is rare. All unilateral 
cortical lesions produce paralysis of the side opposite the lesion. 




Fig. 604. — Alotor and sensory areas of cortex. All lying anterior to the Rolandic fis- 
sure and above temporo-sphenoidal lobe are motor. The localization method of Chiene is 
also shown. This is applied as follows: — Find in the median line of the skull between the 
glabella (g) and the external occipital protuberance (o), the following points: The mid- 
point (m), the three-fourths point (t), and the seven-eighths point (s). Find also the 
external angular process (e) and the root of the zygoma (p) immediately above and in 
front of the external auditory meatus. Having found these five points, join ep, ps, and et. 
Bisect ep and ps at n and r; also bisect ae at c and draw cd parallel to ah. The pentagon 
acbrpx) corresponds to the temporo-sphenoidal lobe, with the exception of its apex, 
which is a little in front of x. mdca correspond to the Rolandic area, containing the fissure 
Rolando, and the ascending frontal and the ascending parietal convolutions, a is over the 
anterior branch of the middle meningeal artery and the bifurcation of the Sylvian fissures ; AC 
follows its horizontal limb. The lateral sinus at its highest point touches the line ps at r. 
ma corresponds to the precentral sulcus, and, if it be trisected at z and l, these points will 
correspond to the origins of the superior and inferior frontal sulci. The supramarginal 
convolution lies in the triangle kbc The angular gyrus is at b. {Sherrington, Chiene 
and Griinbaum.) 



Silent Areas. — The frontal lobe may be greatly damaged without symp- 
toms as may the corpus callosum and corpus striatum, though in right-handed 
persons aphasia may indicate a lesion of the left inferior frontal convolution, 
or agraphia one of the central convolution and it is probable that the corpus 
striatum is concerned in deglutition and contralateral muscle sense. A 
reference to the motor areas will show the lesions that must follow irritation 



LESIONS OF CRURA AND PONS 



I2II 



or destruction of any one of 
monoplegia, crural monoplegi 



r*ce 




MEDULLA 
DECUSSATION « ^ 




Fig. 605. — Explains symp- 
toms caused by lesions affect- 
ing the motor tract in the brain 
and cord. Lesion at a, b, or 
c: — monoplegia of opposite 
side. Lesion at d: — hemi- 
plegia of opposite side. Lesion 
at e: — oculo-motor paralysis 
of same side, hemiplegia of 
opposite side. Lesion at f: — 
facial and abducens paralysis 
of same side, hemiplegia of 
opposite side. Lesion of (1) 
anterionhorns : — causes flaccid 
paralysis and lost knee-jerks. 
Lesion at 2 : — spastic paralysis 
of muscles below lesion if 
pyramidal tracts only are in- 
volved or the lesion is incom- 
plete; flaccid paralysis if lesion 
is complete. Lesion at 3: — 
causes Brown- Sequard's 
paralysis. 4. — Normal cord. 
{After Van Gehuchten, modi- 
fied.) 



them alone, i.e., opposite facial paralysis, brachial 
a, hypoglossal paralysis, etc., bilateral combined 
cortical lesions being extremely rare. 

Mere irritation would produce the peculiar 
phenomena of Jacksonian seizures, viz., clonic 
convulsions, initially representing the motor 
point of maximum irritation and following the 
motor areas in orderly succession. This is 
usually unilateral though rarely bilateral through 
commissural transmission and is ordinarily due 
to injury, rarely to paretic dementia. If the 
parietal lobes be involved there may be loss of 
sensation and of stereognostic sense on the op- 
posite half of the body or ptosis (angular gyrus) , 
conjugate deviation of the eyes or even visual 
aphasia and hemianopsia. The occipital lobe is 
so related to the optic tract as to produce hemi- 
anopsia, visual aphasia or even mind blindness. 
The temporal lobe lesions chiefly produce sensory 
aphasia, or, if bilateral, sound deafness. 

Centrum Semiovale. — The structure and 
anatomical position of this great tract of projec- 
tion and association fibers makes its lesions 
present either cortical or capsular symptoms 
and includes both marked sensory — and the 
widest range of motor — disturbances, including 
those of special sense. 

Optic Thalamus. — It is said that the diag- 
nosis of an isolated lesion of this ganglion de- 
pends chiefly upon the loss of the facial expression 
of psychical emotion upon the opposite side, the 
voluntary facial innervation being retained, a 
condition rarely observed. Irritation symptoms 
are sometimes present as in cortical lesions, as 
is crossed homonymous hemianopsia (pulvinar). 

The last symptom occurs in lesions of the 
posterior third, and, if associated with hemi- 
chorea hemiathetosis or hemiataxia forms a defi- 
nitely localizing syndrome. 

Lesions of the Internal Capsule. — Almost 
all projection fibers between the cortex and the 
periphery (sensory, motor, and special sense) 
pass through this narrow and sharply defined 
area and any lesion entails serious consequences. 
The anterior limb is a symptomless area, but the 
angular portion (knee) is highly motor and 



1212 



MEDICAL DIAGNOSIS 



Gendrin's type. 



Hemiplegia. 



Tegmenta] 
lesions. 



lesions therein cause paralysis in the opposite hypoglossal and lower facial 
distribution , and, if left-sided, aphasia. If in the posterior one- third of the pos- 
terior limb, patchy hemilateral anesthesia, and perhaps hemianopsia and 
auditory disturbances. If in the anterior two-thirds of the posterior limb, 
there is hemiplegia of the opposite arm and leg. In most instances the paralysis 
is extensive and results in a combination of these lesions, i.e., complete hemi- 
plegia. The upper branches of the facial, the trunk muscles, those of the 
neck, eye, and of mastication are paralyzed only in bilateral lesions. 

The Crura. — At this level the mixed type of paralysis commences and 
extends throughout the pons and medulla, the relation of the pyramidal 
tract to the cranial nerve nuclei being such that the lesion may produce 
spastic paralysis of the lower segment (brachio-crural type) and a flaccid 
paralysis of cranial nerve areas. Thus, lesions of the crus are associated with 
hemiplegia with crossed oculomotor paralysis, sometimes including partial 
paralysis of the third and fourth nerves of the other side through basal exudate. 
The type of tegmental lesion is hemiataxia with crossed oculo-motor paralysis 
(Osier). 




._Aud.it ory 




Fig. 606. — Showing relative position of 
motor and sensory fibers in the internal 
capsule. [{After Monakow.) 



Fig. 607. — Topography of motor 
tract in internal capsule. 



Lesions of the corpora quadrigernina are characterized by flaccid nuclear 
or tract oculo-motor paralysis, third and fourth nerves, stumbling gait, and 
ataxia {cerebellar type).* 

Lesions of the Lower Pons. — The picture is usually characteristic, the 
ordinary type of paralysis being a crossed spastic hemiplegia, with paralysis 

* The region is rich in nuclei and lesions may be unilateral or bilateral and involve the 
tegmentum (incomplete hemianesthesia), the optic tract or lateral geniculate body (hemi- 
anopsia), the crusta (paralysis of opposite leg and arm or even hypoglossal and facial hemi- 
plegia) or produce defective hearing through involvement of the median geniculate body 
(Jakob). 



SEGMENTAL LESIONS 



1213 



of the facial and trigeminus on the side of the lesion, i.e., paralysis of the 
muscles of mastication, anesthesia of trigeminal distribution and facial 
paralysis. If the lesion is extensive, bilateral paralysis of the extremities may 
result. A bducens paralysis {external rectus of same side, and internal rectus] 
opposite to lesion), defective taste and articulation (facial and hypoglossa, 
fibers), brachio-crural hemiplegia of opposite side, and, perhaps, ataxia, 
vertigo, or trismus are also encountered, in the lesions of the lower pons. 
Lesions of the Upper Pons. — These produce paralysis of the face and ex- 
tremities of the side opposite the lesion, as in the case of the internal capsule- 
Lesions of the Medulla Oblongata. — Here again lesions may be unilateral 
or bilateral. The type is: brachio-crural hemiplegia and hemianesthesia of the 




Fig. 608. — Illustrating the mechanism 
of crossed paralysis in pontine lesions. 
(After Hermann.) 




Fig. 609. — Ventral aspect of medulla 
oblongata. (After Edinger and Hermann 
modified.) 



opposite side with the tongue pointing toward lesion, or, if the fillet be involved, 
bilateral anesthesia. Anarthria or dysphagia results and the type of glosso- 
labio-laryngeal paralysis may be present and is usually bilateral. Coarse 
lesions are rapidly fatal. 

Lesions of the Cerebellum. — Though sometimes lacking symptoms if 
unilateral, the chief and commoner characteristics of involvement of the 
vermiform process are cerebellar ataxia (staggering, drunken gait), vomiting, 
headache, vertigo or even movements of forced body rotation. 

The ataxia of cerebellar disease is characterized by being almost entirely 
limited to the muscles of the pelvic girdle and the lower extremities. Nys- 
tagmus and optic neuritis are common. Incoordination is coarse and may 
be greatly diminished in recumbency with closed eyes. 

SUMMARY OF SEGMENTAL PARALYSES 

Segment Symptomatology.- — The paralysis of muscle groups is the basis of 
localization in diseases of the cord and peripheral nerve lesion, and the 



Coarse lesion. 



Involves lower 
cranial nerves. 



Maybe 
symptomless. 



Ataxia and 
vertigo. 



1214 



MEDICAL DIAGNOSIS 



diagrams show the lack of correspondence between the point of nerve emer- 
gence, its segmental origin and the segmental sensory areas. So far as 
possible this topic will be dealt with on the basis of segment symptomatology 
preceded by a discussion of lesions affecting certain of the cranial nerves. 




Fig. 6io. — Segments of spinal cord and their relation to the vertebral landmarks. The 
variation between the level of origin of the spinal nerves and their point of exit is well 
shown. The numerals indicate the segments, those to the right the spinal nerves, and cor- 
responding vertebrae. The lettered nerves when grouped will be named in their order, 
a, nerves to rectus lateralis, to rectus anticus minor, anastomosis with hypoglossal; b, anas- 
tomosis with pneumogastric; c, nerve to rectus anticus major; d, to mastoid and great auric- 
ular and transverse cervical; e, to trapezius, ang. scap. and rhomboid; /, supraclavicular 
and supra-acromial; g, phrenic, lev. ang. scap. to rhomboid subscapular and subclavicular; 
h, to pectoralis major; i, posterior thoracic, serratus magnus.; j y circumflex; k, musculo- 
cutaneous; I, median, radial, ulnar internal cutaneous and lesser internal cutaneous; m, 
ilio-hypogastric and ilio-inguinal; n, external cutaneous and genito-crural; o, anterior cru- 
ral; p, obturator; q, superior gluteal; r, to pyriformis and gemellus superior; s, to gemellus 
inferior and quadratus; t, lesser and great sciatic; u, to levator ani; v, to obturator int. 
to sphincter ani and coccyx. (Dejerine and Thomas.) 

The Tongue (Hypoglossal Nerve). — In bulbar palsies and basal proc- 
esses deviation of the tongue to the paralyzed side (geniohyoglossus) , loss of 



SEGMENTAL LESIONS 



1215 



backward movement (styloglossus) or deviation toward the sound side 
when retracted or the paralyzed side when protruded, associated perhaps with 
atrophy, unilateral or bilateral (lirigualis), may be encountered. 

The Uvula and Velum Palati {Pharyngeal Plexus, possibly Seventh Nerve). 
— Nasal voice and regurgitation of-food through the nose indicates bilateral 
palsy; deflection toward the sound side, unilateral palsy of the azygos uvula. 
Food regurgitation and immobility in "ah" intonation (paralysis involving 
the levator palati). Food regurgitation and nasal speech are also seen in 

palato-pharyngeus paralysis (fifth nerve). 
Pharynx and Larynx. — Choking in 
deglutition due to the entrance of food 
into the larynx may arise from the failure 
of epiglottis closure due to paralysis of 
the stylo-pharyngeus {glossopharyngeal 
nerve), or to deficient downward move- 
ment due to paralysis of the constrictors 
{pharyngeal plexus). 

Hoarseness, aphonia or paralytic 
stenosis and the various faulty positions 
of the cords as shown in the illustration 
may be due to paralysis of the muscula- 
ture (recurrent laryngeal nerve, excepting 
for the crico-thyroid). 

Spasm or paralysis of the sterno- 
cleidomastoid {spinal accessory, medulla, 
first, second, third cervical segments) may 
cause wry neck (spasm), the head being 
inclined to one side with the chin raised 
and pointing to the opposite shoulder. If 
unilaterally paralyzed, the face cannot be 
turned to the opposite side; if bilateral, 
the head cannot be raised from the bed in 
recumbency. 

Flexion and Rotation of the Head. — If 
the chin cannot be brought to the chest 
the rectus capitis anticus, major and minor, are at fault. Failure of rota- 
tion can seldom be traced to the rectus capitis lateralis and is usually due 
to sterno-mastoid paralysis. 

Deficient thoracic respiratory movement affecting the elevation and lateral 
movements of the ribs suggests paralysis of the scaleni {lower cervical segments). 
Deficient Upper Spine Flexion. — This suggests lesions involving the 
longus colli {lower cervicals). Impaired power to raise the chin may be due 
in part to a lesion involving the clavicular portion of the trapezius {spinal 
accessory); a depressed shoulder to a lesion of the middle portion; abduction 
of the scapula to a lesion of the lower portion {spinal accessory, second and 
third cervical segments). 




Fig. 611. — Areas of anesthesia 
following segmental lesions of spinal 
cord, the numbers shown correspond- 
ing to the affected segment. {After 
Starr.) 



I2l6 



MEDICAL DIAGNOSIS 



Loss of power to approximate the scapulae indicates a lesion of the rhom- 
boids {fourth and fifth cervical segments). 

Oblique Position of the Scapula. — The inferior angle approaches the 
median line, the bone is raised, the arm cannot be raised above the horizontal 
position and if stretched forward the scapula projects (alar scapula). This 
indicates weakness or paralysis of the serratus magnus (posterior thoracic 
nerve, fifth and sixth cervical segments) . 

Inability to Raise Arm though Shoulder Rises. — The latter is flattened 
from atrophy and a groove appears below the 
acromiom. This indicates paralysis of the deltoid, 
any one of the three divisions of which may be sep- 
arately affected (circumflex nerve, fourth, fifth and 
sixth cervical segments). If the arm cannot be moved 
outward, the infraspinatus is involved (supra-scapu- 
lar) . If writing is difficult the teres minor is involved 
(circumflex), if the arm cannct be moved inward, a 
lesion of the subscapularis is suggested (subscapular). 
All three represent the fourth, fifth and sixth cervical 
segments. 

Impaired lateral trunk movement with failure of 
dorsal spine extension and backward movement of 
the arm indicates a lesion involving the latissimus 
dorsi (subscapular, sixth and seventh cervical segments, 
chiefly). 

Inability to firmly approximate the volar surfaces 
with extended arms suggests a lesion of the pector- 
alis major (anterior thoracic nerve, fifth, sixth and 
seventh cervical segments). 

Inability to extend arm against resistance indi- 
cates a lesion of the triceps which is associated with 
a tendency to subluxation of the humerus, either 
spontaneous or induced by slight causes (musculo- 
spiral, sixth, seventh and eighth cervical segments). 

Impaired flexion of the arm suggests a lesion of 
the biceps (musculocutaneous, fourth, fifth and sixth 
cervical segments), and if flexion and pronation are 
both deficient the supinator longus is to be con- 
sidered. The arm is usually spindle-shaped from 
atrophy of the muscle (musculo-spiral nerve, fourth, fifth and sixth cervical 
segments). 

Deficient supination with arm extended indicates supinator brevis in- 
volvement (musculo-spiral, fifth cervical segment) . 

Failure of dorsal flexion and abduction of the wrist with atrophy of the 
forearm indicates a lesion of the extensor carpi radialis longior and brevior; 
if adduction also fail from paralysis of the extensor carpi ulnaris, drop wrist 
is produced; if extension and abduction of the first phalanges fail, a paralysis 



■w o> 



W; W 



'KN W 



m w 



'W. w 



]£[G. 612. — Vocal cords. 
(Diagrammatic mirror 
picture.) 

i. Normal position in 
breathing and phonation 
respectively. 

2. Adductor paralysis 
(left) 2'. Bilateral ad- 
ductor paralysis. Both 
in phonation. 

3. Unilateral abductor 
(left) and 3'. bilateral 
abductor paralysis both 
during breathing. 

4. Left recurrent pa- 
ralysis phonation, 4'. 
same in respiration, 4". 
recurrent bilateral in 
both respiration and 
phonation. 

5. Arytenoid paralysis, 
phonation. 5'. Thyro- 
arytenoid paralysis, 
phonation 5". Aryte- 
noid and thyro-arytenoid 
paralysis. 



LESIONS OF CERTAIN SPINAL NERVES 12 1 7 



of the three extensors of the fingers is indicated (musculo-spiral and seventh 
cervical segment). 

Impaired flexion of the fingers and wrist suggests paralysis of the flexors 
of the wrist and fingers. The median nerve supplies the flexor carpi radialis, 
palmaris longus, flexor sublimus digitorum, and, in part, the deep flexor 
of the digits, the ulnar supplying the remainder of the last-named and the 
flexor carpi ulnaris, all being related to the eighth cervical segment. 

Failuie of abduction and adduction of fingers suggests a lesion of the 
interossei and lumbricales (ulnar and median eighth cervical and first dorsal 
segments). With extension of the first phalanges, flexion of the second 
and third and deep interosseus spaces it forms the claw hand (main en 
gritfe). 

Atrophy of the Ball of the Thumb. — An impairment of its extension and 
adduction suggests a lesion of the extensor pollicis brevis and thenar muscles, 
to which is added flexion of the second toward the first phalanx if the extensor 
pollicis longus is involved, with deficient abduction if the abductor pollicis 
longus is affected (musculo-spiral nerve, first dorsal segment) . If flexion of the 
thumb fails and atrophy is present the "ape hand" ("monkey hand" "Simian 
hand") is formed (abductor brevis pollicis, flexor brevis and adductor pollicis). 
The opposing movement may be absent (opponens pollicis and in part flexor 
brevis and abductor pollicis brevis) or flexion of the terminal phalanx may 
fail from paralysis of the flexor pollicis longus. The nerve supply is from the 
median and ulnar and first dorsal segment. 

Lower spinal lordosis with deflection toward sound side in unilateral 
lesions indicates a lesion involving the erector spinae, sacro-lumbalis and 
longissimus dorsi (dorsal nerves, second to twelfth dorsal segments). 

Lordosis with Prominent Nates and Abdomen. — Inability to rise up from 
a dorsal recumbent position without assistance from the hands indicates a 
lesion of the abdominal muscle group (dorsal nerves, second to twelfth dorsal 
segments). 

Imperfect lateral movement of the lower spine suggests involvement of 
the quadratus lumborum (lumbar nerves and segments). 

Loss of thigh adduction indicates paralysis of the adductors (obturator 
nerve, great sciatic and crural, third lumbar segment). The thigh rolls 
outward. 

Imperfect flexion of the thigh suggests involvement of the sartorius 
(crural nerve, third lumbar segment). 

Impaired leg extension indicates involvement of the quadriceps femoris 
(crural, third lumbar segment). 

Impaired flexion and difficulty in rising from the horizontal position 
suggests involvement of the ilio-psoas (crural nerve, fourth lumbar segment) 
and the tensor fasciae femoris (superior gluteal, fourth lumbar segment). 

Impaired outward rotation, the leg being turned inward, suggests involve- 
ment of the external rotators, pyriformis, gemelli and quadratus femoris 
(sacral plexus, fifth lumbar segment), as well as the internal and external 
obturators (obturator nerve, lumbar plexus) . 
77 



12 1 8 MEDICAL DIAGNOSIS 



Complete loss of thigh extension and abduction with a waddling gait and 
inability to climb indicates paralysis of the gluteal muscles {inferior gluteal 
nerve, sacral plexus, first and second sacral segment and superior gluteal, first 
and second sacral segments). 

Impaired flexion, perhaps associated with hyperextension through the 
action of the quadriceps points to a lesion affecting the biceps, semitendinosus 
and semimembranosus. 

Deficient foot extension, i.e., patient cannot stand on tiptoes or raise heel, 
indicates gastrocnemius, plantaris and soleus paralysis {internal popliteal 
nerve, fifth lum.bar segment). 

Drop Foot. — Usually with excessive knee and hip flexion with perhaps 
pesequinus or equinovarus from contracture points to involvement of the 
anterior tibial muscles, i.e., tibialis anticus, extensor longus pollicis {anterior 
tibial nerve, fifth lumbar and first sacral) . 

Deficient Abduction. — Tendency to flat-foot increased by contracture 
points to involvement of the peroneus longus {peroneal nerve, first and second 
sacrals) . 

Deficient adduction with resulting deformities suggests involvement of 
the tibialis posticus {posterior tibial nerve, first and second sacrals), and the 
peroneus brevis {peroneal nerve, first and second sacral segments). 

Adduction of Toes. — Paralysis of interossei with hyperextension of first 
phalanges and flexion of the second and third (claw foot) indicate involve- 
ment of the interossei and lumbricales {posterior tibial, first and second 
sacral segments). 

Deficient Toe Flexion. — Impaired power to push foot off ground indicates 
a lesion of the adductors, flexor brevis and abductor hallucis. 

BRACHIAL PLEXUS PARALYSIS.— Paralysis usually results from 
traumatism or compression commonly below the clavicle, and may be either 
partial or complete. If only the upper portion be involved, the lower muscle 
groups (forearm and hand) may with the exception of the supinator longus 
escape ("Erb's type"). Complete lesions involve a total motor and sensory 
paralysis of the arm, and there is a lower arm type in which forearm exten- 
sion and the use of the hand are lost, the triceps, flexors of the wrist, pronators 
extensors and flexors of the fingers being involved. Ocular signs indicating 
involvement of the sympathetic are frequent. 

SUMMARY OF LESIONS OF CERTAIN SPINAL NERVES.— Occipital. 
— Neuralgia, anesthesia. 

Posterior Thoracic. — Arm cannot be raised above horizontal and rotated. 
Projecting scapula (serratus magnus). 

Anterior Thoracic. — Inability to adduct arm (pectoralis major). 

Musculo-cutaneous. — Loss of elbow flexion power (biceps, brachialis 
anticus). Anesthesia inner border of forearm. 

Circumflex. — Loss of outward rotation and elevation of arm (deltoid, 
teres minor), third head of triceps. 

Suprascapular. — Impaired outward shoulder rotation and elevation. 

Musculo-spiral and Radial.— Paralysis from lead, arsenic or alcohol, 



CRANIAL NERVE LESIONS 



I2IQ 




Fig. 613. — Drop wrist. 



tumor and crutch pressure. Traumatism or whatever cause, is common 
and leads to the characteristic dropping of the wrist from extensor paralysis 
{drop wrist) so commonly seen in clinics. A factor in differential diagnosis 
is the involvement or non-involvement of the supinator longus which is 
usually spared in lead poisoning. The triceps and anconeus are paralyzed, 
extension of forearm lost and there is wasting of the back of the arm. 

Median. — Abduction of thumb and flexion of thumb and first and second 
fingers are lost. Thenar and anterior forearm 
atrophy is usually marked. If the forearm be 
flexed pronation is impossible. The thumb and 
index finger are approximated and there is paraly- 
sis of the abductor pollicis. 

Ulnar Nerve. — Impaired abduction and flexion 
of hand (flexor carpi ulnaris and part of flexor 
sublimis digitorum) and wasting of ball of little 
finger and interosseous spaces are present and one 
cannot cup the palm nor span. The ring and little 
fingers are "clawed" ("claw hand," "main en 
g r i£z")> Paralysis of their lumbricales and inter- 
ossei prevent flexion of the proximal or extension 
of the distal phalanges and the unopposed mus- 
cles exaggerate the position. 

Intercostal Nerves. — Violent neuralgic pains or other symptoms of irri- 
tation occur, sometimes herpes zoster along the course of affected nerves or 
anesthesia. 

Crural Nerve. — Patient cannot stand or walk and tendon reflex is absent 
(psoas-quadriceps extensor) . 

Obturator. — The obturator plexus is a frequent seat of pain, referred to 
the inner side of the thigh and knee-joint in disease of the 
mid-lumbar, sacroiliac and hip-joints. Obturator paralysis 
means loss of adduction. 

Sciatic Nerve. — Paralysis of leg flexors, foot and toe, 
sciatica. 

Peroneal Nerve. — Foot-drop from paralysis of flexors of 
foot or leg by contracture, talipes equinus or varus may 
appear. 

Tibial Nerve. — Paralysis of calf muscles, loss of foot ex- 
tension or toe flexion. Talipes if contractures occur. 

THE CRANIAL NERVES.— Irritation produces excess 
or perversion of functional activity, i.e., spasm, tremor, 
pain, itching, formication, etc. Destructive lesions cause 
ultimate loss of function, muscle atrophy, etc., inasmuch as a peripheral 
neuron is thus disturbed or destroyed. The nucleus of the cranial nerve 
corresponds to the nutrient anterior horn cell of the spinal nerve. 

Olfactory Nerve. — Test. — Apply to each nostril in turn bottles contain- 
ing well-known aromatic oils (peppermint, cloves, asafetida, bay, etc.) and 




Fig. 614. 

Dropped 

foot. 



1220 



MEDICAL DIAGNOSIS 



Oculo -motor 

and 

sympathetic. 



Local disease. 



have the patient describe the odor. Any inflammation, degeneration, 
necrosis, traumatism or pressure affecting the terminal filaments, bulb or 
tract, from the uncinate gyrus and thalamus to the Schneiderian membrane, 
produces lessened, absent {anosmia), or perverted {parosmia), function. 
These constitute also symptoms of hysteria, epilepsy, locomotor ataxia and 
insanity {hallucinations of smell). Trigeminal paralysis and certain catarrhs 
act no doubt by lessening the secretion. 





Fig. 615. — Nuclei of cranial nerves in medulla Fig. 616. — Lateral aspect cranial 

oblongata. {After Erb.) nerve nuclei within medulla 

The nuclei by Roman numerals. The nerve oblongata. (After Erb.) 

roots are similarly shown at the side. 1 , Brachium 
pontis. 2, Brachium conjunctivae. 3, Cerebellar 
peduncle. 4, Eminentia teres. 5, Striae acous- 
ticae. 6, Ala cinerea. 

THE EYE, ITS REFLEXES AND THE OPTIC NERVE.— The Pupil.— 

The shape, equality or inequality on the two sides, and the mobility or response 
to 'light and accommodation should be noted. 

Irregularities in outline suggest chiefly adhesions from past iritis. In 
acute iritis the color of the iris is turbid and greenish, the corneal circumfer- 
ence showing an hyperemic zone. Difference in the color of the iris of the 
one eye as compared with the other is especially important in detecting 
iritis in eyes normally dark. The commoner causes of iritis are gout, rheu- 
matism, trauma and syphilis and the first two are usually of the unilateral 
relapsing type, the last is bilateral, belongs to the period of secondary in- 
fection and seldom recurs. 

Inequality. — Even in healthy persons, slight inequality occurs, but decided 
pathologic irregularity is important and may represent either unilateral con- 
traction or dilatation. 

Contraction {miosis) may be due to iritis, oculo-motor irritation, or paraly- 
sis of the sympathetic, but occurs normally with suspended reflexes, e.g., in sleep. 

Dilation {mydriasis) indicates conversely sympathetic irritation (aneurysm 
of the arch, goiter, enlarged glands or other swelling, etc.) or oculo-motor 
paralysis. Furthermore, glaucoma, cataract, disease of the optic nerve and 
the retinal hemorrhages of albuminuria may cause a dilated pupil, unilateral 
or bilateral. 

Persistent mydriasis is frequently noted in cases of hysteria, high myopia, 
neurasthenia, severe dyspnea or actual asphvxia, cerebral abscess, -hemor- 



THE OPTIC NERVE — THE EYE 



1221 



rhage, thrombosis and tumor, exophthalmic goiter, epileptic coma, catalepsy 
melancholia, mania, active delirium, late meningitis, aortic regurgitation, 
shock, fear or other strong emotion, nausea, and poisoning by such mydriatics 
as tobacco, alcohol, nitrous oxid gas, cocain, chloral, chloroform, ether, 
duboisin, hyoscin, scopolamin, stramonium, conium and belladonna. Cer- 
tain cases of locomotor ataxia show as an early symptom dilated pupils and 
lid-ptosis, with beginning atrophy of the nerve head in many instances, and 
such cases run a course marked by long delay in the development of ataxic and 
paralytic symptoms. 

Persistently Contracted Pupils. — The following conditions may be asso- 
ciated with persistent bilateral miosis. Locomotor ataxia, general paresis, 
high hypermetropia or astigmatism, disseminated sclerosis, tumor, hemor- 
rhage, meningitis, inflammation or degeneration of the brain or cord, uremia, 
sunstroke (early stage), photophobia, congestion of the iris, etc. 

The primary action of ether, chloral, opium, eserin, and pilocarpin is 
miotic and general venous congestion, unless associated with marked dysp- 
nea, may produce bilateral pupillary contraction. 

Unilateral Contraction. — Marked unilateral contraction aside from adhe- 
sions, iritis, paretic dementia and apoplexy is an important suggestive sign 
of a serious lesion of the brain, cervical cord or any region involving the 
motor oculi or sympathetic. Mediastinal tumors aneurysmal, glandular or 
malignant, with their pressure effects, account for many cases, and should be 
constantly borne in mind. In not a few cases an artificial eye has puzzled 
temporarily the careless physician. Tuberculous cases often present persis- 
tent slight dilatation, usually unequal and sometimes merely transient. 

Hippus. — An oscillating contraction and dilatation of the iris on sudden 
exposure to light is of little clinical importance, though often associated with 
nystagmus and sometimes present in disseminated sclerosis. 

EYE REFLEXES. — Light response : Proper testing demands that the con- 
sensual light reflex be remembered and involves both light and accommodation 
reactions, that of convergence being of no special importance. The best 
methods demand the use of the ophthalmoscope in a darkened room and the 
use of such a + lens as will enable the observer to see the magnified pupil as 
the mirror flashes the light upon the eyes. Each must be separately tested 
and the patient should look slightly to the right or left of the observer to 
avoid the accommodation reaction. As a matter of fact there is normally 
a sympathetic reaction of the other pupil {consensual reaction). 

Reaction to Accommodation.* — Ordinarily contraction of the pupil attends 
accommodation for near vision. In locomotor ataxia and general paralysis 
especially, this reflex persists though that for light is lost {Argyll-Robertson pupil). 

In general, such a pupil indicates a lesion of the optic tract, or Meynert's 
fibres, whereas fixed contraction indicates a lesion of the centre or of the 
motor oculi. 

THE OPTIC NERVE.— The primary optic neuronsf receive the visual 

* Probably inseparable from the convergence reaction, 
t "The true optic nerve ,; (Church and Peterson). 



Early eye 
changes in 
tabes. 



Often a serious 
symptom. 



Trivial. 



Direct and 
indirect. 



Argyll- 
Robertson 
pupil. 



DESCRIPTION OF PLATE XII 

Fig. i. — Normal Fundus of Left Eye. 

Direct Method. — Disc is round, having light-colored center, distinct margins and yellow- 
ish-red intermediate zone. Choroidal ring almost complete and slightly more pigmented 
to the temporal side. Two cilio-retinal vessels on the lower outer edge of disc passing toward 
the macula. The crescentic fovea centralis, with surrounding blood-red area, is unusually 
well shown and most typical in youth. Veins and arteries are slightly to the nasal side of 
the disc. The arteries cross the veins on the disc, but in the periphery the veins cross 
the arteries. 

Fig. 2. — Embolism of the Central Artery of the Left Eye. Direct Method. 

Large, oval-shaped, blanched area, which includes the disc and macula. Cherry-red. 
spot at the macula. Intermediate zone of the disc shows apparently normal except for a 
faint fogginess. The arteries are almost empty and the smaller ones have the blood stream 
broken in different places. The arteries have lost their light streak. The veins are slightly 
distended, but not tortuous; the light streak is almost lost in the veins, but can be faintly 
seen. 

Fig. 3. — Thrombosis of the Central Vein of the Left Eye. (Apoplexy of the 
Retina, Hemorrhagic Retinitis.) 

Fundus Changes. — Left Eye. Acute papillitis. Disc very much swollen and apex seen 
with + 4D. and fundus without any lens at the sight hole. Arteries small and very few 
of them in view. The veins are very tortuous, looking like half hoops or serpentine, hence 
the name, "Medusa Nerve." The light streak in the veins is conspicuous at the top of 
each loop. The hemorrhages are of all sizes and shapes and shades of red. 

Fig. 4. — Albuminuric Retinitis. Bright's Disease. Right Eye. Direct Method. 

Fundus Changes. — Swollen disc, striated edges; exudation ("snow banks") about its 
edges with two areas above and one below the disc. Macular figure unusually well marked. 
Many scattered and flame-shaped hemorrhages seen in the periphery and about the disc. 
Vessels about the disc show effusion into their sheaths by the white edge at each side of the 
vessel. The disc resembles that of choked disc in brain tumor, but the "snow banks" and 
macular figure are almost too conspicuous for such a diagnosis. 



PLATE XII 




Fig. I. Normal Fundus 



Fig. 2. Embolism of the Central Artery 




Fig. 3. Thrombosis of the Central Vein 
{So-called Hemorrhagic Retinitis) 



Fig. 4. Albuminuric Retinitis 



From Thorington-s "Ophthalmoscope and How to Use It-0 



1 4 






TESTS OF VISION 



1223 




impressions through their dendrites, the retinal rods and cones, the axons 

passing to the visual centers in the optic thalamus (pulvinar), corpora quad- 

rigemini and geniculate bodies, through the posterior portions of the internal 

capsule and finally, in the optic radiation, to the cuneus. 

The axons from the nasal sides of the retina, which represent the outer and 

larger portion of the visual fields, cross and pass to the centers of the opposite side. 

Those of the temporal portion (inner and lesser visual field) run direct to the 

centers of their own side. The point of decussa- 
tion (chiasma), therefore, represents all fibers. 

Anterior to it lie the mixed fibers for the 
respective halves of each eye; posteriorly, those 
for the outer segment of the eye of the same 
side (nasal visual field) and the inner portion of 
the opposite eye (temporal visual field). 

Interference with these fields causes hemi- 
anopsia and the variety of the hemianopsia and 
the naming of the affected visual field represent 
the patient 7 s viewpoint; hence the variety of hemi- 
opia is the reverse of the retinal field affected, i.e., 
temporal retinal change = nasal hemianopsia, 
etc.* The condition may be unilateral or bilat- 
eral, total, partial or concentric, affecting cor- 
responding halves (homonymous), both temporal 
or both nasal fields (heteronymous), or even 
both upper or lower halves (superior or inferior 
altitudinal). 

A lesion may occur at any point from and 
including the retinal surface to the cortical centers. 
If unilateral and in front of the chiasm, blind- 
ness of that eye follows. // at the chiasm either 
the anterior or posterior angle (nasal half of 
retina) is usually affected causing bitemporal 
hemianopsia. If the outer portion only be in- 
volved, unilateral or bilateral nasal hemianopsia 
follows. A lesion behind the chiasm if on the 
right side causes left hemianopsia; if on the left, 
right hemianopsia. f Precisely the same phe- 
nomena occur if a lesion affects the more central 

tracts, save that the difficult "hemianopic" (Wernicke's) pupillary reaction 

is to be considered. 

Test. — Carefully note size of pupils by plane mirror illumination in a 

dark room, then with the ophthalmoscope direct a narrow, strong beam of 

* Hemiopia, hemianopsia, hemianopia are synonymous terms. 

f For example, a lesion of the right tract cuts off the retinal impressions of its own tem- 
poral half and the opposite nasal half of the retina, hence left visual fields are lost for both 
■eyes (left homonymous hemianopsia). 



Fig. 617. — Course of optic 
nerve fibers from cortex to 
retina showing relation of visual 
fields. (After Sahli, slighly 
modified.) 

Explanation. A lesion at a 
produces unilateral blindness, 
at b and c a temporal hemiopia 
by interruption of the nasal 
fibers, at rf, e or/a lesion will 
produce right homonymous 
hemiopia. 1 and 2 represent 
the retina; 3 and 4, optic nerves; 
5, the chiasm; 6 and 7, optic 
tracts; 8, the pulvinar; 9, the 
primary optic center; 10, the 
1 terior corpora quadrigemini; 
the external geniculate 
body, 12, the occipital lobe. 
The right and left tracts, their 
pective retinal distribution 
ai I visual fields are indicated 
by the solid red (left tract) and 
dotted black (right tract) lines. 



Hemiopia. 



Effect of 
lesions. 



Wernicke' 

localizing 

reaction. 



DESCRIPTION OF PLATE XIII 

Fig. i. — Albuminuric Retinitis of Pregnancy. Neuro-retinitis. Papillo-retin 
itis. Left Eye. Direct Method. 

Fundus Changes. — Disc hidden and slightly swollen. Punctate dots above and at the 
macula (neuritic dots) are conspicuous. Areas of exudation some distance from the disc 
Hemorrhages numerous, small and flame-shaped. The veins full and tortuous, some ar- 
covered by the swollen retina. 

Fig. 2. — Retinitis Diabetica. Right Eye. Direct Method. 

Fundus Changes. — Arteriosclerosis showing in the upper and lower temporal vessels 
where they cross. Small flame-shaped and round hemorrhages scattered irregularly in 
the fundus. The disc edges are foggy and the membrana cribrosa is indistinct. The inter- 
mediate zone and in fact the entire disc has a canary-yellow color appearance. 

Fig. 3. — Retinitis Pigmentosa. Right Eye. Direct Method. 

Fundus Changes. — The periphery of the eye ground is characteristic of many myopic 
eyes, the choroidal vessels being very conspicuous. The retinal vessels are not very 
numerous and the smaller ones can be traced with difficulty in the periphery. The disc is 
quite yellow. The retinal vessels narrow. The reflex immediately around the disc approxi- 
mates the normal, but beyond this the condition is atrophic. A few stellate pigment spots, 
together with irregular pigment massings on the vessels, are scattered throughout the fundus. 
This is an unusual variety of the disease. The patient is color blind for red and has night 
blindness. 

Fig. 4. — Partial Detachment of the Retina. Right Eye. Direct Method. 

Fundus Changes. — Retina detached downward and forward. The wavy condition 
of the retina, the course of the dark-colored vessels without their usual light streaks, as 
they appear on the detachment, are all quite characteristic. This disc appears foggy 
because it is out of focus as compared with the detachment. The disc is seen with — 7 D., 
whereas the detachment is best seen with a + 1 D. The white streaks are very likely 
congenital and possibly obliterated vessels. A rupture of the choroid would be crescentic 
in shape and situated elsewhere in the fundus. 



1224 



PLATE XII 




Pig, r . Albuminuric Retinitis of Pregnancy 



Fig. 2. Retinitis Diabetica 




Fig. 3. Retinitis Pigmentosa 



Fig. 4. Detachment of the Retina 



iFROM THORINGTON'S "OPHfHALMOSCOPE AND HOW TO USE IT " ) 



OPTIC NEURITIS — OPHTHALMOSCOPY 



1225 



light upon the blind portion of the retina. If pupillary contraction occurs, the 
lesion is posterior to the corpora quadrigemina.* It should be remembered 
that (a) tract lesions ordinarily produce hemianopsia, (b) nerve lesions total blind- 
ness and that (c) central vision is retained in unilateral tract lesions because 
the macula of each eye receives fibers from both optic tracts. 

Diagnostic Significance. — Disturbances of vision due to tract lesions are 
usually associated with gummata, new growths and syphilitic and tuberculous 
meningitis. 

Associated Lesions. — Incomplete hemianopsia with aphasia and mind or 
word blindness indicates a cortical lesion. Angular gyrus lesions are suggested 
by impaired vision in one eye associated with a contracted visual field of the 
opposite eye. Athetosis suggests a pulvinar lesion; altitudinal hemianopsia, 
a lesion of the upper or lower part of the chiasma, or if unilateral, a lesion of the 
cuneus. 

Hysterical hemianopsia is associated with the usual stigmata, hemianesthesia, 
insensitive conjunctiva, and more often takes the form of contracted fields and 
alteration of color vision areas. Fugitive hemianopsia may accompany mi- 
graine. Total unilateral blindness may be due to a destructive lesion of the 
occipital lobe or optic nerve. Bilateral lesions of the cuneus or optic nerves or 
total destruction of the chiasma will cause bilateral blindness. High refractive 
errors of long standing may be associated with unilateral loss of vision. 

Amblyopia, Amaurosis. — Amblyopia and amaurosis describe respectively, 
the one, impairment, the other, total loss of vision without actual lesions, 
but in the latter associated with various neuroses and toxemias. Amaurosis 
is alarming but usually transitory, lasting from a few hours to several days. 
It suggests uremia, diabetes, severe and especially acute anemias, spasmodic 
contraction of retinal vessels, hysteria and migraine, and has followed the 
administration of quinin and the salicylates, the overuse of alcohol and 
tobacco, cerebral trauma and lead poisoning. f 

Testing Vision. — Acuity. — If total blindness be suspected the patient 
should be asked to count the fingers of the physician as held before him at 
varying distances; failing in this, he should be tested for light perception in a 
dark room J (see also "Simulated Blindness"). 

The Visual Field. — Rough Test. — Squarely face the patient at a distance 
of 18 inches. If the left eye is to be tested the right should be covered and 
the patient told to look squarely and fixedly at the right eye of the examiner 
whose left is closed. The latter then holds his open hand well off to the side 
but on a level with the eye and brings it inward, moving the fingers constantly 
until the patient sees them without moving the head or eyeballs; the same pro- 
cedure tests all portions of the field and checks the patient's range with the 

* As the pupillary reflex sensory fibers run in the tract nearly to the corpora, any lesion 
anterior means an interrupted reflex arc. 

f Unilateral amblyopia suggests either the "amblyopia exanopsia" of existing stra- 
bismus or of a pre-existing deviation Which has become straightened, or lesions that may 
produce complete blindness, or affect the angular and supramarginal convolutions. 

X Minor disturbances are tested by the use of the well-known Snellen's test types. 



General laws 
of localization. 



Causes of 
tract lesions. 



Angular gyrus. 
Pulvinar. 



Chiasma and 
cuneus. 

Hysteria. 



Total 
blindness. 



Transitory 
blindness. 



Simple 
methods. 



DESCRIPTION OF PLATE XIV 

Fig. i. — Atrophy of the Optic Nerve (Post-papillttic Atrophy). Also Medullary 
Nerve Fibers. Right Eye. Direct Method. 

Fundus Changes. — Disc is bluish, the edges not well defined, lamina cribrosa not present 
As a coincidence there are medullary nerve fibers present. The whole fundus is mottled 
(map-like). The retina is atrophied and the macula cannot be distinguished. Arteries 
are straight and some of the larger veins slightly tortuous. 

Fig. 2. — Primary Optic Atrophy. Right Eye. Direct Method. 

Fundus Changes. — Disc bluish and glistening. Membrana cribrosa at center of disc. 
A cilio-retinal vessel is seen on the temporal edge of disc passing toward the macula. Fun- 
dus reflex apparently normal. Vessels are not particularly narrowed at the present time. 
Arteriosclerosis evident at crossing of vessels. Disc has "saucer "-shaped excavation. 

Fig. 3.— Retino-choroiditis (Specific). Left Eye. Direct Method. 

Fundus Changes. — Nasal edge of disc hidden and cannot be distinguished from the 
neighboring retina. Temporal edge of disc is clear and reveals a narrow crescent. A few 
yellowish-colored spots seen in the choroid. Other spots of choroiditis have become ab- 
sorbed and white areas (atrophy) have taken their places with irregular pigmentations. 
The choroidal circulation is exposed in the periphery. A large patch of retino-choroiditis 
is seen close to the temporal side of the disc. 

Fig. 4. — Glaucoma. Left Eye. Direct Method. 

Fundus Changes. — Edge of disc seen with + 6 D. and the bottom of the cup is seen with 
a — 5 D. Vessels of the retina disappear as they pass into and around the edge of the disc, 
and are out of focus when they reach the bottom of the cup, where they appear indistinctly 
at the nasal side. The nerve is bluish or pearly white in color and atrophic (glaucoma 
atrophy). The edges of the disc have a distinctly yellowish color and the pigment is broken 
into fine particles. There is a peculiar redness showing at the macula. 

The cupping embraces the entire disc. 



226 



PLATE XIV 




Fig. i. Atrophy of the Optic Nerve 

{Post Papillitic Atrophy) 

Also Medullated Nerve-fibers 



Fig. 2. Primary Optic Atrophy 




Fig. 3. Retino- Choroiditis 



Fig. 4. Glaucoma 



(From Thorington-s "ophthalmoscope and How to Use It-0 



OPHTHALMOSCOPY — RETINOSCOPY 



1227 



presumptive normal of the physician. For more accurate or graphic de- 
lineation the various perimeters may be employed. 

Central Scotomata. — Loss of central vision or central amblyopia if unilateral 
is usually due to choroiditis or retinitis, if bilateral, to chronic toxemias or 
syphilis. Scotomata of color vision are best detected by the perimeter.* 
In migraine and certain conditions of cerebral meningeal irritation the so- 
called " flittering" scotomata appear. These are "like a sunset cloud." 
Muscce Volitantes. — Little floating motes, specks or thread-like figures are 
common in overstrain, hysteria, anemia, dyspepsia, eye-strain, and various 
other conditions. 

Color Fields. — The limits of color vision may be indicated by concentric 
circles, the inner and least being for green, then red, blue, and finally white. 
Aside from actual nerve lesions color perception is greatly modified in toxic 
amblyopias (tobacco, etc.) and the neuroses. 

Optic Neuritis ("Choked Disc," "Papillitis").— This important clinical 
condition occurs in from 70 to 90 per cent, of all brain tumors, is usually found 
in meningitis, especially if that be basal and is not infrequently present in 
cerebral abscess. In all cerebral lesions it is likely to be bilateral, though more 
advanced in one eye than in the other. If in such cases it is unilateral it is 
on the side of the brain affected. As regards the location of brain tumors 
in relation to the frequency of optic neuritis, it may be said that it is invariable 
in tumors involving the corpora quadrigemina, occurs in 90 per cent, of those 
at the base, parieto-occipital region and cerebellum, and with scarcely less 
frequency in those of the crura and frontal lobes. In the case of no region 
does it fail to appear in much less than 50 per cent, of the lesions. Among 
other causes of optic neuritis are chronic nephritis, diabetes, hydrocephalus, 
sinus thrombosis, syphilis, lead poisoning, cysts, meningeal hemorrhage and 
trauma; rarely it is noticed in severe acute infections and sunstroke. In 
these diseases it does not assume often the high grade (choked disc) en- 
countered in the conditions previously described and in many instances is 
unilateral. 

The Wassermann test has shown that primary optic neuritis is frequently 
syphilitic. 

OPHTHALMOSCOPY.— Every physician should be able to use the 
ophthalmoscope at least so far as its findings relate to the common lesions, 
other than actual refraction errors. It often proves the master key of diag- 
nosis in obscure cerebral lesions, syphilis, tuberculosis, locomotor ataxia and 
arteriosclerosis, and of prognostic value in diabetes and chronic nephritis. 
Any good form of ophthalmoscope will suffice, the difference being rather 
in the skill and cerebration of the physician than in any marked advantages 
possessed by one over another instrument. The best of all, nevertheless, for 



* A rough test consists in holding before the patient's eyes at a distance of i}4 to 2 feet 
a black square of cardboard with a central white spot. While his eyes are fixed on the white 
spot a black strip carrying a green or red spot or wafer at its extremity is placed quickly 
at the outer side of the white. If not seen, it indicates central color scotoma. 



Unilateral vs. 
Bilateral. 



Scotomata. 



Muscae 
volitantes. 



Vary with 
color. 



Modifying 
conditions. 



Extremely 
important. 



Unilateral vs. 
bilateral. 



Brain tumor. 



Other associ- 
ated lesions. 



Often the 
master key. 



1228 



MEDICAL DIAGNOSIS 




the practitioner is the electric ophthalmoscope, simple, compact, portable, 
yet for illumination of the background almost automatic. 

Oblique Illumination. — A beam of light is focused obliquely upon the 
corneal surface by an indirect examination lens, which is held 2 to 4 inches 
above and to the side of the affected eye, slightly in front of the patient; a 
second lens may be used for magnification. Opacities of the cornea appear 
as small (nebula) or larger (leucomata), cloudy or opaque areas. Deep- 
seated opacities such as occur oftenest in syphilis yield a reflection, superficial 
areas are dull. The presence or absence of the light reflex should be noted and 
the consensual reflex tested. Hippus, photophobia and the pupillary contrac- 
tions of accommodation and convergence, 
are readily noted and the pupillary out- 
line and its bilateral uniformity observed. 
The aqueous humor, iris, lens, and 
vitreous may be observed if the lens is 
moved or the eyes of the patient turned 
as becomes necessary.* 

Iris. — The iris may show inflamma- 
tion, adhesion (synechias), or the colo- 
boma of a past iridectomy. 

Iritis. — A delicate pink injection, max- 
imal at the corneal margin and not moving 
on sliding pressure upon the conjunctiva, 
a darkened turgid greenish iris, photo- 
phobia, and a sluggish, contracted, 
sometimes irregular pupil, indicate iritis. 

Conjunctivitis. — This shows a vivid and tortuous general hyperemia most 
marked in the cut de sac, the vessels being readily moved by sliding pressure. 
Common in all catarrhal affections and eye strain, it may in severer suppura- 
tive forms be gonorrheal, diphtheritic or meningeal, or, if associated with pain, 
a symptom of corneal ulcer or even glaucoma. Ecchymoses occur as the 
result of traumatism, violent physical strain, asthma, epileptic seizure or 
in connection with hemophilia, purpura, leukemia, malignant endocarditis 
or pernicious anemia. In several cases observed by the author an apparently 
causeless hemorrhage has preceded for weeks or months a cerebral apoplexy. 

Retinoscopy. — fitting 1 meter from the patient, whose vision should be 
directed straight ahead, the source of light being slightly higher than the 
head, a beam from the perforated mirror is thrown upon the pupil. The 
red reflex appears if the media are transparent. The mirror should then be 
tilted in all directions, the fugitive central reflex produced being carefully 
noted as it gives an exact clinical indication of the nature of the refraction. f 

* It is best to dilate the pupil for inspection of the lens margins and anterior layers of 
the vitreous. (Thorington.) 

t If the source of light be vertical (Argand burner, not electric light) and the mirror 
concave, a straight pupillary shadow moving quickly in a direction opposite the tilting of the 
mirror indicates either a normal, hypermetropic or less than 1 diopter myopic eye. 
Movement of the shadow in the same direction as the mirror tilt indicates myopia exceeding 



Fig. 618.— "Choked disc." (ex- 
treme optic neuritis). Brain tumor. 
The swelling of the disc exceeds two 
diopters. {After Cowers.) 



THE FUNDUS OCULI 



I229 



A subtraction of 1 diopter is always made for the 1 meter distance, or 
a + 1 spherical lens may be placed in a trial frame before the eye, in which 
case the subtraction need not be made. The eye must be completely under 
the influence of a mydriatic in doing retinoscopy, if accuracy is desired. 

THE FUNDUS OCULI.— Indirect Methods of Ophthalmoscopy— Proper 
dilatation having been secured,* the patient with head slightly bent forward 
sits close to the source of light which is on a level with the ear lobe.f The 
examiner sits from iy 2 to 2 feet distant, the left shoulder advanced, a convex 
lens (13 diopters) in the left hand, the ophthalmoscope in the right. The 
perforated center of the larger (concave) mirror should be exactly opposite 
the eye-hole of the instrument in which a + 3 diopter lens is placed. When 
a beam of light is thrown (from the mirror) upon the pupil a rosy reflex en- 
tirely fills it. The patient's gaze should be fixed upon the examiner's left 
ear if the left eye is under examination, upon the right little finger-tip as 
extended while holding the ophthalmoscope if the right eye is under inspec- 
tion. This reveals the optic disc, and slowly shifting the patient's gaze from 
right to left and up and down brings the periphery into view and the macula 
should be seen when the patient looks directly at the center of the examiner's 
forehead. The large convex lens should be held between finger and thumb 
at about 2H to 3 inches from the eye or at such distance as is indicated by 
its strength and the clearness of the image. It may be steadied by resting 
the little finger upon the patient's brow.i In indirect ophthalmoscopy the 
image is inverted, all relations being exactly reversed but the image is large and 
the method easy. Astigmatism is indicated by shrinkage or expansion of the 
image in any meridian attending the slow withdrawal of the lens, and in 
general the contraction of the field upon withdrawal indicates hypermetropia; 
its enlargement, myopia, so that simple, compound, mixed or irregular astig- 
matism may be thus detected. These conditions are merely suggestive, not 
accurate. 

The Direct Method. — The advantages of this method he in the magnified 
(cornea and crystalline lens) direct image obtained and the better showing 
of details though a smaller surface is brought into view in any one position. 
The light should be close to the patient but behind and slightly above the 
level of the ear corresponding to the eye under examination. The examiner 
must be able to slowly bring his own eye within 2 inches of the one under 



Dilating pupil. 

Position of 
patient and. 
examiner. 



Red reflex. 



Observing 

disc. 



Accessory lens. 



Gives inverted 
image. 



Refractive 

errors 

revealed. 



Magnified 
direct image. 



Technic. 



1 diopter and the higher the error the more crescentic and slow moving is the shadow. 
Astigmatism is evident if the shadow edge moves differently or with different rapidity in 
opposed meiidians. Simple astigmatism is present if there is movement of the shadow in 
only one meridian, the other being normal ; compound astigmatism, if the movement of the 
shadow is similar in each meridian but of different degree. Mixed astigmatism is evidenced 
by different directions of the shadows in opposite meridian. 

* A drop or two of 2 per cent, homatropin solution, or better, a fresh 4 per cent, 
cocain or euphthalmin solution is dropped into the eye a half hour or more previously 
and followed after examination by a drop of eserin solution (gr. Y± to 1 ounce of water). 

t A light directly above the head may be used for this indirect method. 

X Bed-ridden patients may be examined whether recumbent or sitting up by proper 
adjustment of the light and correct position on the part of the physician. 



1230 



MEDICAL DIAGNOSIS 



Relaxing 
accommoda- 
tion. 



Use of 
mydriatics. 



Muscles 
supplied. 



Nuclei. 



Often in- 
volved in 
basal lesions. 



Isolated 
paralysis of 
the 4th. 



Crossed 
paralysis. 



Isolated paral- 
ysis of motor 
oculi. 



examination and the eye used should correspond to the one examined (ex- 
aminer's right, patient's right). The ophthalmoscope is applied flat to the 
operator's cheek, the elbow at the side, the small mirror so adjusted as to give 
maximum reflection, and the patient told to look off into space over the shoul- 
der of the examiner and under no circumstances to look at a near object (re- 
laxation of accommodation) . The examiner must relax his own accommoda- 
tion or if necessary use a — i D or — 2 D lens* if the patient's refraction is 
normal. The proper lens must be inserted in the ophthalmoscope when the 
patient's refractive error does not permit a distinct view of the retinal struc- 
tures which might lead to serious misinterpretation. If the examiner's refrac- 
tion is faulty, the proper glasses should always be worn. As the patient must 
look directly in front of him to bring the macula into view and as the impinge- 
ment of light upon that point will surely cause pupillary contraction, pre- 
liminary dilatation is often necessary. 

MOTOR NERVES OF THE EYE.— Motor Oculi (third), Patheticus 
(fourth), Abducens (sixth). These three nerves, closely related in origin and 
course and connected by an elaborate system of association fibers, control 
the movements of the eye. The third supplies the ciliary muscle, levator 
palpebrce superioris, inferior oblique and superior, inferior and internal recti. 
The fourth supplies the superior oblique, the sixth the external rectus. The 
multiple nuclei of the third and that of the fourth lie beneath the floor of the 
Sylvian aqueduct, while that of the abducens lies lower beneath the floor of the 
fourth ventricle. 

All are much exposed to pressure in basal lesions, the third emerging at the 
inner surfaces of the crura, the sixth between the medulla and the pons, while 
the fourth is the only nerve emerging on the dorsal surface, springing from the 
roof of the fourth ventricle immediately after it has decussated with its fellow. 
All three nerves may be affected in gumma, meningitis, tumor, or hemorrhage, 
by syphilitic or other forms of neuritis or by direct injury affecting the base, 
and one may be affected alone, the patheticus most rarely. Furthermore, 
isolated paralysis of the fourth indicates cerebellar tumor or an exudate on the 
anterior inferior aspect of the cerebellum. As the unilateral lesions of the base 
usually affect cranial nerves of the same side with the exception of the pathet- 
icus, while producing hemiplegias of the opposite side, the value of crossed 
paralysis as a localizing symptom is readily seen. Partial paralysis of motor 
oculi innervation may result from lesions involving individual nuclei or the 
roots springing from them and passing through the knee of the internal cap- 
sule. Complete uncomplicated unilateral paralysis of the motor oculi indi- 
cates a lesion of its trunk and the effects of orbital and sinus lesions or pres- 
sure at the sphenoidal fissure should be held in mind. Hemiplegia of the oppo- 
site side co-existing suggests in the case of the motor oculi, a mid-brain lesion 
or a tumor involving pressure upon a crus, in which latter case the hemi- 
plegia precedes the eye involvement. If the paralyses are coincident and 
simultanous a lesion above the corpora quadrigemina is suggested. 

* It is entirely unnecessary and wholly unwise to close one eye in using the ophthalmo- 
scope and the observer should imagine that he is looking at a distant object. 



PARALYTIC SYMPTOMS 



1231 



TESTS FOR LESIONS OF THE THIRD, FOURTH AND SIXTH 
NERVES. — These are essentially tests of pupillary activity and muscular 
strength, the latter being best indicated by diplopia (double vision) inas- 
much as marked impairment may exist without strabismus (squint). 

PARALYTIC SYMPTOMS.— Motor OcuU.— Paralysis involves abolition 
of pupillary reflex and fixed moderate dilatation due to unopposed sympa- 
thetic influence, the eyeball swings outward and slightly downward 
(unopposed influence of abducens and patheticus) and any attempt to over- 
come the ptosis present is accompanied by excessive contraction of the oc- 
cipito-frontalis and a characteristic predominance of forehead wrinkles on the 
affected side.* Irritant lesions will of course cause contracted pupils and 
various ocular spasms, such as nystagmus, nictitating or various non -rhythmic 
movements. Blepharospasm or hippus may replace ptosis. 

Strabismus. — The "cross-eyed" person cannot bring the visual axis oj both 
eyes simultaneously to the same point and ordinarily the defect is lateral, more 
rarely vertical. In a divergent strabismus the defective eye swings outward, in 
convergent squint inward. If the squint be spasmodic {concomitant) it is 
always made evident by asking the patient to look straight ahead; further- 
more, the eye moves in any direction in direct ratio to the movement of the 
sound eye, though retaining its lack of parallelism, and diplopia is usually 
absent. Paralytic strabismus, on the other hand, shows either total loss of 
movement in the affected muscles or marked weakness, which, however, may 
be apparent only when the patient looks in a certain direction, or under con- 
tinued fixation of the gaze upon one object in the weak axis. 

The abducens, supplying the external oblique muscle is the nerve oftenest 
affected. 

Diplopia. — In double vision the image of an object is received on the 
macula lutea of the fixing eye while in the other eye it strikes some other 
portion of the retina. Double vision occurs only in paralytic squint except 
when developed by special tests. It is a frequent symptom of the toxic irrita- 
tion produced by certain drugs such as alcohol and belladonna or of any 
irritative or destructive lesion at the base of the brain. Having the patient 
follow with his eyes the finger or pencil moved laterally and vertically before 
them and noting their convergence as it is brought gradually close to his nose 
measures roughly the extent and indicates the specific muscles affected. 
He should be asked to tell the number of fingers held before him in each 
position, no rotation of the head being permitted. To find the eye and 

* Firm downward pressure over the brow by cutting off the action of the frontalis 
enables one to estimate the actual degree of ptosis. Ptosis or pupillary signs without other 
symptoms of oculo-motor involvement are not infrequently seen in locomotor ataxia, as in 
a case under the author's observation for a long time. Ptosis may be incomplete and is 
simulated by (a) hysterical orbicularis spasm, {b) a transient ptosis upon waking seen in 
neurotic or overworked persons, (c) or by paralysis of the Mullerian fibers of the sym- 
pathetic in the orbital tissue, a paralysis which differs from true ptosis in the accom- 
panying pupillary contraction and the symptoms of inflammation and edema of the 
corresponding lower lid. Furthermore, the inhibiting action of the association fibers of 
the trigeminus (fifth) may cause ptosis in trigeminal lesions. 



Pupillary 
dilatation. 



Strabismus 
and ptosis. 



Irritative 
symptoms. 



Divergent vs. 
Convergent. 

Concomitant. 



Paralytic. 



Causes. 



Simple test. 



1232 



MEDICAL DIAGNOSIS 



Looking 
"toward" or 
"from" the 
lesion. 



Taste affected. 



Neuralgia. 



Trismus 
or jaw-drop. 



Substances 
used for tests. 



Jaw deviation. 



Tensor 
tympani. 



muscle producing double vision requires in many instances a resort to 
special tests.* 

Conjugate Deviation. — Due either to a tonic contraction of the associated 
muscles which rotate both eyeballs to the same side or to a paralysis of the 
antagonists. If both eyes deviate to the same side they are said to "look 
toward" the lesion, if it be paralytic, and "away from it" if the condition 
be spasmodic (irritation), but in lesions of the pons the reverse is true. 

Sixth Nerve. — Abducens. — This has the longest course of any cranial 
nerve and is frequently involved in basal lesions, producing internal strabis- 
mus. Its associations in disease are essentially the same as those of the third 
nerve. It supplies the, external rectus. 

TRIFACIAL. — The fifth consists of two roots, one sensory and one motor. 
The sensory root bearing the Gasserian ganglion divides below the ganglion 
into three divisions, the third of which, the inferior maxillary, is joined by 
the fibers from the motor root. 

Hence the ophthalmic and superior maxillary divisions of the trigeminus 
are sensory; the inferior maxillary, both sensory and motor. 

Lesions of the fifth nerve produce the following symptoms : 

Ophthalmic Division. — Anesthesia of the conjunctiva, skin of brow and 
nasal bridge, the upper lid, forehead and anterior portion of scalp. 

Supramaxillary. — Anesthesia of the alae nasi, cheeks, temples and nasal 
mucous membrane, upper pharynx, tonsils, soft palate, roof of mouth and 
upper teeth, upper lip, diminished taste and lost palate. 

Inferior Maxillary. — Taste impaired in anterior portion of tongue, salivary 
flow checked; anesthesia of the mucous membrane of the mouth, lower part 
of the face and lower lip, trifacial neuralgia, paresthesia, and, as it receives 
the motor root, trismus or paralysis of the muscles of mastication. Unless 
the paralysis be bilateral little actual disability occurs but in complete dis- 
ability the jaw drops and even swallowing is difficult. Dryness of the nasal, 
buccal and conjunctival mucous membrane of course follows a lesion of the 
fifth and partial deafness may result. 

Taste. — This sense is tested by placing upon the tongue successively, 
sugar, salt, quinin and tartaric acid, the tongue being protruded continu- 
ously throughout the procedure and the anterior and posterior portions sep- 
arately tested. Paresthesia (taste perversion) may be evident or admitted. 

Motor Action. — The deviation of the jaw is toward a unilateral lesion, 
and when the teeth are clenched the affected muscle fails to contract forcibly 
under the palpating finger placed over the masseters. The perception of 
muscle notes of different pitch tests the field of hearing. 

* The Candle Test. — In the usual test-spectacle-frame of the test-case place in front of 
one eye a red lens. Standing several meters away move about a lighted candle until two 
images (one red, one plain) are reported by the patient who also states where the colored 
image lies with relation to the other. Then the colored image represents the visual axis 
of the covered eye, the plain one that of the uncovered. If now by moving the candle in 
the direction of the colored image the double vision increases, it proves the eye covered by 
the red glass to be affected and the weak muscle is that which turns the eye in the direction 
of the false image. 



THE SEVENTH NERVE 



1233 



Miscellaneous Symptoms. — Loss of the corneal reflex is an early and im- 
portant sign. No sneezing follows tickling the nose, irritating substances 
do not affect the tongue or nostrils, a cup placed to the lips feels as if broken, 
the patient may support the jaw with the hand to aid mastication and swal- 
lowing, and atrophy and loss of reactions may follow the paralysis. Herpes 
zoster, dental decay and ulceration of the nasal, buccal, and corneal surfaces 
may occur as expressions of lost trophic function. 

Trismus is the result of infective tetanus or general convulsions, a con- 
vulsive tic occasionally results from reflex irritation. Tonic spasm also 
occurs, rarely also in hysteria, and after long-continued and enforced stretch- 
ing of the muscles. Clonic spasms, slow or fast, are seen in the fear, chill and 
" teeth grinding" so common in children and indicative of overwrought nerves, 
worms, gastro-intestinal disorders, adenoids, impacted cerumen, etc. The 
trifacial, while frequently the seat of neuralgia, is well protected from ordi- 
nary injuries and pressure; but may, nevertheless, be involved in certain 
bulbar palsies and in focal and gross lesions at the base. 

THE SEVENTH NERVE.— The Facial.— An accurate knowledge of the 
origin and connections of the facial nerve is of the utmost importance to the 
clinician. It is almost purely motor and essentially the nerve of facial 
expression. 

The cortical fibers decussate in the raphe of the tegmentum and enter 
nuclei at the junction of the pons and medulla, external to that of the sixth 
nerve. 

From its origin in the pons nucleus it sweeps about the nucleus of the 
sixth, which lies just external, and emerges with the eighth nerve between the 
restiform bodies and the olive at which point any lesion must include both nerves 
{seventh and eighth) as they run together into the internal auditory meatus. 
In the Fallopian aqueduct it runs with its branch to the stapedius and the 
fibers of the chorda tympani and, emerging from the stylo-mastoid foramen 
it passes forward in the substance of the parotid gland, dividing behind the 
ramus of the lower jaw into branches which supply the superficial muscles 
of the face and upper part of the neck. Though its cortical center lies below 
the motor areas of both leg and arm {inferior portion of the anterior frontal 
convolution) it lies between the two in the internal capsule, crus, and pons. 

Facial Spasm and Paralysis. — It is evident that a lesion may be either 
supranuclear, nuclear or infranuclear, and that the last may be {a) within the 
aqueduct, {b) external. 

In supranuclear paralysis, usually associated with hemiplegia, the orbicu- 
laris palpebrarum is not affected, R. D. is absent and the paralysis is on the same 
side as that of the leg or arm muscles, save in lower pontine lesions. 

Nuclear paralysis is essentially that of the infranuclear type, but seldom 
exists alone. A lesion within the aqueduct involves the chorda tympani and 
the stapedius branch, hence there is a loss of taste over the anterior two-thirds 
of the tongue, and often hyper acusis (exaggerated sound sensation). 

General irritative symptoms may be present, such as muscle spasm, bleph- 
arospasm and convulsive tic. 
78 



Nasal and 
labial. 



Masseters. 



Trophic 
changes. 



Spasm. 



Clonic 
spasms. 



Neuralgii 



Origin and 
course. 



Cortical center. 



Three 
varieties. 



Supranuclear. 



Nuclear and 
infranuclear. 



1234 



MEDICAL DIAGNOSIS 



Usual type. 



Audition and 
equilibration. 



Cochlea. 



Tinnitus 
aurium. 



"Nerve 
deafness.' 



Sudden 
deafness. 

Ordinary form. 



Paralysis of such muscles as control the expression results. Facial 
expression lines are obliterated and the victim cannot whistle, draw the corners 
of the mouth outward, close the watering eyes tightly or wrinkle the forehead of 
the affected side. 

A lesion involving the nerve at its point of emergence involves the auditory 
nerve, hence is associated with the various symptoms of irritation or paralysis 
of that structure. If the fibers are involved between the nuclei and their 
decussation {lower pontine lesions), crossed paralysis results. 

Bilateral palsy is rare as an independent lesion. Monoplegia is the type 
and in hemiplegia with alternating facial paralysis we deal with the nuclear 
form. 

AUDITORY NERVE.— The dorsal root contains the auditory fibers, the 
ventral those of equilibration, and passing out on either side of the restiform 
body, they join and within the internal meatus pass to the cochlea for audi- 
tion and to the vestibule and semicircular canal for equilibration. 

The cortical center for hearing lies in the opposite temporal lobe, that of 
equilibrium in the cerebellum. 

Symptoms. — Deafness and paresthesia are present alone if the cochlea only 
be involved. Vertigo, vomiting, tinnitus aurium, sibilant or roaring sounds 
(" escaping steam"), with disturbance of equilibrium, are present in varying 
degrees if the labyrinthine branch be affected {Meniere's syndrome). 

That common and ordinarily trivial symptom, tinnitus aurium, like deaf- 
ness, may be due to the many common causes, such as catarrh of the middle 
ear and Eustachian tube, or psychasthenia, inflammation or impacted ceru- 
men in the external meatus, full doses of salicylate or quinin, or, to 
anemia, digestive disorders and various toxemias, tympanites, meningitis, 
syphilis, or even brain tumor. Tinnitus cerebri, i.e., the similar sound seem- 
ing to arise in the brain itself, is frequent in arteriosclerosis and is also 
found in meningeal cases. 

Deafness. — "Nerve deafness," i.e., that arising from cortical, nuclear, or 
peripheral nerve lesions, is rare; that due to catarrh of the middle ear and impacted 
cerumen common. 

Tests. — Hearing is ordinarily tested roughly by the watch which should 
be held at varying distances from the ear and the range of audition of the 
patient compared with the known normal for the particular watch used. 
If deafness is evident the tuning fork should be employed to test by bone 
conduction the integrity of the cochlear nerve and centers.* If the vibrating 
fork or watch is best heard when placed directly upon the mastoid the nerve 
is not at fault. In most instances sudden deafness is due to impacted ceru- 
men, hysteria, or syphilis of the internal ear. As common causes of deafness, 
nasopharyngeal catarrh, usually associated with Eustachian involvement, 
adenoids and polypi must be remembered as well as growths in the auditory 

* Rinne's Test. — Set tuning fork in vibration, place handle against mastoid or zygoma. 
When the sound becomes inaudible hold the still vibrating fork close to the meatus. Nor- 
mally, the sound should still be heard at the meatus; abnormally, bone conduction is the 
greater. 



THE VAGUS 



1235 



meatus. In headache, mental strain or fatigue, or pronounced mental 
irritability, sounds may be exaggerated (hyperacusis) or actually painful. 

Though rarely bilateral, cortical lesions involving the auditory center 
may cause deafness. Such deafness is usually progressive and affects one 
ear chiefly in most instances. The direct cause is usually an irritation of 
the vestibular nerve but its basic etiology is still unknown. 

A similar condition may result from gross disease of the ear or attend or 
follow syringing or unduly inflating the ear drum, and a lesion of the left 
cortical center may cause word deafness, i.e., inability to interpret the sounds 
heard. 

Tumor, hemorrhage, meningitis, abscess and syphilis may produce deaf- 
ness by' involvement of the internal capsule or corpora quadrigemina. 

The nerve itself may be injured or compressed by tumors and inflamma- 
tory or hemorrhagic exudates, or be involved in diphtheritic paralysis, loco- 
motor ataxia, and traumatism. Deaf mutism is not an unusual sequence 
of cerebro-spinal meningitis. 

Certain forms of deafness, usually transient, follow the administration 
of quinin and the salicylates, or arise from violent concussion or constant 
and repeated lesser sounds (occupational deafness). 

In hysteria decided or complete deafness may come on suddenly, is mani- 
fested chiefly in defective range for notes of varying pitch and shows relatively 
equal loss of both aerial and bone conduction. It may as suddenly disappear 
and usually follows emotional shock. 

MENIERE'S DISEASE.— C Labyrinthine Vertigo") .—This combines pro- 
gressive nerve deafness with sudden attacks of vertigo, lasting but a few moments 
or for several hours, persistent and exaggerated tinnitus aurium (hissing, buzzing, 
throbbing, roaring or loud reports), and, sometimes, a peculiar incoordinate jerk- 
ing of the eye ("nystagmoid movements") and head muscles. 

Nausea, extreme pallor, vomiting, and, in rare instances, even transient 
unconsciousness or temporary collapse may accompany the attacks which 
may occur several times daily or be separated by months of immunity. 
Simple vertigo is usually present more or less persistently in these 
cases. 

Labyrinthine disease is usually a primary disease of the labyrinth or second- 
ary to middle ear suppuration and necrosis and mastoid disease* 

GLOSSOPHARYNGEAL NERVE.— The ninth nerve is seldom para- 
lyzed alone and a lesion is recognized only through its sensory disturbances, 
through its motor for the stylo-pharyngeus and middle pharyngeal constrict- 
ors. The sensory fibers run to the brain with the fifth nerve and a loss of 
taste over the posterior surface of the tongue, and absence of the pharyngeal 
reflex are the only sources of information. Root involvement does not affect 
taste on account of the peculiar course of the sensory fibers. 

THE VAGUS. — The tenth nerve has most interesting and complicated func- 
tions. It is motor for the pharynx, larynx, and soft palate and both motor and 

* The exquisitely delicate and difficult tests of Barany must be sought in the special 
monographs. 



Hyperacusis. 



Word 
deafness. 



Deaf mutism. 



Transient 
deafness. 



Hysteria. 



Seldom 

paralyzed 

alone. 



A marvelous 
nerve. 



1236 



MEDICAL DIAGNOSIS 



Spinal 

accessory 

association. 



Dysphagia. 



Laryngeal 
supply. 



Chiefly 

recurrent 

branch. 



Common types. 



As affecting 
heart action. 



Bulbar 
paralysis. 



Sterno- 
mastoid and 
trapezius. 



sensory for the heart, respiratory passages and most of the abdominal viscera, in 
connection with which the sympathetic plays an important part. 

Its motor fibers, including the cardio-inhibitory group, are contained in 
what was formerly regarded as the bulbar portion of the spinal accessory 
which joins it outside the cranium. The pharyngeal plexus is formed by the 
vagus and glossopharyngeal nerves and supplies the pharyngeal muscles and 
mucosa, hence a lesion of the nerve nuclei or trunk gives rise to marked 
dysphagia. 

The Laryngeal Nerves. — The superior and inferior laryngeal nerves sup- 
ply the musculature and mucosa of the larynx. The recurrent laryngeal which 
supplies the mucosa of the lower portion and all muscles except the crico- 
thyroid, is especially liable to pressure paralysis by reason of its relation to 
mediastinal structures, aneurysm being one of the commoner causes of paraly- 
sis of the left recurrent. Bilateral paralysis of the abductors causes imperfect 
approximation and separation of the vocal cords in respiration and voice pro- 
duction. The symptoms are inspiratory stridor and whispering voice with- 
out aphonia, the cords being nearly approximated. It is encountered in 
cases of hysteria and occasionally follows a simple laryngitis though usually 
toxic. Pressure upon one recurrent nerve, usually aneurysmal or due to 
pleural adhesion, produces unilateral abductor paralysis, immobility of the 
affected cord in inspiration and hoarseness. Adductor paralysis is usually 
hysterical and the separation of the cords produces aphonia. 

Laryngeal Spasm. — The croup of children, locomotor ataxia {laryngeal 
crises) and hysteria are the commonest sources; the last form being chronic 
and usually associated with speech production. 

Laryngeal Anesthesia. — This, due to diphtheria, neuritis, bulbar paraly- 
sis, or hysteria, makes feeding difficult and inhalation-pneumonia common. 
Laryngeal Hyperesthesia. — This is rare, but occasionally seen, especially 
in sexual psychasthenia. 

Cardiac Plexus. — Formed by the vagi and sympathetic nerves, its 
branches control the activity of the heart. Stimulation of the vagus slows 
or temporarily arrests the heart action, and in rare instances the power of 
voluntary self-inhibition of the heart beat has been observed. In complete 
paralysis the accelerator fibers act unhindered causing rapid heart action. 
Palpitation and obtrusive auto-audible cardiac heart action are probably 
appreciated through the vagus path. 

Gastric Branches. — The vagi control the activity of both stomach and 
esophagus, conveying sensory impressions as well as motor stimuli and are 
probably concerned in some degree with so-called nervous dyspepsia and the 
gastric crises of locomotor ataxia. In bulbar paralysis the nuclei of the acces- 
sory nerve and the hypoglossal are involved with those of the vagus. 

SPINAL ACCESSORY. — The chief function of the eleventh nerve is the 
supply of the sterno-mastoid and trapezius muscles, and, through the vagus, the 
pharynx and larynx. 

Tests. — Laryngeal paralysis has already been covered. Paralysis of the 
sterno-mastoid prevents wholly or in part rotation of the chin toward the 



THE SYMPATHETIC NERVOUS SYSTEM 



1237 



sound side, and if the trapezius be paralyzed, shrugging of the shoulders is 
interfered with. 

Complete paralysis of the palate is indicated by regurgitation of fluids 
through the nose in swallowing and thick nasal speech. If the palate be 
examined while the patient says " eh "and "ah," defective upward movement 
is perceived. If the lesion is unilateral, immobility of one side with dragging 
of the median raphe toward the sound side will be manifest. 

Hypoglossal Nerve. — The twelfth nerve is entirely motor and supplies 
the tongue and depressors of the hyoid bone. It rises from a nucleus nearly 
median in the lower portion of the floor of the fourth ventricle and its cortical 
center lies in the lower frontal convolution. 

Tests. — Note evidence of any wasting, tremor, or fibrillary contraction. 
Wasting indicates a nuclear or trunk lesion; its absence, a supranuclear or 
cortical lesion. Deflection of the tongue toward its paralyzed side is evident 
on protrusion (see also "The Tongue" under " Segmental Paralyses"). 

THE SYMPATHETIC NERVOUS SYSTEM.— The anterior horns of the 
cord carry fibers of unknown cortical origin to the sympathetic ganglia 
through a special set of axons running in the anterior nerve roots, and 
sympathetic ganglion cells, with their axons, in turn constitute the motor 
sympathetic neuron. 

A similar set of fibers (sensory) traverse the posterior roots and there 
is a free communication between the cranial nerves and the sympathetic 
system. The vasomotor fibers are especially plentiful in the anterior roots 
of the dorsal region. The visceral fibers are chiefly in the cervical region 
where they accompany the accessory and vagus nerves and ultimately 
pass to the alimentary canal. 

The remarkable structure of the so-called "chromaffin system" is consid- 
ered elsewhere under the diseases related to the internal secretions. 

The wonderful automatic control exercised by these nerves cannot be 
dealt with here, but though their activity may continue when all central 
nervous connections are cut, they are to a certain extent governed and regu- 
lated by the higher centers. 

The cilio-spinal fibers are important in diagnosis, irritation causing pupil- 
lary dilatation; section, contraction. Other symptoms of sympathetic origin 
are: vasomotor spasm or relaxation, abnormal sweating in the involved areas 
and various disturbances of glandular secretion and cardiac and visceral 
activity. 

DISEASES OF THE BRAIN AND SPINAL CORD 

HEMORRHAGIC PACHYMENINGITIS {"Internal Meningeal Hema- 
toma"). — This may be encountered in either the brain or the cord. The 
cerebral form is almost exclusively confined to the insane {especially paralytic 
dements, 20 per cent.), and the aged (90 per cent.), occurs in those over fifty 
years of age, but is occasionally encountered in vascular degeneration, pro- 
found anemias, alcoholism, tuberculosis, syphilis, heart disease, cachexias, 
diseases of the purpuric type and even in acute infections. 



Palatal 
paralysis. 



Cortical vs. 

peripheral 

palsy 



Chiefly In the 
insane, alco- 
holic and aged. 



I2 3 8 



MEDICAL DIAGNOSIS 



It may occur in infants as a result of forceps injury, or contracted pelvis 
in the mother, and, in rare instances, may complicate chronic Bright's dis- 
ease, the acute infectious diseases, pernicious anemia, scurvy or hemophilia. 

Pathologically three forms of pachymeningitis may be seen, (a) simple 
subdural hemorrhagic exudate, (b) an inflammatory exudate converted into a 
delicate vascular membrane by granular tissue and vascular extension, (c) the 
two conditions combined. In the insane and aged it is supposed that the 
cerebral atrophy and arteriosclerosis so frequently encountered- are contributive 
factors. 

Symptoms of the Cerebral Form. — If any exist they express intracranial 
| pressure, headache, choked disc, slow and irregular pulse, recurrent convul- 
sions, coma, and a paralysis, usually but not invariably unilateral, and often 
associated with aphasia. Fever and albuminuria may be present. 

The pupils are sluggish, that opposite the lesion being dilated usually 
in the earlier stages. Nystagmus, conjugate deviation of the eyes and head, 
and forced attitudes may or may not be present. Recurrences are frequent 
and complete recovery is rare. 

Symptoms of Spinal Form. — This may involve any portion of the dura 
mater of the cord (most commonly the cervical enlargement) or be accom- 
panied or preceded by cerebral hematoma. 

Irritative pressure symptoms occur accompanied by secondary degenera- 
tion and producing intense peripheral neuralgic pain chiefly brachial and 
cervical with hyperesthesia and paresthesia, slowly progressive muscular 
weakness, paralysis and muscle atrophy. 

Prognosis. — The disease is chronic, usually fatal within two years, and, 
during the later months, is often associated with spastic paraplegia of the 
lower extremities. 

Differential Diagnosis. — It cannot be distinguished from tumors of the 
cord. Amyotrophic lateral sclerosis lacks the severer neuralgic pain, and 
syringomyelia may be differentiated by its characteristic sensory symptoms. 

EXTERNAL PACHYMENINGITIS.— Both the cerebral and spinal forms 
yield the symptoms of compression and result ordinarily from traumatism, caries, 
or the extension of some suppurative process. It is most frequently secondary 
to syphilis and tuberculosis, tumors, or suppuration, involving the adjacent 
structures. 

Pseudo-membranous and purulent pachymeningitis are not worthy of 
detailed consideration. 

LNTRAMENLNGEAL HEMORRHAGE.— This is more often a complica- 
tion of acute febrile toxemia, convulsive seizures and the rupture of basilar 
vertebral aneurysms, less often it results from traumatism. 

Symptoms.' — These are usually localized pressure symptoms of sudden 
development, and cases secondary to acute febrile toxemia and traumatism 
furnish the most favorable prognosis. 

Extrameningeal Hemorrhage. — Aneurysmal rupture or traumatism in- 
volving the peridural plexus may cause hemorrhage usually with pressure 
symptoms. 



HEMATOMYELIA — MULTIPLE SCLEROSIS 



1239 



Decompres- 
sion the factor. 



HEMATOMYELIA. — Hemorrhage into the cord itself, usually associated 
with hematorrhachis, may result from the causes of intrameningeal hemor- Hemator- 
rhage, but is more often due to direct injury involving fracture or dislocation 
of the vertebrae, and is undoubtedly one of the causes of the disturbances noted Usually 

....... •?./»• 7 directly follows 

after injuries involving violent flexion or torsion of the spine. injury. 

The hemorrhage varies greatly in extent and position and the paralysis 
may be paraplegic or unequally affect the two sides, but is frequently uni- 
lateral, producing the well-known Brown-Sequard symptom-complex, 
viz., unilateral motor paralysis with anesthesia of the opposite side. 

Pain is usually slight or absent, paresthesias common and the lumbar 
or cervical regions most frequently affected. The onset is sudden, and in sudden onset 

. ii. • . • • e 1 i valuable sign. 

low-seated lesions urinary retention or incontinence is often observed. 

Prognosis. — Partial recovery is the rule and a fatal termination the 
exception, both primary and residual paralysis are chiefly of the spastic 
type. 

CAISSON DISEASE ("Divers' Paralysis").— -This obscure ailment is en- 
countered almost exclusively in caisson workers and divers subjected to ex- 
treme and sometimes sudden changes of atmospheric pressure, and, in sub- 
marine workers similarly exposed. The changes seem to be strictly limited 
to the cord, taking the form chiefly of punctate hemorrhage, myelitis or 
laceration. 

It is believed to be due to nitrogen saturation and its sudden release, 
which gives rise to gas emboli, for the most part affecting the spinal cord, but 
also occurring in the liver, spleen, lungs and even the superficial tissues. 

Symptoms. — Immediately after leaving the caisson or perhaps not for 
forty-eight or seventy-two hours a series of symptoms develops, varying in 
severity from excruciating pain in the lower extremities to spastic paraplegia 
with anesthesia and urinary retention. Coma is sometimes observed and 
sudden death or exitus after a few hours exceptionally occurs. 

The upper extremities are seldom affected and many minor symptoms 
such as temporary albuminuria, vertigo, deafness and tinnitus aurium may 
be encountered. The disease is rarely fatal and the symptoms ordinarily 
disappear in a few weeks or days. 

"MILIARY," "DIFFUSE," AND "TUBERCULOUS," SCLEROSIS.— 
This may be dismissed as of little practical importance, all three varieties 
being associated with mental disease and seldom encountered save in the 
autopsy rooms of asylums. 

MULTIPLE SCLEROSIS {"Insular" or "Disseminated" sclerosis).— This 
is a disease of unknown causation* but usually follows an acute infection and 
occurs chiefly in young male adults (90 per cent, under the thirtieth year) . 

It is characterized anatomically by an extensive, irregular dissemination 
of reddish-gray areas of sclerosis involving both the gray and white substance 
of all portions of the cerebrospinal tract, the white being chiefly affected. 

The cerebral lesions ordinarily predominate and, in the cord, the cervical 
region and the cauda equina are usually chiefly affected. In the former 

* In nearly half of a large series recently reported a positive Wassermann was present. 



Transient. 



Male adults 
chiefly. 



1240 



MEDICAL DIAGNOSIS 



Indeterminate 
symptoms. 



Characteristic 
complex. 



Varied findings. 



No concrete 
picture. 



Marked 
chronicity. 



Septic phlebitis 
usually, 



the brain stem and the basal ganglia suffer most, the cortex being but slightly 
involved and the cerebellum sometimes escaping. 

The disease is remarkable for its lack of ascending or descending degener- 
ative changes and the inconclusiveness of its symptoms, both facts being 
explained by the extraordinary persistence of the axis cylinders in the tissues 
involved. 

Diagnosis. — Intention tremor, lessened in recumbency, nystagmus, scanning 
speech, muscular weakness and transient palsies, are the important symptoms. 

Vertigo, optic atrophy {temporal side), spastic weakness of the lower extremi- 
ties and a stiff awkward gait are common. Enfeebled mentality and sudden 
attacks of coma or of epileptoid convulsions may occur and the symptoms may 
be extraordinarily varied and both slow and insidious in development. The 
sphincters may be afected in the terminal stage. 

Differential Points. — Paralysis agitans lacks nystagmus and shows its 
tremor during rest. Hysteria lacks nystagmus and usually presents 
distinctive stigmata. 

It is obvious from the pathology that no concrete picture is possible and the 
very multiplicity and variability of its symptoms is diagnostically helpful. 

A mere slowing up of movements, paresis of universal distribution, muscular 
rigidity and spasticity make a striking melange — aside from scanning speech (60 
per cent.), intention tremor (75 to 80 per cent.) and nystagmus (50 to 60 per cent.). 

Bulbar symptoms such as anarthria and dysphagia may be present in rare 
instances and causeless laughing or crying may strongly suggest hysteria in 
some cases. 

The eye backgrounds should be examined carefully for optic nerve changes. 
Partial or ; more rarely, complete, temporal atrophy or neuritis and central 
scotoma may be present. 

Prognosis. — It is markedly chronic and terminates by intercurrent dis- 
ease, usually after the patient has become bed-ridden. 

SINUS THROMBOSIS.— This may arise in the course of wasting dis- 
eases or even a chlorosis but usually represents a septic phlebitis resulting 
from disease of the adjacent structures. 

Lateral Sinus Thrombosis. — This usually results from suppurative dis- 
ease of the middle ear and mastoid cells. 

If pyemic symptoms developed during a middle ear and mastoid suppu- 
ration persist after apparently successful operation, or arise following such a 
surgical procedure, suspicion amounting almost to certainty results. 

If tenderness, swelling and persistent emptiness, of the jugular of the af- 
fected side, is present the diagnosis is practically certain and further surgical 
procedure is demanded. 

Cavernous Sinus Thrombosis. — This may follow suppuration, necrosis or 
operation, within the nasal passages or orbital tissues. 

The most striking symptoms are orbital and conjunctival edema with 
unilateral exophthalmos and septicemic or pyemic symptoms. 

Longitudinal Sinus Thrombosis. — This condition occurs usually in con- 
nection with a pachymeningitis and is seldom recognized ante-mortem. 



CEREBRAL CONGESTION CONGENITAL HYDROCEPHALUS 1241 



Epistaxis and orbital and conjunctival edema are suggestive symptoms, 
CEREBRAL CONGESTION.— Cerebral congestion has lost its place as an Reduced in 

importance. 

important clinical entity, most of the symptoms formerly classed under that head 
being due to toxemia rather than mere congestion and now referred to under- 
lying disease to which congestion is purely secondary. 

Mental excitement, indeed any mental effort, means temporary conges- 
tion and certain drugs such as alcohol, quinin and strychnia undoubtedly 
produce it. 

The arterial hypertension of nephritis may be associated with evidences of 
active cerebral congestion so plainly foreshadowing an apoplexy as to be of 
clinical interest and prophylactic value. 

Passive congestion cannot be distinguished from relative cerebral anemia, 
according to the author's experience. 

The symptoms of active congestion are headache of varying degree, often asso- 
ciated with a subjective sensation of pressure and throbbing, chiefly frontal but Familiar 
often occipital or temporal, vertigo, tinnitus aurium, mental irritability and 
impaired concentration. 

CEREBRAL ANEMIA. — Relative cerebral anemia may be (a) simply a 
part of general anemia; (b) due to temporary vasomotor changes; (c) the actual 
loss of or impoverishment of the blood; (d) arteriosclerosis; (e) myocardial 
weakness, with or without valvular lesions. 

Nausea, vertigo, and faintness or actual syncope, mental depression, impaired '• 
concentration, drowsiness during the day and particularly after meals, frequent j Symptoms 
dull or severe headache, disturbed sleep, early waking or actual insomnia, are I types. 
some of the chief symptoms, but there is no sharp line of division between the 
various groups, and the complete picture is seldom present. 

Unrefreshing sleep and bad dreams are more or less common manifestations 
and all of those mentioned assume special importance as relatively early signs 
of cardiovascular inadequacy or decompensation. 

The headaches associated with marked general anemia are usually dull 
but may assume a very violent type. The insomnia usually comes on after a insomnia, 
period of sleep, the patient lying awake the balance of the night or merely 
catching short naps. The early morning awakening, bad dreams and unre- 
freshing sleep, usually associated with advanced age is not uncommon in the 
cardiac decompensations of younger persons. 

CEREBRAL EDEMA.— This condition is chiefly of interest in connec- 
tion with the uremia of Bright's disease, the unilateral paralysis or spasm 
sometimes observed therein being due, possibly, to a localized cerebral edema. ^fy umptive 

Congestive edema may be a part of general edema, especially that of ante-mortem, 
nephritis or a local congestion due to obstruction, cerebral growths or ab- 
scesses. The "wet brain" is considered under alcoholic meningitis. 

CONGENITAL HYDROCEPHALUS.— These cases cause much diffi- 
culty in labors and the children usually die within the first five years. Rarely, 
even somewhat extreme degrees of change do not prevent full mentality 
and reasonably long life; but ordinarily, children are backward, mentally 

* In some instances the dominant symptoms are of cerebellar origin. 



::_: medical diag: 



defe md subject to spas akness of the lower extremities and 

perhaps convulsive seizures. 

HYDROCEPHALUS IN ADULTS.— This is ordinarily secondary to tu- 
mor though possibly in rare instances primary. There may or may not be 
enlargement of the skull through separation of the sutures, the symptoms 
are variable and the disease is not positively diagnosticable. 

During life the most common symptoms are headache, recurring attacks of 
coma, optic neuritis and occasionally, ataxia. 

TUMORS OF THE BRAIN.— About one-half of the tumors of the brain 
are tuberculous, and of these So per cent, occur under the age of twenty-one, 
whereas cysts and s}-philitic tumors occur almost exclusively in adults. 

Sarcomata, usually primary constitute about 20 per cent, of which 7c 
per cent, occur in adults; carcinomata of the softer sort and usually secondary 
70 per cent., of which 75 per cent, occur in adults; gliomata 15 per cent., of 
which 60 per cent, are in adults: gliosarcoma 5 per cent., of which 80 per cent. 
are in adults. 

Tuberculosis, rarely primary, is usually secondary to some preexistent 
lesion and basal in location. 

5 r '::.::. .■ :u < u : :. always acquired and seldom developed later than three 
years after the primary infection, constitute but 3.7 per cent, 99 per cent, of 
u : :;'; : : :<": ;>: :-zu'.:s. 

Cysts are ordinarily the result of hemorrhage or softening, rarely parasitic. 

Gliomata and neurogliomata may be cense, but more often are soft or 
myxomatous and the seat of slight reactive inflammation or perhaps cyst: : 
changes; they occur most often in the substance of the cerebrum, cerebellum 
or brain stem. 

Osteoma ta, fibromata and lipomata are rare." 

This tumor exists only in the nervous system: is essentially infiltrating in 
type, remaining throughout limited to the tissue in which it originates and 
varies greatly in size and extent. 

It is peculiarly vascular and hemorrhages are easily induced. 

The color is usually gray or reddish-gray but may be exactly that of the 
main tissue. 

Symptoms . — I : . :ve symptoms are: (a Pers i stent or paroxys- 

mal, often violent, headache, usually at its maximum in the early morning. 
(b) Apparently causeless vomiting without antecedent nausea, and oftentimes 
t without relation to meals, most constant in children, (c) Optic neuritis, gen- 

* 5:irr states that gumma ta are not only rare in children but are never inherited and 
may appear within one year after infection or as late as twenty. "Organic Nervous Dis- 
eases." 10-05, p. 592. 

" Stan's table shows that ■:: 600 uses of brain tun 
:i:.::tr. ::: — ere si:::~i.::us 5: i.~ 2. i _l:s , :: ~er< 



invade the adjacent tissues. 



105 ~e:e :uoercu-ous 


15: m 


: 102:2. ;S iu acu-ts . 


jo were 


4.1 carcinomatous (31 


acu^is . 


e the sarcomata most 


raz-ii'.v 



TUMOR IDENTIFICATION- 1243 



erally double, {d) Mental changes {usually apathy), (e) Vertigo. (/") Gen- 
eral or slight convulsions or epileptiform seizures closely resembling grand mal, 
petit mal, Jacksonian epilepsy, or even showing the psychic equivalents, (g) 
Pressure symptoms, irritative or destructive, (h) Syncopal attacks, (i) Ema- 
ciation, (j) Polyuria, (k) Insomnia. (/) Slowed pulse. 

Large tumors in important locations may produce no characteristic localizing 
symptoms whatever, or, the order and type of the symptoms may be suggestive 
or definitive. Unlike hemorrhage they are usually of gradual onset and pro- 
gressive in type though inflammatory reaction may intensify them and periods 
of intermission are common. 

TUMOR IDENTIFICATION.— Tuberculosis.— Three-fourths of all cases 
occur in persons under twenty, 50 per cent, in those under ten years of age. One 
finds usually a personal or family history of tuberculosis, predominance of basal 
signs, or, if the lesion is cortical, "irritative" rather than "destructive" symp- 
toms. Retinal tubercle is both rare and late in appearing. Early progressive 
symptoms followed by prolonged intermission and pontine or cerebellar localiza- 
tion are common. Single and multiple lesions are about equally balanced. By 
fusion they may attain the size of an orange, but such large growths are unusual. 
Their effects are chiefly those of thrombus formation and pressure, for they do 
not invade the brain tissue itself. 

Syphilis. — Syphilis of the brain is almost without exception a disease 
of adult life. There is usually a curious indermiteness, shifting quality, and 
lack of completeness in the symptoms present. The chief diagnostic factors 
are the following: (a) History or symptoms of acquired, never a congenital, 
syphilitic lesion, usually of not more than three years' standing, (b) Cortical 
localization and irritative lesions are the rule, (c) Rapid advance is often fol- 
lowed by temporary arrest, (d) .Headache may be extreme and is usually worse 
at night, (e) Disappearance or striking betterment under antisyphilitic 
medication* (/) Positive luetin.or Wassermann test. 

Varied Forms.- — One must consider the isolated gumma, which yield 
tumor symptoms, meningoencephalitis, or gummatous leptomeningitis, with 
or without decided symptoms of high intracranial pressure and, with especial 
frequency an involvement of cranial nerves oculo-motor, auditory etc. 

Paretic dementia and tubo-paresis are syphilitic and the various condi- 
tions are dealt with separately in this section. See also "Cardiovascular 
Syphilis.) 

It should be remembered that the Wassermann reaction is much more 
constant in these cases if the spinal fluid is used in sufficient quantity (1.0 c.c.) 
than is the case if the blood is employed. Increased globulin (actual tur- 
bidity) and a decided lymphocytosis are present in cerebrospinal lues. 

It should be remembered that normally the cerebrospinal fluid is poor 
in cells. 

The average for ten fields with a magnification of 300 diameters should not 
exceed eight cells in normal fluid. 

If desired a special counting chamber may be obtained (Fuchs-Rosenthal) 

* It should always be tried in doubtful lesions. 



1244 MEDICAL DIAGNOSIS 



or, more conveniently the simple white blood cell counter and pipette may 
be employed. More than eight or ten cells to the cubic millimeter of fluid 
represents a pathologic finding. As stated elsewhere, it is not certain that 
the complicated " colloidal gold test" is of any decided clinical value. 

Glioma. — There is usually sudden coma followed by accession of symp- 
toms, irritative cortical phenomena. Long periods of latent and symp- 
tomless development are not uncommon. 

Sarcoma. — The existence of a primary growth, and the rapid, progressive 
and diffuse symptoms are suggestive. 

Carcinoma. — The patients are usually over fifty and a primary growth is 
present. Local tenderness may be present rarely in cortical tumors. 

Terminal Symptoms of Tumor. — Rapid pulse, dementia, persistent con- 
tinuous vomiting and Cheyne-Stokes respiration are sometimes present, 
stupor and coma the common phenomena. 

The symptoms indicative of increased cranial pressure should be held 
clearly in mind. 

These include headache, optic neuritis, vomiting, vertigo, convulsions 
and more or less marked and profound mental disturbance. 

Such are not peculiar to brain tumor of course nor need they all be present 
in the given case. 

Optic neuritis is the most constant sign in brain tumor, vomiting is a 
common event and headache rarely fails to appear at some time. Convul- 
sions arise in a considerable proportion of the cases. 

SUMMARY OF FOCAL SYMPTOMS.*— ,4// lesions may involve other 
areas by contiguity, transference of irritation, actual pressure, or invasion and 
incomplete clinical pictures are common. 

Cerebral Cortex. — Frontal. — Impairment of mentality, change of dis- 
position, irritability, loss of memory, apathy and somnolence, childishness, 
fits of passion, maniacal outbursts or non-delusional dementia, motor aphasia 
and agraphia Qeft lower frontal). 

Parietal. — Word blindness (left inferior parietal), hemianopsia (if occipital 
lobe is affected), disturbed muscle sense and sensation of opposite side of 
body, incoordination, homolateral tremor. 

Motor (Rolandic) Area. — Jacksonian epilepsy (tonic or clonic convul- 
sions) followed by transient, perhaps ultimately permanent paralysis and 
accompanied or preceded by localizing numbness or tingling (the origin and 
course of the spasm indicate the area of involvement); spastic paralysis, 
i.e., increased reflexes, preservation of muscle tonus, nutrition and electrical 
reaction. 

Vertex. — Monoplegias with heightened reflexes or rigidity, are the rule, 
often preceded by an extremely localized weakness (fingers, toes. etc.). 
Median growths may produce hemiplegia of the spastic type. 

Occipital. — Mind blindness, lateral homonymous hemianopsia. 

Temporal. — Intercortical sensory aphasia and word- deafness (left side). 

Sylvian Fissure and Island of Reil. — Superimposed growths may involve 

* Largely based upon the admirable descriptions of Starr, Nothnagle and Ziehen. 



CEREBRAL HEMORRHAGE — EMBOLISM — THROMBOSIS 



1^45 



adjacent lobes and with the following results: internal capsule, paraphasia or 
hemiplegia; inferior parietal or superior temporal, sensory aphasia; third left 
inferior frontal, motor aphasia; operculum, facial palsy. 

Cerebellum. — Median Lobe. — Optic neuritis and severe headache appear 
early, staggering gait or propulsive movements, vertigo (when erect) or 
actual falls. Inferior Surface. Associated cranial nerve involvement. Mid- 
dle Peduncles. Unilateral swaying in direction opposite to growth, or propul- 
sion and cranial nerve involvement on same side as lesion. Superior Pedun- 
cles. Same as corpora quadrigemina. 

Corpora Quadrigemina. — Partial, usually unequal and bilateral oculo- 
motor palsy, nystagmus, staggering gait, superior and inferior recti chiefly 
affected, incoordination of eye movement, unsteady vision. These symptoms 
are pathognomonic. 

Cms Cerebri. — Oculo-motor paralysis same side, hemiplegia opposite 
side with perhaps bilateral hemianopsia (optic tract). 

Pons. — Upper Pons. — Paralysis of third and fifth nerves, hence anesthesia 
of face, external strabismus, corneal dryness and ulcer, dilated pupil, ptosis, 
etc. Knee-jerks often inhibited. 

Lower Portion. — Sixth, seventh and eighth nerve paralysis, internal strabis- 
mus, with alternating hemiplegia. 

Medulla. — Hemiplegia, hemianesthesia, hemiataxia, paralysis of related 
cranial nerves including the hypoglossal, vagus and spinal accessory. The 
wealth of vulnerable structures in this region may yield a multitude of diverse 
symptoms. Ataxia, vertigo, projection movements, dysphagia, unilateral 
or bilateral sweating, vomiting, lingual paralysis, cervical retraction, etc. 

Internal Capsule. — If this be affected there is hemianopsia, hemiplegia 
and hemianesthesia. 

Optic thalamus, awkward positions of the body and athetoid movements, 
marked sensory disturbance and, in posterior lesions, homonymous hemian- 
opsia; voluntary facial expression present, involuntary emotional expression 
absent. In most cases no characteristic symptoms. 

CEREBRAL HEMORRHAGE, EMBOLISM AND THROMBOSIS.— 

Age. — Cerebral hemorrhage is rare before forty and the tendency in- j 
creases with age though cases are occasionally seen in children and in young 
men or women who have a precocious arteriosclerosis. It. is doubtful 
whether there is much difference in its incidence as between men and women. 

Family History. — Hereditary predisposition certainly is of the highest 
importance but relates to the basic cause. 

Associated Diseases. — Chronic alcoholism, lead poisoning and syphilis 
are important antecedent conditions as are gout and nephritis because of 
the associated high pressure and vascular changes. Traumatism and the Syphilis and 
hemorrhagic diseases such as hemophilia, leukemia and pernicious anemia factors. 
must be considered. The acute infectious diseases exert little influence. 

Two factors are essential to the ordinary type of cerebral hemorrhage, namely, 
weakened vessels and high vascular tension, local or general. Hemorrhages may 1 ision. 

be large and single or punctate and multiple, cortical or " capsulo-ganglionic.^ 



1246 



MEDICAL DIAGNOSIS 



Miliary 
aneurysms. 



Absorption vs 
softening. 



Hemorrhage 
into ventricles 



Cause evident 
or absent. 



Signal 
symptoms. 



One of the commonest of immediate pathologic causes is the rupture of 
such miliary aneurysms as may frequently be found in the medulla, pons, 
caudate and lenticular nuclei, and optic thalamus. The lenticulo-striate 
artery, being unsupported, tortuous and without collateral circulation, is 
the chief offender (75 per cent.). Other cases may be due to congenital 
hypoplasia or acute toxemic degeneration. 

The cases associated with "renal cirrhosis" are said to constitute about 35 
per cent., but this figure must be enormously expanded if modern methods of diag- 
nosis are employed and the term u renal inadequacy" is substituted. 

The author's experience leads him to believe that relatively few cases 
occur without hypertension due to renal inadequacy. In this condition 
extreme lability of the blood pressure, uremic exacerbations of general 
and local arterial hypertension and associated arterio-capillary fibrosis 
usually coexist. 

No common condition is so frequently overlooked as is renal imper- 
meability and high arterial tension, because of the lack of focal subjective 
symptoms. 

Absorption may be prompt in minor hemorrhages but ordinarily the brain 
tissue suffers permanent damage and the clinical symptoms depend both 
upon the position of the clot and its extent. Any hemorrhage that reaches 
the fourth ventricle will of course produce almost instant death. By exten- 
sion from the neighborhood of the internal capsule exuded blood may reach 
and fill any of the ventricles. Cortical lesions result from lesions of the 
Sylvian artery and occasionally the pons or even the cerebellum may be the 
site of the rupture. 

Exciting Causes. — Violent muscular strain, uremic arterio-capillary 
spasm, the sexual act, labor, defecation, fear, anger, joy and similar physical 
strains or emotional states frequently determine an attack, but more often 
no definite cause can be assigned and it often occurs during sleep. 

Premonitory Symptoms. — Usually none are present, occasionally numbness, 
prickling or formication in the lower extremities, transient visual disturbance, 
irritability, throbbing frontal and occipital headache, vertigo, drowsiness during 
the day, or insomnia may be noted before the attack* 

They may also be present when no cerebral hemorrhage follows. These are 
for the most part merely symptoms of general arterial hypertension, toxemia, 
and local shortage of the cerebral blood supply and may be present in cardiac 
decompensation, arteriosclerosis and hypertension with chronic nephritis. 

The reported experience of life insurance companies shows the frequency 
and early fatality of moderate grades of arterial hypertension, even when 
associated with no lesion discoverable by the usual tests. 

* In a case recently observed two attacks of momentary unconsciousness, mental con- 
fusion and sensory aphasia with barely perceptible transient tremor of the left hand were 
followed in a few days by an apoplectic seizure producing instant death. In another, on 
two occasions, the patient fell suddenly to the floor without stumbling or tripping, arose 
immediately, showing neither loss of consciousness, mental confusion or motor weakness, 
only to die instantly a few weeks later as in the preceding case. Such occurrences are 
extremely common. 



APOPLEXY — RESIDUAL SYMPTOMS — LOCALIZATION 



1247 



They are significant, therefore, and demand attention, but do not neces- 
sarily mean an impending cerebral hemorrhage. 

Unilateral choreiform movements and spasm of the ocular muscles are 
rare, and in many instances such symptoms undoubtedly indicate a slight 
antecedent hemorrhage.* There are two distinct types of seizure, the sudden 
and the gradual, the former furnishing the typical cases of " apoplectic insult" 
or "stroke." 

Symptoms of Attack. — Loss of consciousness is immediate and complete, 
the face congested or ashen and cyanotic. All voluntary muscles are relaxed, 
the pupils may be moderately dilated, irregidar, or, in ventricular or pontine 
hemorrhage, contracted. The pulse is slow, full, and of high tension. There 
may be conjugate deviation (head and eyes) toward the lesion because of the 
paralysis of the muscles on the side opposite the lesion. Conjugate deviation 
toward the sound side is spasmodic if due to irritation only and the temperature 
is normal or more usually subnormal. Respirations are slow and stertorous, 
the cheeks are blown outward with each expiration, and facial paralysis may be 
indicated by the greater excursion of the paralyzed side. The lips are relaxed, 
spluttering and foam-covered. In cases of gradual onset, paralysis and loss of 
consciousness may not appear for several hours. In lesions of the pons, medulla 
or central ganglia, fever may be present at the onset. 

Second Stage. — After a period varying from a few hours to one or two 
days there is a febrile inflammatory reaction lasting from one to seven or 
eight weeks. A preagonal hyperpyrexia or sudden drop to subnormal usu- 
ally indicates extending hemorrhage, rupture into the ventricle or involve- 
ment of the medulla or pons. 

After a variable period consciousness returns, and, usually, to some extent, 
motor power, while in the limbs that remain paralyzed early rigidity develops. 
Trophic changes, chiefly in the form of bed sores, and congestion of the lungs, 
may add to the gravity of the case. It is important that paralysis should be 
recognized in the cases of coma, as it often at once differentiates apoplexy from 
other conditions. Ordinarily, it is only necessary to raise the arms and legs 
and note the comparative resistance offered to passive movement and the 
change in the tonus as indicated by the dropping of the lifted arm or leg. 
Bilateral comparison of the passive drop of the arms, hands, or legs is usually 
most effective and produces sharply defined contrasts between the sound and 
paralyzed members. Facial paralysis is readily noted and eye symptoms 
such as conjugate deviation at once suggest the cause, f Loss of power may 
be complete and include the opposite half of the body including the area of the 
facial and hypoglossal nerve; or, incomplete, the face being unaffected. If 
the ventricles be affected tonic rigidity or marked convulsive seizures may occur. 



"Insult" or 
"stroke." 



Striking signs. 
Eye symptoms. 



Larval cases. 

Reaction. 

Hyperpyrexia. 

Remission. 



Trophic 
changes. 



Signs of 
paralysis. 



Ventricular 
symptoms. 



* The author has seen a number of cases in which ocular hemorrhages shortly preceded 
an apoplectic seizure. 

t As stated, the most frequent source of hemorrhage is the lenticulo-striate region, a 
crossed hemiplegia being produced rather by pressure than actual destruction which 
accounts for the marked diminution in extent and degree of paralysis so frequently following 
apoplectic insult. 



1248 



MEDICAL DIAGNOSIS 



Reflexes. 



Superficial 
reflexes. 



Paralyses. 



Aphasia and 
dysphasia. 



Hemiplegic vs 
spastic gait. 



Arthritis. 



Secondary 
degeneration. 



Hemianes- 
thesia. 



Relative 
involvement. 



Athetosis. 



Indefinite in 
early stage. 



Important 
local signs. 



The reflexes are entirely abolished during coma or longer periods, though 
greatly increased usually when the first shock of the attack has passed, and the 
theory of suspended function through shock seems a sufficiently reasonable 
explanation of this departure from the law that governs reflex action. 

Residual Symptoms. — The superficial reflexes are absent permanently 
or for long periods over the affected side. Conjugate deviation is usually 
transient but occasionally persists for weeks or months and in these cases 
there is probably a direct lesionof the inferior parietal lobule. In residual 
paralyses we ordinarily find crossed hemiplegia, usually most marked in the 
leg and least in the trunk, with increased patellar reflexes. There is unilateral 
lagging of the thorax. In respiration the shoulders drop downward, yet the 
muscles react normally to the electric current and their atrophy is that of 
disuse. Speech is restored either entirely or to a considerable degree, often 
very early, but dysphasia may persist for some time. The well-known 
hemiplegic gait is due to the patient's throwing the balance of the body 
constantly toward the sound side, the affected leg swinging outward and striking 
the ground in a flail-like manner. Later flaccidity is replaced by spasticity, 
when, as a rule, predominating extensor contraction and a typical spastic 
gait appears. Usually improvement in the leg is more rapid than in the 
arm and in the latter spastic contraction produces flexion of both elbows and 
fingers. A low-grade arthritis from disuse is frequent with pain and partial 
ankylosis, symptoms of vasomotor paralysis may appear and a secondary 
descending degeneration may intensify the deep reflexes even of the sound 
side. Hemianesthesia affecting pain, temperature and touch is present 
though imperfect and ordinarily transient. If marked and persistent it con- 
stitutes a direct focal symptom. Muscle sense is less often affected but 
disturbances of vision and aphasia may be indirectly produced, and be tran- 
sient or focal, persistent, or even permanent. Facial paralysis usually affects 
only the lower branches; the muscles of the neck and trunk are relatively 
less affected than those of the extremities and the hypoglossal paralysis is 
seldom complete. Choreic or athetoid movements may appear during the 
regenerative stage and usually indicates a focus in the posterior part of the 
internal capsule or the adjacent optic thalamus. 

Localizing Symptoms. — As regards the localizing symptoms it must be 
remembered that correct localization is seldom possible in the earlier stages of an 
apoplexy. 

The persistence of a hemianesthesia suggests a focal lesion in the posterior 
portion of the internal capsule, the central convolutions or the intermediate 
medullary tissue. 

Monoplegia indicates a lesion of the centrum ovale, the cortical motor center, 
or a central paralysis of such nerves as the facial and hypoglossal if these are 
alone affected. 

If aphasia complicate a monoplegia a cortical lesion is most probable, if 
aphasia is absent the centrum ovale is suggested. 

If hemiplegia is associated with cranial nerve paralysis of the opposite side 
from the fifth backward, a lesion of the pons or pons medulla on the 



INTRACRANIAL ANEURYSM — EMBOLISM 



1249 



side of the cranial nerve paralysis is probable. If ocular motor alternating 
paralysis co- exists with hemiplegia a lesion of the peduncular tract is 
suggested. Hemorrhage into the internal capsule generally produces 
complete hemiplegia. 

Differential Diagnosis.— Symptomatic apoplexies, those pseudoapoplectic 
seizures that occur in the course of such diseases as cerebral tumor or abscess 
and paralytic dementia, may present the greatest diagnostic difficulty, though 
in most instances such a case history is known or obtainable as at once sug- 
gests their true nature. Absence of choked disc helps to exclude brain tumor. 
If hemianesthesia appears, it is usually transitory. Certain epileptic seizures 
resemble apoplexy, but the subsequent course and previous history usually 
suffice. 

Uremia. — An immediate diagnosis is often impossible even in the pres- 
ence of urinary signs of renal disease. Convulsions are more likely to occur 
as an initial symptom of uremia and the subsequent course is usually distinc- 
tive, "uremic paralyses" without actual vascular rupture being rare. 

Meningitis. — This condition often offers serious difficulties particularly 
as certain apoplexies are associated with painful contraction and rigidity of 
the neck muscles. The persistence of convulsions, their bilateral incidence, 
the general hyperesthesia, the possible demonstration of optic neuritis and 
the history and course of the case must be depended upon as indicating 
meningitis. 

Acute sepsis may produce pseudo-apoplexies but the clinical picture soon 
becomes distinct. 

Hemorrhagic pachymeningitis if unilateral cannot be differentiated from 
a cortical hemorrhage of slow onset. 

Hysteric Hemiplegia. — Hysteric paralyses are usually shifting and tran- 
sitory and seldom involve the facial nerve or produce hemiopia. Sensation 
is markedly and usually atypically affected as compared with apoplexy. There 
are usually visual, olfactory and auditory disturbances or hallucinations and as 
a rule the well-known hysteric stigmata make the diagnosis. 

As regards the secondary changes it cannot be decided positively by any 
known diagnostic test whether in a given case these are due to cerebral softening 
or to cerebral hemorrhage. 

Finally it cannot be too emphatically repeated that focal disturbances cannot 
be correctly localized during the apoplectic seizure, and judgment must in every 
case be suspended until the various and confusing indirect primary symptoms 
have had an opportunity to subside. 

INTRACRANIAL ANEURYSM.— This extremely rare condition usually 
affects the basilar artery and probably is almost invariably syphilitic in 
origin. 

Symptoms. — Unless associated with a distinct bruit these may closely 
resemble or be identical with those of cerebral new-growths. 

Choked disc is said to be rare. 

EMBOLISM. — The diagnosis depends almost entirely upon a consideration 
of the factors of antecedent disease and sometimes the age, as the symptoms of an 
79 



Case history 
helps. 



Condition of 
disc. 



Uremic 
paralyses rare. 



12^0 



MEDICAL DIAGNOSIS 



Antecedent 
disease of the 
heart. 

Associated 
conditions. 



Heart murmur. 



actual attack are so nearly like cerebral hemorrhage as to render positive differ- 
ential diagnosis impossible in most cases. 

Diseases of the heart and bloodvessels are most important, whether rheumatic, 
arteriosclerotic, myocardial or aneurysmal. 

Nine out of every ten cases of cerebral embolism are due to preexisting 
heart disease, less frequently perhaps in the acute cases of endocarditis than 
in the recurrent inflammations attacking valves already diseased. 

This is especially true of mitral stenosis in the young and luetic cardio- 
vascular lesions in persons above forty years of age. 

In acute septic endocarditis the embolus may be capable of exciting 
abscess instead of the mere softening due to the blocking of the area supplied 
by one of the cerebral arteries. 

In any form of severe decompensation such emboli may result, not neces- 
sarily from particles detached from the valves, but from fragments of a 
clot which may exist either in the auricles or ventricles. 

The attack may come on during quiet sleep, be transient and quickly 
recovered from and not infrequently there is a history of antecedent embolism 
in other portions of the body. 

In certain cases a marked and sudden change in the character of the heart 
murmur may suggest the detachment of a particle of vegetation or auricular clot. 

A large number of differential symptoms are given by different authorities, 
but neither the author's experience nor his knowledge of the conditions at- 
tending the two lesions lead him to give them any important place. 

The fact that 90 per cent, of all cases of cerebral embolism depends upon an 
antecedent lesion of the left heart points the way to differential diagnosis. 

THROMBOSIS. — This lesion may be entirely symptomless even when 
not occurring in the so-called "silent'' regions. The localizing symptoms 
and resulting paralysis are so nearly alike in thrombosis, embolism and 
hemorrhage as to permit no accurate differentiation from this standpoint. 

The mode of onset of the paralysis in thrombosis is more suggestive, more 
or less distinct premonitory symptoms usually being present. 

Premonitory Symptoms. — Headache, vertigo, numbness, formication, 
slight weakness of a limb or of one side of the body, defects in memory or 
speech, irritability are some of the many symptoms, suggestive if progressive 
and not removed by treatment directed to sustain the heart, the symptoms 
being far less violent, coma seldom present and consciousness being, as a rule, 
either wholly or partially retained. 

Mental symptoms are much more pronounced than paralytic symptoms after 
Mental state, the attack and usually assume the form of general mental impairment with marked 
irritability and a tendency to emotional excitement. Slowing of the pulse is 
seldom present. 

Finally, the differential diagnosis of these diseases is assisted by the fact that 
80 per cent, of the so-called "apoplectic" attacks are chargeable to cerebral hemor- 
rhage, and the physician's mind is also comforted by knowledge that an immediate 
differential diagnosis is of little importance to the patient. 

CEREBRAL ABSCESS.— It might be thought that cerebral abscess 



Mode of onset. 



DEMENTIA PARALYTICA 



1 2 CI 



would present striking general symptoms which differentiated it from 
cerebral tumors and other confusing lesions. 

Such, however, is not the case save in exceptional instances, and the diagnosis 
ordinarily depends more upon the recognition of one of the well-known causative 

factors than upon any specific or exclusive symptomatology. 

Of such causes we may enumerate acute or recurrent septic endocarditis, 
traumatism with or without fracture, suppurative diseases of the scalp, empyema, 
pulmonary cavities and most important of all chronic suppurative otitis media, 
a condition frequently associated with mastoiditis and caries. 

Abscesses caused by middle ear disease and mastoiditis are most frequently in 
the cerebellum, whereas, when from other causes, they chiefly affect the cere- 
brum, abscesses of the basal ganglia or brain stem being rare. 

The accumulation may be superficial or within the substance of the brain. 
and 80 per cent, are single; multiple abscesses resulting usually from more 
remote foci, such as empyema. In diameter they vary usually from 2 cm. 
to S cm. 

Symptoms. — Extraordinarily latent cases have been reported which for 
several months or years yielded few or no indications of their presence. More 
often the symptom-complex is essentially that of brain tumor and consists 
largely of pressure phenomena. 

In acute cases following operation or injury or in those secondary to an 
otitis media, the symptoms are primarily those of a tneningeal inflammation, 
and there may be fever, chills, vomiting, delirium and severe headache, perhaps 
preceded by symptoms that are irritative in character. 

In the later stages of abscess, mental torpor, drowsiness and optic neuritis 
are common, a period of latency is the rule in cases which arise from distant 
foci and not uncommonly from those due to direct injury. 

The localizing symptoms are, of course, less distinct than in tumor but 
follow the same rules. 

Fever is very often entirely absent and overlooked when present if the primary 
disease be febrile. Xot infrequently, there is subnormal temperature. 

It is evident, therefore, that it is only by a combination of suggestive 
etiological factors, the symptoms of intracranial pressure and perhaps 
of septic absorption, that a differential diagnosis is made. MacEwen's 
method of skull percussion is more likely to yield results in abscess than in 
any other condition producing intracranial pressure. The increased resonance 
obtained depends upon a distention of the lateral ventricles and compres- 
sion of the venae galeni. Optic neuritis is relatively common but choked disc 
is far less constant than in brain tumor or meningitis. 

DEMENTIA PARALYTICA. 

("General Paralysis of the Insane"), ("General Paresis'') 
Etiology. — The etiologic factor in general paresis is identical with that 
of locomotor ataxia and the diseases seem to differ only in the seat of the mor- 
bid process. Both are caused by the vascular ravages of Treponema pallidum of 
syphilis and they may occur in combination (tabo paresis). 



Larval cases. 



Primary vs. 

secondary. 



Meningeal 
form. 



Brain tumor 
symptoms. 



Seek causative 
factors. 



Skull 
percussion. 



Optic neuritis. 



A form 
of syphilis. 



I2s2 



MEDICAL DIAGNOSIS 



Neurasthenic 
symptoms. 



Change of 
character. 



Garrulity. 



Delusions of 
grandeur. 



Impaired 
memory. 



Writing and 
speech. 



Knee jerks. 
Pupils. 



Various 
symptoms. 



Morbid Anatomy. — Amongst the multitude of diverse findings are: 
a small brain in the late stages, with shrunken convolutions, sclerotic arteries, 
hyperemia, and edema in the active early periods, hypertrophic pachymen- 
ingitis, thickened and adherent pia, an increase of cerebrospinal fluid with 
dilatation of the fourth and lateral ventricles, and loss of the fine tangential 
fibers in the superficies of the cortex. (See Cardiovascular Syphilis.) 

Microscopically there is general neuroglia overgrowth (sclerosis) with degen- 
eration of cells and fiber atrophy, and changes are often found in the spinal 
cord identical with those of locomotor ataxia. The whole brain is involved 
though in varying degree. 

Symptoms. — As in locomotor ataxia we deal with a syphilitic-progressive 
degeneration ending in general exhaustion and palsy, but, unlike its purely 
spinal congener, associated with marked mental symptoms and terminal 
dementia. 

It may be divided into two stages, to which some add a prodromal stage, 
and varies considerably in type. 

First Stage. — The early symptoms of this stage are significant but not 
distinctive, being identical with those of certain forms of so-called "neuras- 
thenia." A change of character is soon evident, carefulness, good nature, self- 
restraint, frugality, good judgment, high ethical standards, concentration, 
vigor, and modesty, give place to carelessness in matters large and small, 
peevishness, irritability, or violent outbreaks of temper, periods of extrava- 
gance and foolish investment, coarseness and perhaps brazen immorality. 
The victim is inattentive to occupational and domestic duties and obligations, 
tires easily and lacks concentration and ability to perform sustained work. 
He is garrulous, egotistic, yet jocose and loud in voice and manner. Delusions 
of grandeur shortly appear and the patient deals only in superlatives. His 
enormous wealth, marvelously simple yet grandiose schemes, his house, his 
wife, his children, are all wonderful beyond description and he, incom- 
parable. 

Violent outbreaks may occur in this later period of the first stage, often 
associated with drinking bouts and with sexual excesses marked perhaps by 
extreme perversion. 

In the later period of this stage or even during the earlitr exaltation period 
lapses of memory may occur, the handwriting may be uncertain, letters lack 
coherency, errors in figuring occur and one may note tremor of the facial muscles 
and tongue, difficult enunciation of consonantal words such as u British Con- 
stitution," the speech being hesitant, slurring or even stuttering. The knee- 
jerks are increased or lost, but always abnormal and the pupils miotic, often 
sluggish and unequal or of the Argyll-Robertson type. 

The Argyll-Robertson pupil is practically a pathognomonic sign of syphilis 
of the nervous system, occurring very rarely in any conditions other than paretic 
dementia and locomotor ataxia. 

Attacks of vertigo or syncope, pseudo-apoplexies with hemiplegia, or tran- 
sient epileptiform seizures may occur and insomnia may be troublesome and 
intractable but true apoplexy is uncommon in this stage. 



PARETIC DEMENTIA 



1253 



Sexual weakness and loss of vesical power may be manifest but the vegeta- 
tive function may be long preserved and the appetite is often gluttonous. 
Either the Wassermann or the luetin test is usually positive and the spinal 
fluid yields a lymphocytic picture. 

Second Stage. — This is the stage of decided and increasing dementia. 
Memory, even for familiar faces and common events, becomes fitful and 
almost lost. Personal cleanliness is neglected, there is slobbering at meals 
and a gradually increasing dependency. Apoplectiform attacks are followed 
by permanent paralysis, hemiplegic in type, and true apoplexy may supervene 
and terminate the case. 

The duration of this form is extremely variable, the stage of dementia 
being usually reached in a few months after the appearance of pronounced 
mental symptoms. Death occurs sometimes within a year, usually within 
two or three, but in tabo-paresis may be postponed for fifteen or twenty. 

Remissions are not infrequent but entire recovery usually means an error in 
diagnosis. 

Variation in Type. — Dementia is sometimes primary, the period of exalta- 
tion and excitement being entirely lacking. In such instances the premonitory 
symptoms are almost precisely like those of pronounced "neurasthenia," in other 
cases a marked hypochondriasis is substituted for exaltation. In some of these 
cases there is much complaint of dull pain in the head, trunk and extrem- 
ities. Other cases are of a primary exudative type evidenced by primary 
ocular palsies or cephalalgia with convulsive seizures. These cases are of 
especial interest because of the fact that terminal symptoms of dementia 
are often postponed for five or ten years. Of equal importance are those cases 
of tabo-paresis presenting a combination of locomotor ataxia and paretic dementia. 
In these the onset may be primarily that of a locomotor ataxia, or, such as 
to immediately suggest the combined lesion. When the cord symptoms are 
pronounced the brain symptoms are usually delayed and vice versa. It must 
be remembered that various forms of mental disease other than general paresis 
may complicate tabes dorsalis. 

Differential Diagnosis. — The earliest stages of paralytic dementia in its 
ordinary form cannot be made the basis of an absolute diagnosis without risking 
a serious and dangerous error in diagnosis unless lues is proven. 

With the appearance of pupillary symptoms and marked tremor of the face 
and tongue, or marked and characteristic exaltation, the clinical picture is 
greatly cleared. 

Furthermore, cases of pure cerebral syphilis of the curable type exactly 
simulate one form of paresis and lead to error. A differential diagnosis may 
be impossible in such instances for a considerable length of time, pending the 
result of active and radical specific medication. 

All cases resembling a suggesting paretic dementia should be carefully 
examined for lead poisoning (lead line, occupation, etc.) and alcoholism must 
be given consideration. Hemorrhagic pachymeningitis actually complicates 
about 20 per cent, of the cases of paretic dementia. 

Senile dementia runs a very slow and relatively passive course and occurs 



Dementia. 



Primary cere- 
bral palsies. 



Duration. 



Remissions. 



Primary 
dementia. 



Hypochondria. 

Cephalalgia. 
Tabo-paresis. 



Cord vs. Brain 
symptoms. 



Early accurate 

diagnosis 

impossible. 



Curable 
cerebral 
syphilis. 



1254 



MEDICAL DIAGNOSIS 



Adult males. 



Syphilis 
the cause. 



Degeneration 
of sensory 
structures. 



Pupillary 
signs. 



after the sixtieth year almost invariably. Disseminated sclerosis lacks the 
mental symptoms and is a disease of youth. 

A positive Wassermann or luetin test may be determinative and the spinal 
fluid mononucleosis and globulin increase are of great differential value in 
many instances. 

It should be remembered that general paresis represents a very consid- 
erable proportion of the insanities and must be borne in mind when dealing 
with dubious cases. 

ANEMIA OF THE CORD.— Only in the most profound acute and 
chronic anemias do symptoms from the cord manifest themselves. 

In pernicious anemia hemorrhage may occur or even a true postero-lateral 
sclerosis. Cord symptoms of severity may follow a great loss of blood and on 
the other hand marked changes may be found at autopsy which have yielded 
no symptoms during life. The diagnosis can seldom be made save tentatively 
and is based upon the presence of anemia as an etiological factor together with 
localizing symptoms in the cord itself. 

THROMBOSIS, EMBOLISM, ENDARTERITIS OF THE CORD.— 
However important these conditions may be as the primary factor in certain 
degenerative changes, they are by themselves of no clinical importance. 

LOCOMOTOR ATAXIA 

{Tabes Dor satis), [Syphilitic Posterior Spinal Sclerosis) 

Definition. — A disease characterized by a gradual onset and prolonged 
course, associated with loss of the deep reflexes and normal pupillary light re- 
action, visceral crises, incoordination, lightning pains and ultimate paralysis. 

Etiology. — It is essentially a disease of the male, more common in the 
white than in the colored race, occurs most frequently between the ages of thirty 
and fifty, and is caused by the Treponema pallidum of syphilis. 

Alcoholic and sexual excess, exposure, fatigue and injuries are occasional 
associated conditions, but are probably not causative and usually not even 
contributory. Aside from hereditary syphilis, which occasionally causes 
the disease in children, heredity plays no part. 

Morbid Anatomy and Pathology. — 77 is essentially a posterior spinal 
sclerosis involving primarily the larger dorsal root fibers, though changes in 
the blood vessels of the nerve roots, pia mater and cord may appear early. 
The disease is a progressive degeneration and even though the primary lesion 
is not in the cord itself, the major changes are ultimately. to be found there, 
and even macroscopic examination reveals the morbid condition in most 
instances. 

SYMPTOMS. (Incipient Stage).— Eye Symptoms.— The Argyll-Robert- 
son pupil* showing a loss of the iris reflex to light, with normal reaction to ac- 
commodation, is one of the earliest symptoms. The pupils are often contracted, 

* As stated previously this pupil reacting to accommodation and not to light, wherever 
found, single or double, with or without other symptoms, almost invariably means syphilis 
of the nervous system. 



TABES DORSALIS 



1255 



perhaps unequally so, and there may be optic atrophy, ptosis, paralysis of the 
external recti or even total blindness. Dysuria. This is an early symptom, 
whereas incontinence occurs later in the disease. 

Loss of Deep Reflexes. — Early in the disease the knee jet k is diminished 
and finally lost, the response being often unequal on the two sides until both 
are abolished, and the Achilles jerk is usually first to disappear. 

Pain. — The characteristic lightning pains are acute, darting, stabbing, 
follow dorsal root areas, are irregular in occurrence, variable in intensity, 
likely to be initiated by excesses of any kind and leave as suddenly as they 
appear. They most often affect the legs, but may occur in the arms, head or 
trunk, and sensitive areas and herpetic eruptions may follow them. 

Ataxic Stage. — Romberg's sign is one of the earliest, the patient being 
unable to stand steadily with the feet together and the eyes closed. Further- 
more, he cannot stand on one leg or start off promptly when ordered, his 
turns are made laboriously and cautiously and descending stairs is difficult. 
It may be present in the first stage and antedate the loss of knee-jerks. 

The characteristic gait (ataxic) develops later, the patient throwing out 
the leg with jerky, uncertain action, keeping the feet far apart to secure a 
wider base, and bringing them down heel first with a sort of stamp; being 
obliged ultimately to use one or even two canes or becoming totally disabled. 

Incoordination is less prominent in the arm movements than in those of the 
leg and muscle power is remarkably preserved, as is nutrition, until the later 
stage of the disease. There is unusual mobility and relaxation of the joints 
which occasionally appears at a comparatively early stage. 

Various sensory symptoms develop even during the pre-ataxic period, most 
marked in the lower extremities, the patient feeling often as if the feet were 
muffled in cloths or cotton and losing the sense of the resistance of the 
ground. Sensations of numbness and tingling are prominent and lightning 
pains may or may not exist in varying degrees of severity. 

Not only is the tactile sense impaired but the sense of pain as well, and this 
is associated with a marked retardation of pain transmission so that several 
seconds may elapse before the prick of a pin is perceived. 

Oddly enough ataxic symptoms are unusual or at least greatly delayed in 
those cases in which optic atrophy is an early sign (one in ten). 

Visceral Crises. — These remarkable symptoms constitute a frequent source 
of error in diagnosis and may be gastric, intestinal, rectal, renal, urethral, clitoral 
or laryngeal and associated with marked pain in and functional disturbances of 
the parts afected. 

At this stage incontinence of urine may displace simple dysuria or retarda- 
tion, cystitis and even pyelo-nephritis may occur; sexual power, diminished 
in the early stage, is now usually lost, and simple constipation may be re- 
placed by critical rectal pain and spasm and ultimately by relaxation of the 
sphincter. 

Trophic Changes. — Perforating ulcer of the foot and the so-called Charcot's 
joint are the most prominent of these changes. The former appears usually 
on the sole of the foot beneath the great toe, the latter is a painless disinte- 



Dysuria and 
incontinence. 



Knee- and 
Achilles-jerk. 



Often mis- 
interpreted. 



Static ataxia. 



Ataxic gait. 



Incoordination. 



Muscular 
power. 



Joints. 



Anesthesia. 



Paresthesia. 



Analgesia. 



Significance 
of optic 
atrophy. 

Misleading. 



Urinary and 

rectal 

symptoms. 



Charcot's joint 
and perforating 
ulcer. 



1256 



MEDICAL DIAGNOSIS 



Cutaneous 
symptoms. 



Loss of power 
delayed. 



Long duration 



Typical cases 
simple. 



gration of the joint associated with effusion, deformity and tendency to dislocation. 
The bones are brittle in this disease and spontaneous fracture may occur. 

Various skin rashes, areas of sweating, herpes and edema may appear in 
connection with lightning pains. Muscular atrophy seldom appears until 
later in the disease but the nutrition of the nails may be greatly affected. 

Brain Symptoms. — Paranoia, melancholia, and dementia may occur, and 
paralytic dementia is "cerebral tabes," the difference being merely one of 
localization. 

Duration. — Paralyses are seldom marked until from five to eight years 
have elapsed; even then progress is slow, periods of apparent arrest not un- 
common, while actual arrest sometimes occurs. The chronic course of the 
ailment is remarkable, the patient may live for twenty-five or thirty years, 
though rarely cases occur in which the progress of the disease is rapid. Death 
results from intercurrent disease in nearly every instance. 

Differential Diagnosis. — Tabes when established, need seldom be con- 
founded with any other disease though it may be combined with general 
paresis, tabo-paresis and its separation from that ailment is clinical rather 
than pathological, the combination of loss of deep reflexes, the Argyll-Robertson 
pupil and lightning pains making a distinct clinical picture. In true ataxic 
paraplegia the knee-jerks are increased, in chronic multiple neuritis with 
ataxia ("pseudo- tabes") there is marked muscular atrophy and tenderness 
over the affected nerves. 

ATAXIC PARAPLEGIA. ("Gower's disease," " posterolateral sclerosis") — 
A combination of marked incoordination and slowly developed spastic paraplegia 
with retained and increased reflexes and frequently ankle clonus, making it a 
clean-cut clinical picture. 

It occurs chiefly in males between thirty and forty years of age, and 
is associated with degenerative changes in the dorsal and lateral columns of 
the cord and is of unknown causation. The sphincters are usually involved 
and there is a late development of mental symptoms similar to those of paretic 
dementia. Cranial nerve symptoms are seldom pronounced. There may 
be "dull aches," rarely lightning pains. 

The combination of spastic paraplegia with ataxia is striking and lacks all 
important tabetic symptoms. 

Friedreich's Ataxia occurs only in children and young adults, shows 
scanning, syllabic speech and lost reflexes. 

PRIMARY COMBINED SCLEROSIS.— This name has been given by 
Putnam to cases presenting clinically progressive weakness, numbness of the 
extremities, exaggerated tendon reflex, spastic contraction and paraplegia with 
pronounced anemia. 

HEREDITARY ATAXIA {Friedreich's Ataxia).— This disease of child- 
hood or young adults it is not invariably hereditary. It is associated with 
degeneration of the dorsal and lateral columns of the cord. 

Symptoms. — The chief features are marked incoordination involving first 
the legs, but later the arms, and these to a marked degree. The gait is uncertain, 
stumbling and staggering {cerebellar), rather than stamping, as in locomotor 



PRIMARY LATERAL SCLEROSIS 



1257 



ataxia. Arm movements are jerky and irregular and grasping involves pouncing 
upon the object. Tendon rejlexes are diminished or lost though a Babinski is 
sometimes present, there is early talipes equinus, the big toe becomes flexed 
dor sally and nystagmus occurs late. Pupillary reactions and the optic nerve 
are unaffected. Paralysis and mental impairment usually come on late. The 
speech is indistinct, slow and scanning, and both scoliosis and kyphosis are 
common. 

Both choreiform and athetoid movements may occur. Speech is pecu- 
liarly slow and disorderly. 

CEREBELLAR HEREDITARY ATAXIA {Marie).— This later-life form 
of hereditary ataxia, presumed to be associated with a congenital cerebellar defect, 
is characterized by impaired pupillary reaction, exaggerated tendon reflex, 
clonus, ocular palsies, optic atrophy, and, by its development in the third 
decade. 

Incoordination, nystagmus and scanning speech are present as in Fried- 
reich's ataxia, but the gait is more distinctly reeling and drunken. 

It is doubtful if any line should be drawn, as in the two diseases the same 
general tracts are affected, the spine in Friedreich's ataxia, the cerebellum in 
that of Marie, the actual tracts being structurally continuous.* 

PRIMARY LATERAL SCLEROSIS (Erb-Charcot Disease) (" 'Spastic Par- 
alysis of the Adult"). — This is a rare disease of early adult life, between the 
ages of twenty and forty, no definite etiologic factors have been proven and 
the pathologic change is essentially a degeneration of the pyramidal tracts, 
either primary or secondary. 

Symptoms. — Muscular rigidity and weakness are often associated with dull 
pain and a persistent sensation of fatigue. Rigidity and impairment of locomo- 
tion slowly increase and are out of proportion to the loss of power. 

Tension and stiffness of the legs are first symptoms in most instances and 
the constant "stubbing" of the toe may wear away the shoe in a significant 
way. 

The spastic gait is marked early in the disease and later becomes extreme, 
the patient shuffling along with toes dragging, tripping over every obstacle, the 
legs being closely approximated or even so crossed {adductor spasm) that locomo- 
tion is lost. The knee-jerk is extremely active, Babinski' 's sign, rectus and ankle 
clonus are easily elicited, superficial reflexes are increased and in some instances 
clonus appears whenever the foot is placed upon the ground and the slightest 
touch may produce clonic spasm of the legs. The latter may be equally or un- 
equally affected and the arms are usually free until the disease is far advanced. 

The ailment is one of long duration, yet nutrition is remarkably preserved, 
sensation is not affected and the sphincters are rarely involved until late 
in the disease. Ultimately an extreme state of disabling contracture and 
atrophy from disuse develops. Diagnosis is never positive, as primary sclero- 
sis is excessively rare and cases usually prove to be secondary. 

* L. F. Barker working with the clinical collaboration of Sanger Brown, established the 
fact that congenital hypoplasia of the cerebellum and spinal cord "with outspoken degenerations 
of the spino-cerebellar paths" occur in this disease. 



Spasticity and 
lest power. 



"Toe 
stubbing.' 



Spastic gait. 



Increased 
reflexes. 



Atrophy 
terminal 
only. 



I2 5 8 



MEDICAL DIAGNOSIS 



Heredity and 
age important 
factors. 



Spastic type. 



Begins in 
Infancy. 



Normal 
sensation. 



Increased 
reflexes. 



Backwardness 
and mental 
defects. 



Oscillation. 



Athetosis. 



Slight rigidity 



Secondary Spastic Paralysis. — It is hardly possible to separate secondary 
from primary spastic paralysis which may result from any condition pro- 
ducing a lesion in the pyramidal tract, i.e., compression, tumor, caries, etc. 

HEREDITARY SPASTIC SPINAL PARALYSIS (Hereditary Spastic 
Paraplegia), (Family Form of Spastic Spinal Paralysis). — This variety is 
distinguished from spastic paralysis chiefly by its distinctly familial nature and 
the fact that it commences several years after birth, usually at about the age of five. 

Two groups are distinguished, viz., those with the symptomatology of a 
cerebral spastic paraplegia developed in infancy and childhood, but lacking 
all other cerebral symptoms, and those develop- 
ing in early adult life insidiously with primary 
spasticity and late paralyses. 

THE SPASTIC PARALYSIS OF 
INFANTS (Birth Palsy), (Spastic Cerebral 
Paraplegia), (Little's Disease), (Spastic 
Diplegia). — This condition is essentially a 
general spastic paralysis occurring at or shortly 
after the time of birth, more rarely following 
a convulsive seizure or an acute disease. 
The legs are chiefly affected without marked 
sensory disturbances or wasting and the reflexes 
are increased. A thetosis and ataxia are extreme 
and the mental condition markedly affected. 
The condition is no doubt most often due to 
meningeal hemorrhage and the interference 
with mentality will depend upon the extent 
and location of the effusion. In cases of 
premature birth, spastic paraplegia without 
mental symptoms is thought by some to be 
due to an imperfect development of the 
pyramidal tracts. In most instances, however, 
the disease is associated with instrumental 
delivery and seems to be due to actual injury. 

Backwardness of the child may first call 
attention to the condition, or there may 
have been repeated convulsive seizures. The 
head may seem badly supported, the child may 

not be able to sit up and shows no tendency to walk or creep at the proper age. 
Leg rigidity and adductor spasm are usually marked. 

Symptoms are commonly either absent or less marked in the arms; when 
marked it constitutes a spastic diplegia. Constant irregular larger movements 
of a choreic type may be present in the extremities, sometimes most marked 
when coordinate movement is attempted, and pronounced bilateral athetosis 
is often present. 

Erb's Syphilitic Spinal Paralysis. — The leading features are slight mus- 
cular rigidity, exaggerated deep reflexes, pain and sensory disturbance trifling, 




Fig. 619. — Little's disease. 
Diplegia. {Gordon.) 



HYSTERICAL SPASTIC PARAPLEGIA — SYRINGOMYELIA 



1259 



involvement of the rectum and bladder, impotence, a slow onset and a certain 
amenability to treatment. 

HYSTERICAL SPASTIC PARAPLEGIA.— Hysterical persons can 
accurately simulate true spastic paraplegia and differentiation is sometimes 
extremely difficult, but a few positive points can be laid down. 

Such are: spurious clonus, more marked and irregular disturbances of 
sensation, variability in the site and intensity of paralysis, unsustained or 
irregular resistance to passive movements, frequently associated hysterical stig- 
mata and absence of the Babinski. 




Fig. 620. — Little's disease. Paraplegia. (Gordon.) 

AMAUROTIC FAMILY IDIOCY.— The chief characteristic of this form 
of infantile paralysis affecting children during the first or second year of life 
is the constancy of blindness, first, partial, later, complete, associated with 
optic atrophy. The children become idiots and either spastic or flaccid 
paralysis may develop. It is a family disease, kills usually before the end 
of the second year, and is sometimes associated with auditory disturbances, 
strabismus and nystagmus. 

SYRINGOMYELIA.— Gliosis Spinalis.— Pathologically, this disease con- 
sists in the formation of embryonal neurogliar tissue which undergoes hemor- 



Involvement of 
sphincters. 



Spurious 
clonus. 



Peculiar 
resistance. 



BHndness'and 
idiocy. 



Early 
death. 



1260 



MEDICAL DIAGNOSIS 



chiefly. 



Dissociated 
anesthesia. 



Spinal 
symptoms 



Painless 

cutaneous 

lesions. 



Mixed types. 




rhagic or degenerative changes, resulting in an enlargement of the central 
canal of the spinal cord quite distinct from ordinary dilatation; it is a disease 
cervical region of early adult life, almost invariably involves the cervical region, sometimes 
assumes a family type and affects men much more frequently than women. 

A most pronounced diagnostic feature is a loss of thermal and painful sensa- 
tion without marked involvement of the tactile or muscle sense. This is usually 
accompanied by pain in the extremities and cervical region, followed by per- 
ipheral muscular atrophy of the hands, slowly extending centrally. Scolicsis is 
usually present, the legs may, late in the disease, present spastic paraplegia and 
cutaneous disturbances both trophic and vasomotor are common. 

Such are dry or sweating skin, congestion or edema of 
the extremities, especially the hands, bulbous or herpetic 
eruptions, atrophy and disintegration of the nails, erosions, 
fissures and ulceration of the terminal phalanges. It should 
be noted that these cutaneous lesions are painless. Spontane- 
ous fractures and arthropathies may occur and late in the 
disease the vesical, rectal and genital centers may be in- 
volved and bulbar symptoms appear. Reflexes are usually 
increased and frequently the general aspect is that of 
amyotrophic lateral sclerosis, though if the dorsal columns 
are involved, tabetic symptoms may be marked. 

Clinically, one may encounter a straightforward type 
lacking the predominance of confusing motor or sensory 
changes, or the picture may be that of hematomyelia, cervical 
pachymeningitis , progressive muscular atrophy, amyotrophic 
or spastic paralysis, tabes, hysterical hemiplegia or a type in 
which trophic changes predominate. ("Morvan's syndrome. ") 

The last is the only one which often can confuse diag- 
nosis if the peculiar sensory symptoms are present. In 
Morvan's syndrome tactile sense is faint and trophic changes dominate the 
clinical picture. 

MYELITIS. — This may be acute, subacute or chronic and the term is usu- 
ally confined to a lesion involving both gray and white substance, poliomyelitis, 
which involves the gray matter only, being considered separately. As 
regards the position and extent of the lesion we distinguish cases that involve 
a considerable vertical area as ''diffuse," those affecting the whole transverse 
area as ''transverse," and those with foci scattered throughout the cerebro- 
spinal tract as disseminated. 

COMPRESSION MYELITIS.— This type is associated with traumatism, 
spinal caries, aneurysm, new growths and parasites, more rarely with large 
syphilitic growths. 

Diagnosis. — The diagnosis depends somewhat upon the recognition of 
an antecedent caries, aneurysm, malignant growth or syphilitic infection. This 
form of myelitis is as a rule much more painful than acute myelitis and in malig- 
nant disease especially most excruciating suffering may be witnessed from 
compression of the nerve roots, either directly by the bones or a tumor, or by 



Fig. 641. — 
Anesthetic area 
common in 
hysterical para- 
p 1 e g i a . The 
genitals are 
spared. {After 
M.Allen Starr.) 



Varieties. 



Seek cause. 



ACUTE MYELITIS 



I26l 



an exudate. In unilateral compression the Brown-Sequard's syndrome 
may be evident. Paraplegia in these cases is usually slow in develop- 
ment and preceded by weakness and paresthesia, the girdle sensation is 
usually marked and sensation persists longer than motion. If the cord be 
involved above the lumbar region, the paralysis is spastic with exaggerated 
reflexes; if below, the reflexes are usually diminished or lost and the sphincters 
involved. Recovery may be complete in cases of pressure due to deformity if 
the latter be corrected. 

ACUTE MYELITIS. — An inflammation of the cord substance may follow 
or more rarely directly complicate acute infectious diseases, chief of which are 
variola, severe dysentery and acute intestinal toxemia, diphtheria, typhus, 
acute rheumatism, measles, septicemia and pyemia, gummatous or en- 
darteritic syphilis. Less important are erysipelas, pneumonia, malaria, 
puerperal fever, scarlatina and influenza and certain acute chronic intoxica- 
tions such as alcoholic and gas poisoning and gout. Traumatism, with or 
without fractures (sometimes mere concussion, violent torsion or flexion), 
caries, and not infrequently a combination of fatigue and exposure to wet 
and cold may initiate an attack. It may also be due to the extension of 
meningitis or even neuritis, or develop secondarily in tuberculosis and syphi- 
litic processes and it occurs chiefly in men and between the ages of twenty and 
forty. 

Symptoms. — Premonitory malaise, sense of weakness and numbness, chill 
or chilliness and a variable degree of fever accompany the attack. One must 
first diagnosticate a myelitis, secondly, determine the position and extent of the 
lesion; and finally, determine the probable cause as a factor in prognosis. 

The essential symptoms are: (a) Hyperesthesia, absence of reflexes amd a 
girdle pain (painful constriction) at the level of the lesion. 

(b) Rapidly developing, not immediate, motor paralysis below the lesion 
chiefly affecting the flexors, partial or complete, according to the degree 
of transverse involvement. 

(c) Increased reflexes below the lesion. 

(d) Involvement of the sphincters, rectal and vesical. 

(e) Vasomotor phenomena, i.e. congestion, sweating. 

if) Trophic changes, especially pressure necrosis over the heel, hips and 
other dependent portions. 

(g)' Changes in muscle tonus, nutrition and electrical response varying with 
the level of the lesion. 

The actual level of the lesion is best indicated by the upper margin of 
anesthesia, the hyperesthetic level being just above it. It will be seen at 
once that the region involved markedly affects the motor symptom c , 

// in the lumbar enlargement the paralysis is typically flaccid, with atrophy, 
loss of knee-jerks, R.D. and urinary incontinence. 

// mid-dorsal or cervical, the paralysis is spastic and the reflexes are usually 
lost only in the areas corresponding to the actual level of the lesion. The picture 
is ordinarily that of spastic paraplegia with retention of urine, increased muscle 
tonus, Babinski's sign, exaggerated ankle clonus and patellar reflex. 



Brown- 
Sequard type. 



Causes. 



Sex and age. 
Premonitory. 

Localizing. 



Lumbar type. 

Mid-dorsal. 
Ordinary type. 



1262 



MEDICAL DIAGNOSIS 



Upper bound- 
ary zone. 



Unusual signs. 



Hemorrhage 

and 

meningitis. 



Landry's 
paralysis. 



Neuritis. 



Poliomyelitis. 



Subacute 
myelitis. 



Anesthesia 
dolorosa. 



Brown- 
Sequard 
syndrome 
common. 



Determining 
factors. 



In the cervical form flaccid paralysis may be marked and relatively exten- 
sive at the level of cord involvement and if the fourth cervical roots be involved 
death may result from paralysis of the diaphragm, and vomiting, bradycardia, 
syncope, hiccough and dyspnea may occur. Disseminated foci must be rec- 
ognized by regional diagnosis. 

The upper level of a transversa or diffuse lesion is clearly indicated by the 
girdle pain and zone of hyperesthesia, which may be emphasized by passing a 
cloth or sponge over the spine. Optic neuritis and miosis may occur in cervical 
myelitis. Symptoms of irritation (spasm or convulsions, pain) if present 
are usually of short duration, but the diseased area tends to extend. // 
diffuse there is acute ascending paralysis. 

Differential Diagnosis. — Hemorrhage into the cord is characterized by 
absolute suddenness of onset, and frequently lacks fever. Abscess, by 
suppurative foci; in meningitis the irritative, painful and spasmodic symptoms 
predominate, increasing with disease duration until stupor or coma super- 
venes, whereas in myelitis they are relatively slight or of brief duration. 
The diseases may of course co-exist. Only a dorsal myelitis could be con- 
founded with hysteria, and here girdle sensation, sphincteric involvement, 
true ankle clonus with perhaps extension spasm and the trophic changes are 
distinctive. In Landry 's paralysis the lesion is an ascending motor paralysis, 
flaccid throughout, with normal electrical reactions, lost reflexes, and usually, 
good sphincteric control. Multiple neuritis presents at times great difficulty, 
but ordinarily the more gradual onset of paralysis, marked pain and local 
tenderness over peripheral nerve areas, and the less frequent sphincteric distur- 
bance makes the diagnosis clear. The combined cases offer more difficulty. 
Acute Anterior Poliomyelitis. This shows flaccid paralysis throughout, 
seldom involves the sphincters, and lacks the girdle pain and other, sensory 
and trophic phenomena of myelitis. Subacute Myelitis. Differs from the 
acute only in its gradual onset (three to six weeks). 

Compression myelitis is suggested by the history or presence of spinal 
caries, traumatism or new growths, aneurysms, syphilis, echinococcus or 
cysticercus cysts or syphilitic infection, combined with the symptoms of a 
slowly developing myelitis, persistent and perhaps agonizing pain if the nerve 
roots be involved (malignant growths and metastatic cancer causing the 
most severe type), and such pain may be marked over areas anesthetic to painful 
and thermic stimuli (anesthesia dolorosa). The relation of pain to spinal 
flexion may be suggestive, as is its relief in properly treated cases of caries and 
deformity. Aside from the areas directly involved spastic motor paralysis 
predominates, save in the lumbar region, and sensory paralysis varies with 
the transverse area of the lesion. The Brown-Sequard syndrome may of 
course be present, indicating unilateral involvement. This symptom-complex 
is more common here than in any other spinal cord lesion save hematomyelia. 

Primary Chronic Myelitis. — The only essential factors are its slow and 
irregular development, affecting at random the different cord functions, mo- 
tor, sensory and trophic, but lacking the nerve root symptoms of compres- 
sion myelitis. 



PROGRESSIVE MUSCULAR ATROPHY 



1263 



COURSE. — As any region may be involved and any type or grade exist, 
the course varies from early death to complete recovery or the establishment 
of chronic myelitis and permanent deformities. Sensation, last to go, is first 
to return. In unfavorable cases bed sores may hasten the end, sometimes 
being associated with hyperpyrexia; descending and ascending sclerosis may 
occur; the legs may become rigid or the seat of flexor or extensor spasm {i.e., 
' 'jack-knife rigidity "), and the reflex responses extreme. Urinary decomposition 
may produce cystitis or pyelitis and hasten the end. 

It shoidd be remembered that cases of slow onset and a history of antecedent 
acute infectious disease yield the best prognosis. Bed sores, high degrees of 
anesthesia, sudden severe onset and an unusual degree of early pain and spasm 
are bad omens. 

Good habits, relative youth, a vigorous physique, and an absence of tuber- 
culous or malignant disease offer some encouragement. In chronic cases, after 
two years no hope of recovery may be entertained. 

LANDRY'S PARALYSIS.— This rare disease of unknown causation 
chiefly affects young adult males and is characterized by a progressive sym- 
metric ascending paralysis, and an abrupt onset suggesting an acute infection. 

Symptoms. — The sharply febrile onset is succeeded almost immediately by a 
complete paralysis beginning in the legs and involving in a few days or even hours 
the trunk, upper extremities, muscles of respiration and usually of deglutition and 
articulation. Enlargement of the spleen may be noted, the sphincters are usually 
not involved, the reflexes- are lost, but sensation is ordinarily preserved, or but 
slightly affected, and the muscles do not atrophy or show abnormal electrical 
reactions unless the ailment is of unusually long duration. 

Prognosis. — Death in from forty-eight hours to two weeks is the almost 
invariable result.* Nothing definite can be said of the pathologic changes 
save that the lower motor neurons are the point of attack. Acute myelitis 
shows anesthesia, bed sores, reaction of degeneration and atrophy at the 
level of the lesion and early involvement of sphincters. Multiple neuritis 
cannot be differentiated positively in certain rare instances (see u multiple 
neuritis"). 

PROGRESSIVE MUSCULAR ATROPHY 

Definition. — This is a disease of unknown causation, affecting chiefly 
adult males beyond the age of thirty, said to be influenced etiologically by 
the usual factors, such as traumatism, excessive mental or physical strain, 
exposure to wet or to cold, and, to a slight degree, hereditary influence. 

* The author very foolishly and quite vainly kept a young girl alive for forty-one days 
by artificial respiration, breathing having ceased early in the attack. Muscle atrophy was 
well marked only in the last stages. The patient ate and slept during this period, but if 
artificial respiration was suspended during sleep, a wave of intense cyanosis would imme- 
diately follow and the girl would wake as it deepened with a look of utter terror, unable to 
utter a sound, and feeling the pang's of dissolution. Upon resumption of the movements 
her cyanosis would almost wholly disappear. She died very suddenly of acute pulmonary 
edema on the forty-second day. 



Chronic. 



"Jack-knife 
rigidity." 



Ascending 
paralysis. 



Sensation 
preserved. 



Atrophy and 
R.D. usually 
absent 



Adult males 



Usual factors. 



1264 



MEDICAL DIAGNOSIS 



Order of in- 
volvement. 



Fibrillary con- 
tractions. 



Sensation 
unaffected 



Knee jerks. 



Fibrillary con- 
action. 



Characterist 
symtom 




Fig. 622. — Claw hand. 



It is essentially a gradual atrophy of the motor neurons, either lower 
or upper being first involved, the lower in the greater degree and sometimes 
exclusively. 

The degenerative process affects the gray matter of the anterior horns 
and the libers of the anterior nerve roots within and without the cord, to- 
gether with the intermuscular branches. The degeneration of the gray 
matter extends to the medulla and the antero-lateral white tracts and lateral 
pyramidal tracts are affected in varying degree, in some cases even to the 
motor cortex. There is of course marked muscular atrophy. 

Symptoms of the Aran-Duchenne Type. — Following a period of vague 
and indefinite pseudo-rheumatic pain, muscular atrophies appear in the following 
order. The muscles of the ball of the thumb (the patient first noticing an inabil- 
ity to adduct the thumb, separate the index from the middle finger, write, 
button his clothes), the inter ossei and lumbricales , fore- 
arm flexors and extensors and the deltoid, followed by 
other muscles of the shoulder girdle group. One hand 
is usually first affected and the muscles of the legs and 
face and the trapezius are usually attacked late. The 
platysma myoides entirely escapes and indeed may 
hypertrophy, and fibrillary contractions are marked. 

The atrophy of the muscles of the hand and 
forearm produces the so-called "claw hand" and the 
wasting of intercostal and abdominal muscles reduces the patient to a 
helpless skeleton. Later the neck and even in some instances those of the 
face are involved and in prolonged cases those of the legs. The electric 
excitability of the muscles is early diminished and finally lost, the reaction 
of degeneration occurring in rapidly advancing cases. Muscular power 
disappears pari passu with the wasting. Subjective sensory symptoms may 
be present yet sensation is unimpaired and the sphincters unaffected, but 
the knee-jerks are lost when the quadriceps extensor atrophies. 

Amyotrophic Lateral Sclerosis. — In certain cases of a progressive muscular 
atrophy described as amyotrophic lateral sclerosis a primarily spastic paralysis 
is associated with atrophy following the Aran-Duchenne order quite closely. 
In these the reflexes are increased and the picture is one of spastic paraplegia 
with the typical gait but with gradual atrophy. Jaw clonus and Babinski's 
sign are present but the sphincters are unaffected. The tendon reflexes are 
seldom increased in the flaccid type, markedly increased in the amyotrophic 
type. Fibrillary contraction is marked and there is a generally exaggerated 
motor response to muscle or tendon percussion, yet there is usually a partial 
reaction of degeneration. Bulbar involvement is often early and may precede 
the leg involvement. 

The Bulbar Type (Glosso-labio-laryngeal Paralysis). — Bidbar symptoms 
may precede or follow spinal symptoms but no actual pathological distinction 
exists to justify making of the primary bulbar type a separate disease. Bulbar 
involvement is indicated by difficulty in the pronunciation of the Unguals and 
dentals, atrophy and weakness of the tongue leading to dysphagia, dysarthria, 



MUSCULAR DYSTROPHIES 



1265 



the accumulation of saliva and drooling. With involvement of the lips, 
labial pronunciation becomes difficult and succeeding paralyses of the 
pharyngeal and laryngeal muscles increase the dysphagia and enfeeble the 
voice. This type may be associated with progressive atrophy of either the 
spastic or flaccid type and cases of acute onset occasionally occur. A similar 
condition affecting the eye muscles is known as progressive ophthalmoplegia. 

Muscular Atrophy of the Peroneal Type.* — This differs from the preceding 
form in three particulars viz., first, that it is an hereditary or family disease. 

Second, in that the atrophy commences in the muscles of the feet and peroneal 
group, often unilate rally at first, reversing the usual form. 

Third, sensory disturbances are prominent; it especially affects young chil- 
dren, leading to various forms of club-foot, and the sphincters are not involved. 

Differential Diagnosis.— The chief difficulty arises in distinguishing 
between a progressive muscular atrophy of the spastic type and syringomy- 
elia, differentiation being only possible when the peculiar sensory symptoms 
of the latter disease are pronounced. 

The bulbar type must be distinguished from the pseudo-bulbar palsy of 
cortical origin which results from bilateral lesions in the facial area of the 
cortex or between these areas and the cranial nuclei, and lacks the fibrillary 
tremor, rapidly advancing atrophy and R.D. of bulbar palsy. 

A "Werdnig-Hoffmann Type" of infantile, familial, central, muscular 
atrophy shows its primary effect in the muscles of the back, thighs, and pelvis, 

Gower's Type. — The atrophy is limited to the muscles below the knee. 

Eichhorst's Type. — In this the femoral and tibial muscles are first affected. 

Zimmerlin's Type. — The initial atrophy affects the proximal muscles 
primarily of the thorax and arm, etc. 

MUSCULAR DYSTROPHIES.— There are various clinical forms of 
muscular wasting, with or without initial hypertrophy, classed under diseases 
of the nervous system but lacking definite pathologic findings. Atrophy, palsy 
and marked hereditary tendency usually co-exist in all forms. 

Etiology. — The disease may exist in a family for generations and is most 
frequent in the male. Atavism similar to that of hemophilia is evident, the 
mother transmitting the disease even though herself unaffected. 

Classification. — No sharp dividing line can be drawn, but for clinical pur- 
poses cases may be divided into (A) those occurring in youths and adults, (B) 
those of childhood. 

Class (A). — The disease may assume (1) atrophic and (2) hypertrophic 
forms, the former including (a) cases without involvement of the facial muscles, 
(b) those in which they are early involved. The latter includes both cases of 
genuine hypertrophy and those of muscle lipomatosis. 

PSEUDO-MUSCULAR HYPERTROPHY.— {Progressive Muscular Dys- 
trophy). — Symptoms. — The mechanical motor impairment calls attention to 
apparent enlargement of the muscles, first usually of the calves. The leg ex- 

* The tendency to multiply these diseases by the discovery of more or less unimportant 
variants is indicated by the fact that this might be called the " Marie-Tooth-Dejerine 
Sottas type." 
80 



Acute form. 



No pathology. 
Heredity. 

Two classes. 



1266 



MEDICAL DIAGNOSIS 



Prominent 
weak muscles. 



Posture. 



Lifting test. 



Terminal 
stage. 



Tapir 
mouth. 



Erb's type 



Peculiar 
complex. 



tensors, glutei, the lumbar muscles, the deltoid, the triceps and infraspinatus 
are excessively involved and become prominent and resistant yet weakness 
co-exists and is progressive* Placed upon the floor the patient passes through 
a succession of characteristic movements to regain an erect posture. 

When standing there is lordosis, the shoulders are thrown back, belly prom- 
inent and feet widely separated. The shoulder girdle, being greatly weakened 
and extremely movable, makes the arms abnormally long and if an attempt is 
made to raise the child by catching him under the armpits, 
one feels that the body is slipping down between the 
shoulders. 

The terminal picture is that of extreme atrophy and 
helplessness without fibrillary twitching or R. D. but asso- 
ciated with mental degeneration. 

Duration of the disease is from a year to two dec- 
ades or more, death occurring from intercurrent disease 
or inanition, and prolonged remissions may occur. 

Scapulo-humeral Muscular Atrophies. — The chief 
difficulty in diagnosis arises in differentiating between 
certain cases of the disease which present overlapping 
symptoms, it being sometimes impossible to assign a 
case definitely to a single division. 

In the facial type the first changes appear in the 
muscles of the face, particularly the orbicularis oris and 
extend to the muscles of the cheeks and forehead, affecting 
both expression and speech and producing what is known 
as the " tapir mouth." The extension to the general mus- 
cular system is downward. 

Erb's juvenile muscular dystrophy is charaterized by 
being distinctly a disease of youth, having its incidence 
usually at the age of puberty and within the age limit of 
twelve and twenty years (twelve to sixteen usually) and the 
fact that the muscles first involved are those of the shoulder 
girdle. In all forms late contractures are, of course, 
common, with the usual deformities. Fibrillary contrac- 
tion of muscle, reaction of degeneration, disturbance of 
sensation and reflexes are lacking until extreme atrophy 
and weakness have developed. 

MYOTONIA (Thomsen's Disease). — This is a disease of childhood, of 
the familial type, affecting chiefly the male, and very rare in this countrv. 
Occasionally cases of the acquired type may be encountered. 

Symptoms. — The characteristic symptom is a peculiar slowness of 
muscular contraction and relaxation, most marked in prehension and loco- 
motion. The hand closes slowly and awkwardly around the object, and re- 
laxation is equally deliberate. So in walking, the leg is slowly advanced 
and halts for a second or two, yet the awkward gait lasts for but a few steps. 

*In many of the muscles the enlargement is due merely to peculiar fatty deposits. 




Fig. 623. — Charac- 
teristic postural 
changes in pseudo- 
hypertrophic paraly- 
sis accompanying act 
of rising from floor. 
{After Gowers and 
Starr.) 



NEURITIS 



1267 



The laryngeal, ocular and facial muscles are rarely affected, the general 
musculature is well or unusually developed and out of proportion to the 
actual strength. As might be expected the electrical reaction of the involved 
muscles is deliberate, persistent, and often associated with vermicular con- 
tractions between the poles. The disease is essentially chronic and incur- 
able. 

MYASTHENIA GRAVIS {Asthenic Bulbar Paralysis. Erb-Goldfiam 
Syndrome). — This is a progressive loss of muscular power associated with 
rapid exhaustion under interrupted tetanizing faradic stimulation though 
not under galvanic {Jolly's " myasthenic reaction"). The loss of power 
affects first the muscles of the eye, face, jaws and neck, but may involve the 
entire body. The essential symptom is the rapid fatigue of the affected 
muscles, restored by rest, and this in connection with the peculiar electrical 
reaction, the transient nature of the symptoms, simulating paralysis, and the 
absence of true atrophy or fibrillary contractions makes the diagnosis easy. 
The disease is essentially chronic, but the mortality probably exceeds 50 
per cent. 

NEURITIS 

Etiology.- — Inflammation of the nerves may be single or multiple and 
due to toxemia, extension of inflammation, actual, germ invasion {leprosy), 
traumatism involving wounds, tears, concussion and torsion, pressure, and 
finally, to cold. 

The toxemias, whether due to mineral poisoning or acute and chronic 
infections, are often associated with polyneuritis, the acute infectious diseases 
most frequently observed being diphtheria, erysipelas and leprosy, and of 
minerals, lead, arsenic and mercury. Beri-beri is an acute disease of which 
polyneuritis is usually the predominant symptom. 

Fatigue with chilling or prolonged exposure to cold and wet is a common cause 
of both local and poly -neuritis; alcohol is also a potent etiologic factor. 

Symptoms. — Whether the neuritis be local or general, the symptoms are 
essentially the same, the differences being those of anatomic distribution. 

Pain is severe, boring or stabbing, and is associated with tenderness on 
pressure. It is usually most marked at the terminal points, but may be felt 
along the whole course of the nerve. Edema and congestion may be present over 
the same area, muscular power is impaired, motion is painful. 

Tactile sense is impaired or lost, formication and numbness are common, 
and actual paralysis follows, as does muscular atrophy, the skin becoming shiny, 
and the nails brittle and deformed. 

Where the larger trunks are involved the reflexes may be lost and the paralysis 
be typically flaccid. It must be remembered that all degrees of inflammation 
are encountered as is illustrated by the behavior of the muscles in relation 
to the electric current. In some cases reaction of degeneration is complete 
and prompt; in others the response is normal. 

"Neuritis" has become of late almost as much the mode as "lithemia" was 
i decade or two ago, but the greatest care should be observed in differentiating at 



Erb's myotonic 
reaction. 



"Myasthenic 
reaction." 



Simulates bul- 
bar paralysis. 



Infection, 

toxemia, 

traumatism. 



Fatigue and 
chilling. 

Alcohol. 



Pain. 



Tenderness. 



Trophic 
changes and 
reflexes. 



Severity 
varies greatly. 



Caution. 



1268 



MEDICAL DIAGNOSIS 



Multiple 
neuritis. 



Manner and 
extent of 
involvement. 



Prognosis. 



Foot- and 
wrist-drop. 



Prancing gait, 
in peroneal 
type. 



Peculiarities of 
localization. 



Diagnosis. 



Dislocation 
and crutch 
palsies. 



Pressure 
paralyses. 



least the pains of recurrent minor angina and the many cases of deltoid " bursitis " 
both of which, the latter especially, are mistakenly called neuritis in many 
instances. 

ACUTE FEBRILE POLYNEURITIS.— This is merely a primary multiple 
neuritis due to an unknown virus characterized by an acute febrile onset 
exactly simulating that of the acute infectious diseases, the temperature 
being high as a rule. 

Subsequently a typical neuritis symptom-complex develops, taking the 
form usually of an ascending paralysis of varying degree, most often com- 
mencing in the feet, less of ten in the arms. It may be limited to the extremities 
or affect the whole body even to the involvement of the diaphragm and other 
respiratory muscles. 

Death is common in the severe forms, but as a rule the patient recovers 
after an illness of a month or six weeks. Residual partial paralyses are frequent, 
but seldom persist for more than a year. 

Cases of this acute febrile type occurred with considerable frequency during 
the Great War just passed and two distinct types of onset were observed. 
In one the paralysis was preceded by an initial febrile attack of brief 
duration, in the other paralysis was the first symptom. 

In the former type an interval of from five to ten days elapsed between the 
initial illness and the onset of the paralysis. 

The cortex is spared and the virus expends its virulence Upon the spinal 
ganglia, the cord and the peripheral nerves. 

Recurrent Multiple Neuritis. — It would hardly seem that a separate 
place should at present be given to a polyneuritis distinguished only by 
a marked tendency to recurrence. 

Neuritis due to Alcohol, Lead or Arsenic. — In this form the onset is 
usually gradual and preceded by numbness, tingling and neuralgic pain. 
"Foot-drop" and "wrist-drop" are common features, giving rise in the former 
case to the prancing or steppage gait. 

In alcoholic cases mental symptoms may be present, but the history of the 
case usually points the way to a correct etiologic diagnosis, and it should be 
remembered that these paralyses chiefly affect the extremities, and that 
diphtheria shows a preference for the muscles of the eye and throat, lead for 
the extensors of the arms, arsenic for the legs and especially the peroneal 
group. The distinctions are, of course, often disregarded. 

The diagnosis, therefore, depends upon the association of mutiple neuritis 
with edema or marked cardiac disturbance in connection with the known preva- 
lence of the disease, or the past residence, or association of isolated cases. 

PRESSURE PARALYSIS.— It is hardly necessary to do more than call 
attention to the various paralyses due to compression of individual nerve 
trunks. The common musculo-spiral paralysis and circumflex paralysis, re- 
sulting from dislocation of the humerus, are the most common. The former 
also may result from crutch pressure, or pressure during deep sleep, especially 
"in the open," or from the position in which a patient is placed during a long 
operative procedure (see also "Brachial Plexus Paralysis"). 



von Recklinghausen's disease 



1269 



VON RECKLINGHAUSEN'S DISEASE.— This interesting condition is 
characterized by a generalized neuro-fibromatosis, producing a remarkable 
variety of pressure symptoms referred to all parts of the body, patchy pig- 
mentation of the skin and marked impairment of intellection. 

NEURALGIA.— See 'Tain." 

HERPES ZOSTER (Zona), (Shingles). — This disease is characterized 
by violent neuralgic pain along the course of the superficial cervical, thoracic^ 
sacral or abdominal nerves, or the branches from the Gasserian ganglion, asso- 
ciated with the appearance of crops of vesicles corresponding to the superficial 
nerve distribution and has its commonest seat over the lower thoracic of upper 
abdominal zone. 

It is commonly unilateral, but may be bilateral and is supposed to be 
due to an inflammation of the ganglion cells of the posterior roots. 

There is no disease which causes more exquisite pain and suffering, usually 
of a few days' duration, but sometimes extending over long periods, and further- 
more, troublesome ulceration may follow rupture and coalescence of the vesicles. 
The excessive severity and distinctly neuralgic or neurotic type of the pain and 
its distribution, together with the typical rash makes the diagnosis clear, but the 
pain may precede the herpes by many hours or even days and prove misleading, 
especially in the thoracic form. 

PERIODIC TRANSIENT PARALYSIS.— This curious ailment is 
strikingly hereditary, often traversing five or six generations, and is character- 
ized by the rapid onset of paralysis involving the arms and legs, or both, sparing 
the face, though sometimes implicating the regions supplied by the vagus 
and spinal accessory. There is no fever, a slow pulse, general diminution but 
rarely a loss of reflex, deep or superficial, and marked diminution of faradic 
excitability. These paralyses are transient, lasting for only a few hours as a 
rule, but are strikingly recurrent and periodic, diurnal cases being noted. Like 
migraine the periodic paralysis usually ceases at the age of fifty.* 

FACIAL HEMIATROPHY.— This incurable and obscure condition, most 
frequently developed in childhood, rarely in the adult, is a progressive atrophy 
involving all structures on one side of the face. It is peculiar in that it affects 
first the skin and superficial tissues, then the bone and lastly the muscles. 
Loss of the hair and teeth and hemiatrophy of the tongue and palate usually 
occur, but bilateral atrophy is rare and sensation and the electric response 
of the muscles is usually unaffected. It is probably not due to disease of the 
trigeminus and as is generally held should not be confounded with congenital 
asymmetry of the face. In direct contrast is unilateral facial hypertrophy 
in which every symptom is reversed. 

* The transitory paresis or paralysis is strikingly like that observed in infectious anterior 
poliomyelitis in association with the true permanent palsies. These we now believe to be 
due to the edema present in the affected cord. 

In view of the hereditary and neuropathic tendencies of both this ailment and angio- 
neurotic edema, and the fact that the latter is often strikingly familial and may come and 
go in the same irresponsible and disorderly manner, one might hazard the statement that 
a connection between these conditions is suggested. 



A curious 
syndrome. 



Usually 
thoracic and 
unilateral. 



Extreme pain. 



Delayed 
herpes. 



Recurrent, 
afebrile, tran- 
sient paralysis. 



Prognosis. 



Peculiar line of 
march. 



1270 



MEDICAL DIAGNOSIS 



Hiemal. 
Three forms. 



Exciting 
oauBes. 



Lividity. 
Gangrene. 



Necrosis 
limited. 

Sensation. 



Occasional 
symptoms. 



Malignant 
cases. 



Purely 
subjective. 



Usually trivial. 



PARALYTIC VERTIGO (Gerlier's Disease).— This is a form of transient 
paralysis occurring only, so far as known, in one Swiss town. 

Nuchal pain, clouded vision, paralysis or paresis of ocular nerves, unequal 
bilateral ptosis, muscular weakness, and vertigo are its chief symptoms. 

RAYNAUD'S DISEASE (Symmetrical Gangrene, Local Asphyxia)— This 
mysterious hiemal vasomotor affection of unknown causation assumes three 
forms: (1) local asphyxia, (2) local syncope, (3) symmetrical gangrene. Local 
asphyxia and local syncope in their mildest form may be seen in chilblains. 
In Raynaud's disease either emotion or trivial exposure to cold, or even gastric 
disorders are followed by coldness, pallor of the surf ace of the fingers or of both 
fingers and toes. After a variable period and in irregular order the affected 
members become sharply congested and perhaps livid. Stifness and discom- 
fort or even severe pain may accompany the swelling. Symmetrical gangrene 
varies greatly in degree, is rarely extensive, and usually a persistence of the 
extreme stagnation of the cyanotic stage results in superficial necrosis involving 
small areas or oftentimes but one finger or toe. Sensation, often diminished 
in the cyanotic stage, is lost over the gangrenous area which is black, icy 
cold and covered with blebs. The area of apparent involvement greatly 
exceeds that of actual necrosis. The ear is involved frequently, the tip of the 
nose occasionally, symmetrical areas on the arms, legs or trunk rarely. 
Cases of rapid, extensive and fatal gangrene have been reported and occur 
most often in children. Aside from the local symptoms there are no constant 
disturbances. Hemoglobinuria, transient loss of consciousness, mental 
torpor and delirium are occasionally observed.* 

Diagnosis. — The diagnosis depends upon the occurrence of symmetric local- 
ized syncope, cyanosis or gangrene without an assignable organic cause. 

ERYTHROMELALGIA — This rare condition unlike Raynaud's disease 
is essentially a summer ailment and is characterized by superficial congestion, 
swelling and burning pain in the feet or hands usually the former and worse 
at night, the pain being severe and increased by the dependent position. 
It is chronic and irregularly recurrent, often associated with headache and 
vertigo, and occasionally with Raynaud's disease. 

ACROPARESTHESIA.— This symptom-complex is closely allied to 
angio-neurotic edema and is characterized by itching, burning, prickling 
and pain in the fingers and toes. Heat, cold and injury are apparently 
causative factors; constipation and gastric disorders almost constant, and 
occasionally there is rigidity of the fingers. It is hardly worth separate 
classification. 

ANGIO-NEUROTIC EDEMA.— This vasomotor condition seems closely 
related to urticaria and, like it, is usually associated with digestive dis- 

* In one case observed by the author symmetrical gangrene of the ears of the hiemal 
type had resisted treatment for years, but recovered promptly when the cause was found. 
The patient was taking large quantities of morphin by the hypodermic method, the skin 
over large areas of the trunk and limbs being thickened and infiltrated through the use of a 
dirty syringe. As withdrawal was resisted the patient was told to take the drug by the 
mouth, since that time there has been no recurrence of the gangrene. 



EPILEPSY 



1271 



turbances. Exposure to cold and emotion may be associated with it, but 
it often appears without apparent cause. It is essentially a sudden and 
transient swelling, affecting usually the hands, feet, genitalia, or any portion 
of the face, rarely the lips, tongue or even the glottis where it may produce 
dangerous or fatal obstruction. As in Raynaud's disease associated hemo- 
globinuria has been noted. It may be periodic but is more often irregularly 
recurrent. The gastrointestinal symptoms may be severe and associated with 
vomiting and colic, or, extremely slight. Osier reports a case in which the 
whole arm was swollen. Aside from the rare involvement of the glottis the 
disease is as unimportant as it is obscure.* 

INTERMITTENT JOINT EFFUSIONS.— Closely allied to angio-neurotic 
edema is this rapidly produced but painless swelling of the joints. It lasts 
for only a few days, but is liable to recur. 

EPILEPSY. — This psychoneurosis depends to an extraordinary degree 
upon heredity, but in predisposed individuals may apparently arise from 
emotional shock, acute toxemias and sometimes from remote and purely 
reflex causes. One variety arises from direct irritation due to injury, recent 
or remote, or forceps injuries in childbirth. 

From the general etiologic viewpoint it may be (a) idiopathic^ arising 
from no assignable cause; (b) reflex; (c) toxemic; (d) secondary or sympto- 
matic; (d) senile or arteriosclerotic; (e) luetic. f 

One-half the cases occur in the first five years of life and it is so rarely a 
primary lesion in the adult after thirty as always to excite a suspicion of syphilis, 
arteriosclerosis, renal inadequacy and arterial hypertension, brain tumor, or, 
chronic alcoholism. 

Sex. — The incidence is nearly equal in the two sexes. Of inheritance it 
should further be said that it is not so much direct as it is equivalent (see 
"Alternatives in Heredity"). Parental intemperance, for example, is an 
important factor, syphilis and alcoholism common and direct causes. Attacks 
very similar to true epilepsy occur in arteriosclerosis, which condition probably 
accounts for the cases met with in old people. 

Divisions. — We speak of "major epilepsy" (grand mal), "minor 
epilepsy" (petit mal), "Jacksonian epilepsy," and "psychical epileptic 
equivalents." 

Grand Mal. — Aurce and various subjective sensations precede an attack. 
There may be auditory, visual, gustatory and olfactory paresthesias, dis- 
comfort in the epigastrium, intestines or rectum, or peripheral sensations 
usually referred to the hand. In other cases the aura is motor, the patient 
turning rapidly, running for a short distance or twirling about on the toes. 
The actual onset is sudden, sometimes preceded by the so-called epileptic 
cry. A fall is likely to produce injury, a matter of importance in differen- 
tiating hysteria, and, the condition is one primarily of tonic spasm, the patient 
being livid and usually in a distorted attitude; after a few seconds follows the 

* It strongly suggests an anaphylactic phenomenon. 

f Dr. C. A. L. Reed's interesting announcement of the Bacillus epilepticus has not yet 
received confirmation. 



Occasionally 
serious. 



Alternatives£in 
heredity. 



Age. 



Sex. 



Alternatives 
in heredity. 



Senile cases. 



Aurae. 



Onset. 



Seizure. 



1272 



MEDICAL DIAGNOSIS 



Tongue- 
biting. 



Incontinence. 



Increasing 
frequency. 



Nocturnal. 



Transient 
polyuria. 



Mental 
changes. 



Innocent 
exhibitionism. 



Convulsions 
absent. 



Curious mani- 
festations. 



Petit mal 
reversed. 



Motor tract 
spasms. 



Peculiar and 
important. 



stage of clonic convulsions, at first slight, but increasing rapidly in violence 
and affecting the ocular and facial muscles as well as those of the body and 
: extremities. The patient froths at the mouth, is likely to bite the tongue, 
or pass urine or fecal matter involuntarily. The duration of this stage is 
variable, but it seldom lasts over two or three minutes and is followed by coma, 
succeeded by a deep sleep lasting for several hours if undisturbed, the 
patient wakening with slight mental confusion or perhaps headache. The 
attacks vary greatly in frequency, usually tending to increase with the lapse of 
I time. They may occur only at night and the patient may be and often is, 
entirely unconscious of their true nature, a point to be remembered in case 
taking.* In the so-called "status epilepticus" there is fever, rapid respira- 
tion and increased pulse rate, accompanying a succession of attacks without 
persistent unconsciousness. The reflexes are sometimes absent, more often 
increased and accompanied by ankle clonus. The urine if not passed during 
the attack as is usual, is passed in quantity after it. Post-epileptic paralysis 
and aphasia are occasionally seen but are ordinarily . transient. In repeated 
seizures mental deterioration may be marked and post-convulsive mania may 
assume a dangerous form and become of medico-legal importance in murder 
cases. So also these unfortunates may be arrested for indecent exposure 
due merely to mental disturbances, characterized by various automatic 
actions of which the patient has no consciousness or recollection. 

Petit Mal. — This interesting condition lacks the convulsive features of 
epilepsy, though in a majority of instances grand mal develops, either wholly 
replacing or alternating with the minor attacks. Amongst the various forms 
may be mentioned simple incoherence, acts of automatism, usually of short 
duration, sudden falls, with or without transient loss of consciousness, sudden 
jerkings, tremor or subjective sensations of various sorts, mere interruption of 
conversation, and what appears to be a peculiar absent-mindedness. During such 
attacks the patient is likely to turn suddenly pale, there may be fixation of 
the eyes and relaxation of the grasp but aurae seldom occur. All of these 
acts are wholly lost to the patient's recollection. 

Jacksonian Epilepsy. — This is the reverse of petit mal, consciousness 
being retained early in, or throughout, the attack and convulsive seizures present. 
One must admit possible sensory equivalents but direct cerebral irritation is 
nearly always present. The spasms are usually orderly and follow motor areas 
of the cerebrum, but may be limited to one tract such as the face and leg. Partial 
epilepsy, moreover, often becomes general with the lapse of years, old injuries, 
tumor, meningitis, cerebritis, uremia, abscess, hemorrhage and sclerosis 
are the usual causes and post-hemiplegic epilepsy is of this type. 

Epileptic Equivalents, Psychoses. — Hallucinations of hearing, narcolepsy 
(profound sleep), and, possibly, certain cases of somnambulism, seem to 
replace the convulsive stage of epileptic seizures, and in some instances, 
certain moral deficiencies are also prominent, often amounting to an entire 

* In many such cases there is nothing to mark the attack in the morning but a slight 
persistent injection of the facial capillaries, the patient feeling perfectly well, with unclouded 
mind. 



CHOREA 



1273 



change of character or the development of traits or habits abhorrent to the 
patient in a condition of health.* 

Differential Diagnosis. — If an attack of major epilepsy be seen little 
doubt can be entertained as to its nature, though only by an examination of 
the urine can uremic convulsions be positively differentiated. Hysteria offers 
many difficulties, but is seldom accompanied by tongue-biting, involuntary 
passage of urine, and never by the absolute unconsciousness presented by the 
epileptic. Hysterical patients choose a safe place to fall and the movements 
are usually disorderly and to a certain extent purposeful and struggling rather 
than jerking; moreover, the duration of the hysterical attacks is longer and 
often promptly relieved by sharply applied pressure over the ovaries. 

J acksonian epilepsy is unmistakable, though its cause may be obscure; petit 
mal, often beyond the range of absolute diagnosis, its recognition depending upon 
the coincidence of transient unconsciousness, vertigo, and perhaps automatism. 

CHOREA 

(St. Vitus's Dance, Sydenham 's Chorea) 

Etiology. — Within the past few years some remarkable discoveries have 
been made which bear quite directly upon the etiology of Sydenham's chorea. 

Now, one can conscientiously abandon the older views and adopt that 
of intection without binding himself to any microorganism at present vaunted 
as fons et origo malorum. 

It would seem that the true agent of infection is more likely to be found 
through a study of the activities of the bacteria composing the tonsillar, 
adenoid, and peridental bacterial flora than by attempts to recover the causa- 
tive agent from tissues which yield little or no evidence of decided or specific 
anatomic changes. 

Certainly, if one may draw inferences from personal experience the author 
must favor the theory of cryptogenetic focal infection, the most striking re- 
sults he has encountered having followed the removal of chronically infected 
adenoids and tonsils. 

The belief that it represents the reaction of a delicate, high strung, over- 
worked or undernourished organism to the chronic or recurrent toxemias of 
this origin is wholly in accord with the author's limited experience, and ap- 
parently expresses the views held at the present time by a large number of 
clinical and laboratory workers. f 

* The author finds it difficult to credit the assertion so frequently made that either 
somnambulism or "night terrors" should be regarded as epileptic equivalents. . Certainly 
a host of children, who pass through phases of night terrors and somnambulism alike, show 
absolutely no signs of either epilepsy or its "equivalents" in adult life. He also feels that 
the statement, recently encountered, that sudden attacks of angina-pectoris, asthma, actual 
syncope and the like may be so classified, merely because no readily demonstrable cause is 
apparent, is wrong. Nearly all of these are either direct or reflex circulatory phenomena. 
Etiologically, epilepsy is itself a mystery, and can hardly claim the right to take over phe- 
nomena so readily explainable on the basis of known circulatory mechanics. 

f D. J. McCarthy in a very scholarly, conservative and convincing article in Osier's 
"Modern Medicine," defines it as ''due to the effect of an infectious agent or its toxin." 



Uremia 
and hysteria. 



Etiology. 



1274 



MEDICAL DIAGNOSIS 



Rheumatism. 



Precocious 
children. 



Unwise 
parents. 



Secondary 
factors. 



Age and sex.. 



Heart disease. 



A clean-cut 
clinical picture. 



Varieties. 



Misunderstood 
clumsiness and 
"badness." 



Speech, gait. 



Rare mental 
symptoms. 



Heart signs. 



The clinical relationship of rheumatism, rheumatic endocarditis and peri- 
carditis to chorea is too intimate to be dismissed and the concurrences too 
common, but they need not force one lightly to as yet accept the Micrococcus 
rheumaticus as the cause and chorea itself as " cerebral rheumatism." 

Inherited vulnerability may then prove to be the explanation of the 

assumed but ill-proven "hereditary tendency." Precocious, delicate, ex- 

! citable children are peculiarly liable to the disease, especially if, as is so often 

I the case, they are pushed ahead in their studies or encouraged to develop 

! unusual mental traits at an unduly early age. 

Overforcing and depressed nutrition are the chief predisposing factors in 
chorea, and the elements of shock, worry, grief, etc., are merely important as 
tending to increase preexisting vulnerability. 

Seizures due to reflex irritation are rarely seen but may occur in connec- 
tion with various conditions affecting the gastrointestinal tract, sexual 
organs and yet oftener as a result of naso-pharyngeal adenoid growths* 

The disease predominates in females between the ages of five and fifteen, 
is less often seen in the well-to-do, and bears an interesting relationship to rheu- 
matism and a yet more direct one to heart disease. 

It is certain that about two-thirds of the active cases show valvular murmurs 
and that practically all of the fatal cases show actual organic valvular lesions, 
chiefly of the mitral type, but it is by no means proven or even rendered prob- 
able that either embolism or heart disease is the cause of chorea. 

Symptoms. — Involuntary, incoordinate, characteristically jerky movements, 
unilateral or bilateral, localized or general, and associated to a varying degree 
with excitability and emotional disturbances, characterize chorea. 

Though difficult to describe, it is never forgotten when once seen, nor does 
it offer any difficulties to the diagnostician save in its rarest forms. Accord- 
ing to its severity, we recognize a mild and severe form, to which may be added 
a third, the chorea, associated with delirium (maniacal). 

Premonitory symptoms take the form of increased nervous irritability, 
perhaps unusual wilfulness, and a general restlessness. As the irregular 
J movements begin, the apparent clumsiness of a child, associated perhaps 
'with unusual disobedience, may bring about undeserved punishment which 
may precipitate the attack. The face and arms are most commonly involved, 
but in severe cases the whole body may participate. Disturbance of speech 
occurs in about one-fourth of the cases, varying greatly in degree and the 
facial grimaces and jerking, incoordinate and bizarre movements of the ex- 
tremities involved are absolutely distinctive. If the legs be affected, a peculiar 
jerky hitching gait appears, and there may be motor weakness in the leg or 
arm. Occasionally there is crossed chorea, still more rarely one encounters 
the most severe type, maniacal chorea. Mental disturbances of marked 
degree are unusual yet intervals of delirium or temporary hallucinations 
sometimes occur. Practically all of the other associated symptoms would 
seem to be dependent upon rheumatism and endocarditis as concurrent 
factors. The heart symptoms are chiefly those of functional or organic mur- 
* Probably because of the double factor of chronic irritation and toxemia. 



DIFFERENTIAL DIAGNOSIS 



1275 



Cutaneous 
signs. 



murs, the latter being present in about 50 per cent, of all cases and two- 
thirds showing a murmur of some sort. The ordinary hemic murmur with its Murmurs 
maximum at the second pulmonary interspace is common, but of little 
moment, and other functional murmurs may be associated with the accelerated 
heart action almost invariably present. The common murmur is systolic and 
apical and the differentiation between the functional and organic lesion must 
depend upon the application of the usual diagnostic rules. Evidence of sec- 
ondary dilatation and the presence of a loud harsh well-conducted murmur in- 
dicate an organic mitral lesion. Arsenical pigmentation may occur,* but fever, 
purpura, urticaria and joint symptoms have probably no direct relation to 
the disease itself, but rather to the underlying causative infection and 
toxemia with which it is so commonly associated. 

Course. — Although showing a distinct tendency to recurrence (50 per 
cent.), the individual attacks seldom last over two or three months, though 
rarely they may extend over years, particularly the slighter manifestations. 
The death rate during the attacks is almost negligible. 

DIFFERENTIAL DIAGNOSIS.— It should be remembered that chorei- 
form movements are increased by excitement or obstruction, entirely cease dur- 
ing sleep, whether natural or produced by drugs, and, that neither sensibility 
nor, usually, reflex activity is affected. Chorea electrica is merely a variant of 
chorea proper, characterized by lightning-like movements. 

Huntington's chorea is hereditary, appears usually during the third decade 
and is characteristically constant and progressive. Mental deterioration is 
marked and it usually progresses to terminal dementia. The movements them- 
selves are slower, the gait more swaying and the disease should have a single 
descriptive name, t 

Friedreich's Ataxia. — Nystagmus, scanning speech, scoliosis, talipes, the 
slow movements and clear evidence of heredity make the diagnosis clear. 

Hysteria. — Rarely, cases may exactly simulate chorea, but usually the move- 
ments are less jerky and irregular, more rhythmic and there are associated 
stigmata which make the diagnosis easy. "Rhythmic chorea 1 ' of hysterical 
origin produces orderly movements of the muscle groups involved, for example, 
the salaam convulsion. 

CONVULSIVE TIC {Habit Spasm).— This usually takes the form of 
localized facial spasm associated with head movements or the raising of a 
shoulder, though often the spasm affects only the eye or the mouth, or more 
commonly both. It is a somewhat common, transitory and unimportant 
condition. 

GENERALIZED IMPULSIVE TIC (Gilles de la Tourette Disease).— This 
is characterized by involuntary facial, brachial or general muscular movements, 
often violent, in association with marked disturbances of speech and sometimes of 
mentality. Articulation is explosive even to incoherence, mimicry may be 
present, usually in the form of repeated utterance of words heard or of actions Mimicry 



Hereditary 

chorea. 



* If that drug is pushed strongly over long periods. 

* It is variously described as "megrim," "megrum," 
adult hereditary" and "chronic" chorea. 



senile," "chronic progressive," 



1276 



MEDICAL DIAGNOSIS 



The 
"tarantella." 



Bread crum- 
bling tremor. 



Rigidity. 



The mask-like 
face. 



Attitude, voice 
and speech. 



Festinant gait. 



Propulsion and 
retropulsion. 



A disease. 



seen, or, the frequent repetition of obscene words may accompany the spasm. 
The mental disturbances are similar, taking the form of obsessions or fixed ideas. 
Every action may be associated with an impulse to count to a certain number or 
to touch a certain object. 

PANDEMIC CHOREA.— This group of diseases, more closely allied to 
hysteria than chorea, is chiefly of historic interest, although rare instances 
are seen at the present day. The tarantella of the composer was suggested 
by the remarkable religious manifestations epidemic during the middle ages. 
These were characterized by the wildest excitement, violent gesticulation, 
and dancing and leaping to the point of exhaustion. 

SALTATORY SPASM.— This is a transient or chronic condition charac- 
terized by sudden violent contraction of the leg muscles upon any attempt to 
stand. Marked mimicry of words and actions may be present, and 
heredity plays a part. 

PARALYSIS AGITANS {Shaking Palsy, Parkinson's Disease).— Occur- 
ring more frequently in men than in women and seldom under the age of 
forty this disease possesses no definite etiologic factors, nor has it any 
characteristic pathology unless it be a premature senility of a cerebro- 
spinal type. 

Symptoms. — The chief symptoms are tremor, rigidity, weakness and a 
peculiar attitude and gait. The disease, though insidious, is easily recognized 
when fully developed. The tremor chiefly affects the hands and feet, thumbs 
and forefingers showing the so-called "pill rolling" motion; the toes are less 
involved, the chief tremor in the lower extremities being in the ankle-joint, 
and head nodding, if present is usually vertical, more rarely rotatory. Emo- 
tion increases tremor; voluntary movement may or may not check it, and 
it is absent during sleep. Rigidity is shown in slow and aw r kward movements, 
and .weakness may be the earliest symptom but often appears only after 
exertion. The face is immovable and expressionless, the eyebrows raised, and 
the attitude and gait become characteristic as the disease advances. The 
patient stoops with bent head, with the arms held away from the body and flexed 
at the elbow and the fingers bent. The voice is high-pitched and the speech 
curiously hurried though perhaps primarily hesitating. In walking festina- 
tion is observed, the stooping patient apparently trying to overtake his center 
of gravity (Trousseau) and if thrust backward the same short hurried steps 
are taken and the patient will fall if not supported. 

Diagnosis. — The developed disease is unmistakable and a diagnosis 
may be made on the basis of rigidity, weakness and attitude alone. It could 
be confounded only with post-hemiplegic tremor from which the history will 
usually at once distinguish it. 

HYSTERIA. — The fact that one is dealing with a genuine, deep-seated, 
though inorganic pathological state should never be forgotten in relation to hys- 
teria, and further, that it is equalled only by syphilis in the protean nature of 
its manifestations. 

It is perhaps unfortunate that a field of medicine which has shown such 
wonderful results from scientific experiment and painstaking rational inves- 



HYSTERIA 12 77 



tigation should still retain a problem such as "hysteria" to keep alive 
in the domain of etiology the purely speculative and theoretic method. 

The great number of theories, no less than their extreme subtlety, com- 
plexity and inconclusiveness, make any attempt to consider or discuss them in 
a book of this kind wholly futile. Furthermore, as Jeliffe says, "at the pres- 
ent time there are hardly two neurologists agreed as to what shall be con- 
sidered as stigmata or essential features of the hysterical phenomena."* 

"Another feature concerning the revaluation of symptoms and one of the 
most difficult to adequately present, is simulation. Unconscious simulation, 
if there be such, and aggravation are not included here. These are features 
of what must be termed the hysterical mentality. Simulation as here 
restricted is probably rare, yet it is constant and serves to discourage careful 
study of many deserving patients." 

11 Before attempting a systematic presentation of the symptoms of the hysterical 
reaction a few remarks may be made regarding the value of this motley collection 
of observations in which real fragments are mingled with those born of credulity 
and mental laziness. The golden period of hysteria which reached such a high 
point as a result of the stimulus of the Charcot teachings has been followed by one 
of analysis in which the careful sifting of the enormous material has become an 
imperative necessity. One of the first striking facts of this reexamination is the 
astonishing frequency of mistakes in diagnosis." 

"Thus, the tubercle bacillus has shown the real character of many here- 
tofore diagnosed hysterical hemoptyses; gastric chemistry has similarly 
relegated many intestinal disorders into their proper position; microscopic 
and cryoscopic methods enable one to determine the essential features of sup- 
posed hysterical hematurias; methods of blood examination have reduced 
the number of hysterical fevers almost to a minimum." 

"In the field of the paralyses, hemiplegias, monoplegias, paraplegias, etc., 
mistakes have been especially frequent. With the newer signs of organic 
involvement of the nervous system many organic disorders are recognized 
which, heretofore, were called hysterical, and are even called so at the present 
time in their early stages. Literally thousands of sick individuals suffer 
from complaints which a lazy diagnosis dubs hysteria. The falsity would be 
revealed by a searching and intelligent analysis." 

"One knows that for Janet, anesthesias, amnesias, abulias, paralyses and 
changes of character represent the stigmata, while under the head of acci- 
dents, he groups hysterical attacks, somnambulism, subconscious acts, and 
fixed ideas, whereas Babinski claims that careful examination shows that 
anesthesia never exists, and between these one finds all possible variations. 
Some authors lay great stress on restriction of the visual fields, others prac- 
tically deny its existence." 

" Inasmuch as anatomy teaches the absolute interrelation of nervous struc- 
tures within the entire human body, it is an idle distinction to say that hys- 
teria is a psychosis or a neurosis. Splitting the difference by calling it a 

* The attitude of Dr. Jeliffe is so rational and his statements so illumining that further 
quotation seems justifiable. 



1278 



MEDICAL DIAGNOSIS 



Heredity and 
early training. 



Harmful 
sympathy. 



Proper 
treatment. 



psychoneurosis simply implies that the nervous adjustments of the different 
parts of the body, one to another, as well as the adjustment of the individual 
as a whole to his environment, show various types of disturbances called 
hysterical symptoms." 

"Hysteria is a general tendency to certain reactive expressions. The 
difficulty in description is an evidence of the instability of the concept, its 
width, and its fluctuating outlines. There lies in every person the possibility 
of the hysterical reaction, and it all depends either on the stimulus. or the 
change in the resistance to bring it out.'' * 

The clinical field of hysteric phenomena is steadily narrowing as accuracy in 
diagnosis increases. 

There can be no doubt that many who are termed " hysterics" are merely 
grown-up " mother's darlings" and "papa's pets" and, too often, the mother 
or father is of the same basic temperamental type and hereditary influences 
must be considered. 

One cannot doubt the possibility of inherited emotional instability 
or lability and in the tainted individuals who are so exquisitely sensitive 
that any reproof brings floods of tears, whose passionate outbursts seem to 
be hung on hair-triggers, but who turn quickly from anger to passionate self- 
reproach and assuage by impassioned bursts of affection the hurt they 
may causelessly have inflicted, are very likely to be treated as special 
creations set apart from and above wholesome discipline. 

In many families, mother, father and the more stable and unselfish 
brothers or sisters are made slaves to the whims, caprices, and childish moods 
of the tainted family member, and instead of wholesome discipline there is 
found the constant but futile endeavor to avoid offense and to substitute 
harmful sympathy for wholesome correction. 

Heredity and early training, or rather the lack of it, are extremely important 
factors in hysteria, for wholesome discipline and wise control go far to counteract 
congenital faults of temperament. Indulgence of whims, the development 
of the emotional side by excessive sympathy, the failure to demand of the child 
or young adult self-control and consideration for others are factors that can 
seldom fail to create an hysterical temperament, even if the body is not relatively 
feeble, the intellect precocious and the neuropathic hereditary taint marked. 

In such persons psychic instability, intense, yet variable, over-reaction to 
stimuli, lessened will power, and increased suggestibility usually are evident 
early. 

On the other hand, the condition, when once developed, must not be 
regarded as one depending upon the unassisted volition of the individual, or 
wholly subject to his or her control, but rather as an actual acquired psycho- 
neurosis to be ameliorated, and perhaps removed, by suggestion and a com- 
plete control which, though kind, is firm, persistent, insistent and lacking in 
every element that enters into the upbuilding of the hysterical temperament. 

With this must be combined the correction of actual organic disorders 
and the upbuilding of the patient's nutrition when this is lowered. 

* Osier's Modern Medicine, Vol. V, 1915. 



HYSTERIA 



1279 



Age, Sex and Race. — The disease occurs for the most part between the 
ages of fifteen and twenty, and almost exclusively in women, cases of hysteria 
in the male being the rare exception in this country. It rarely occurs in 
children under ten and adults over sixty. Southern races yield many exam- 
ples as compared with the more Northern. 

Relation to Disease. — 77 is found in combination with and apparently as a 
result of actual disease far more frequently than is usually supposed, malnutri- 
tion and anemia, lead and arsenic poisoning, unrecognized dyspepsias, gastric 
or intestinal, reflex irritation, naso-pharyngeal obstruction, or diseases of the 
pelvic organs, movable kidney, chronic appendicitis and unrecognized gastric 
ulcer being some of the exciting causes encountered by the author. 

We generally err about as often one way as the other, failing on the one hand 
to recognize an underlying organic cause in certain cases, and on the other 
construing pure hysteria as the organic disease which it simulates. 

Furthermore, actual malingering or simulation is not a rare cause of mistaken 
diagnosis. 

Sexual excess or sudden deprivation in certain instances is most important, 
though the hysterical woman is usually sexually indifferent and the genesic 
sense may be abolished through anesthesia of the vagina and clitoris. 

Symptoms. — These may be present in almost any portion of the body 
and consequently almost any disease may be simulated. Motor symptoms 
may be paralytic, paretic or spasmodic. Paraplegia and monoplegia are 
more common than hemiplegia. Paralysis is usually incomplete, muscles 
may show disuse atrophy, but the electrical reactions are normal, the knee-jerks 
seldom diminished, usually increased and equal, and a paralyzed leg is 
usually dragged limply along. Urinary retention may be seen, true inconti- 
nence never, true ankle clonus is absent, pseudo-clonus sometimes present; 
aphonia is frequent but the paralysis is seldom complete. Ptosis is usually 
double, often with an overactive orbicularis, but the muscles of the eyeball 
are seldom affected, though conjugate deviation rarely occurs. Both tonic 
and clonic spasm may occur, particularly after injuries and both paralysis 
and spasm may be associated with anesthesia. Pseudo-contractures, persisting 
during sleep but disappearing under general anesthesia, and fine tremor or 
regular and irregular muscular contractions and even edema are encountered. 
Hystero-epileptic seizures' are common among the Southern races, but their 
differentiation is seldom difficult, though their various phases (i.e., prodromal, 
epileptoid, clownism, passional, delirious), may vary greatly in intensity or 
appear in an isolated form. Hyperesthesia is especially marked in the hysteric 
zones, i.e., the hypogastrium and lower spinal and inframammary regions, but it 
may be visual, auditory or olfactory. Anesthesia and more often, analgesia may 
be associated with loss of response to heat and cold and impaired muscle sense. 

Both motor and sensory paralyses affect the left more often than the right 
side, but sensory symptoms may involve the entire body, including the mucous 
membranes and in hemianesthesia they are characteristically limited by a sharply 
defined border representing the median line of the body. The stocking, garter, 
glove, sleeve, or drawers' leg forms are seen, as are irregular or disseminated 



Young women 
chiefly. 



Often associ- 
ated with 
organic 
ailments. 



Sexual factors. 



Hysteric 
stigmata. 



Contractions 
rather than 
contractures. 



Some form of 
anesthesia 
seldom absent. 



I28o 



MEDICAL DIAGNOSIS 



A difficult 
problem. 



islets of anesthesia conforming to neither nerve nor segment distribution while 
they may capriciously shift their seat or boundaries after a seizure or without 
apparent cause. They may also take the form of concentrically contracted 
visual fields, usually unequal and sometimes unilateral, or of hysterical 
color vision. The loss or perversion of special senses and loss of sensation is 
actual and not imaginary in all true hysteria, and the patient is usually uncon- 
scious of the latter. Absolute blindness or deafness is rare and monocular 
diplopia is a rare symptom. Mental symptoms range from mere hysterical 
laughing and crying, to amnesia, loss of will power, impressionability, som- 
nambulism, and even the simulation of actual insanity. The pharyngeal 
reflex is lost in 90 per cent, of the cases of hysteria as is frequently the plantar 
reflex. Auto-hypnotism and catalepsy are among the rare conditions, the 
reflexes being lost in the latter condition. 

Diagnosis. — Most cases are evident to any well-trained clinician, but in 
those simulating organic disease of the spine or cord some difficulty may arise. 
The normal or increased knee-jerk, absence of urinary incontinence and true 
ankle clonus, the normal electrical reactions, absence of true atrophy, and the 
active resistance of spasmodic contractures, i.e., the evident active resistance 
offered the examiner's hand, are quite unlike true spastic contraction. The 
onset of symptoms is, moreover, generally coincident with some violent emotion, 
shock, or injury. The disappearance of contractures during anesthesia or 
sound sleep is also important and the minor seizures may instantly disappear 
under sharp ovarian (hypogastric) or supraorbital pressure. Disseminated 
sclerosis presents oftentimes a strong resemblance, but in that disease tremor 
is absent or markedly lessened when the patient is at rest, whereas it is con- 
tinuous in hysteria. 

Prognosis. — The prognosis in any case depends upon two factors: 
the ability to undergo a proper course of treatment and the physician's 
success in obtaining the cooperation of sensible and intelligent family 
members. 

In many instances surgical or medical treatment directed to the cure of under- 
lying organic disease or the removal of reflex irritation completely removes the 
symptoms, but, in many more, unwise surgery creates havoc. 

TRAUMATIC HYSTERIA.— (The Traumatic Neuroses of Oppenheim) 
(" 'Railroad Spine," (C Railroad Brain"'). — No more difficult task presents 
itself to the physician than that involved in an opinion regarding the effect 
of injuries as represented by purely subjective or indeterminate objective 
symptoms and too often involving a large element of unconscious or deliberate 
deception. To. do justice alike to an injured individual and the harassed 
and much bled corporation is at times well nigh impossible. 

Important Features of Traumatic Cases.— Aside from out-and-out malin- 
gering one may encounter one of four reasonably distinct clinical types, 
viz. : (1) Those in whom a pure nervous depression is manifest. (2) Individuals 
markedly and genuinely hysterical. (3) Cases exactly resembling the first two 
groups, but developing after a variable period actual disease of the brain or cord. 
(4) Cases of manifest injury. 



TRAUMATIC HYSTERIA 



I28l 



Psychically Depressed Type. — This differs in no particular from ordinary 
mental depression save that the morbid introspection relates to the accident 
and its supposed effects. 

Hysteric Type. — This is merely a psychasthenia* with hysteric stigmata 
added, the emotional side being pronounced. 

Symptoms Commonly Presented. — Headache, insomnia, vertigo, subjec- 
tive weakness, mental and nervous irritability and instability are marked, 
mental depression is common and may attain actual melancholia. Pain in 
the back is almost invariable, the reflexes are increased and the impaired 
digestion and lack of appetite, together with the mental depression and 
anxious, drawn countenance, often lend a misleading facial element of suffer- 
ing, emaciation and pallor. The tongue is usually coated and constipation 
is common. Numbness and tingling may be present in either the hysteric, or, 
using the word in its literal sense, the psychasthenic types, but in the former 
may co-exist with either a mere limitation of the visual fields or an achroma- 
topsia. A marked hysteric or emotional tremor is not uncommon. The 
pupils are often dilated and may be slightly unequal. 

Circulatory disturbances are common and tachycardia, marked cardiac irri- 
tability, arrhythmia, and vasomotor disturbances often persist for long periods. 
Subjective sensations of heat and cold, flushing, excessive perspiration or 
recurrent sweats, variations in the urinary secretion and .the like frequently 
occur. Menorrhagia, amenorrhea, sexual psychasthenia and loss of memory 
may be added to the long list of symptoms usually representing purely 
functional disturbances. 

From personal observation the author believes that no line can be drawn 
between "traumatic neurosis" and traumatic psychic depression or hysteria, 
for while at times cases arise that fit the syndrome first named, in many others 
there is a blend of signs that hopelessly blurs any sharply drawn boundaries 
and the element of deliberate or unconscious exaggeration too often fostered 
by alarmist opinions and vague theories on the part of the oversympathetic 
physician pervades and weakens the whole diagnostic structure. 

He also doubts the frequency of " traumatic neuroses, " so-called, after trivial 
falls and injuries when not connected with claims for damages, and has many 
times found them properly attributable to preexisting organic disease of the heart, 
blood vessels, kidneys or nervous system. 

In those predisposed to or actually suffering from physical or psychic 
instability or hysteria those conditions may readily be excited or intensified 
by slight trauma or excitement. There are probably but three actual condi- 
tions, viz.: (1) Genuine injury to and actual lesions of the brain or cord. 
(2) Pure asthenia with psychic depression or hysteria, and (3) pure or adul- 
terated malingering, usually for revenue. 

The diagnosis must depend upon the discovery of symptoms purely sub- 
jective or of the psychasthenic or hysteric type on the one hand, or definitely 
objective upon the other. Lacking objective signs after several months, 
one is reasonably certain that the case will recover after settlement. Only in 

* Using the word in its direct and literal sense. 
81 



Clinical types. 



Psychasthenic 
and hysteric. 



Physiognomy. 



Paresthesias. 



Tremor. 
Pupils. 



Heart. 



Trivial injury. 



How 
explained. 



Actual 
conditions. 



1282 



MEDICAL DIAGNOSIS 



Prognosis. 



Evident 
exaggeration. 



Sprains, 
fractures, etc. 



the presence of the signs of organic disease is the physician justified in a lugu- 
brious prognosis on or off the witness stand. In fully 80 per cent, of such 
cases, examined by the author, in which suit was pending, the element of 
exaggeration was evident. In hardly any of those injured in a similar 
manner but without liability on the part of a corporation have there been any 
symptoms save those of direct injury such as bruises and sprains, neither has 
the pain in these been persistent over long periods even in the cases associated 
with great primary mental shock save in exceptional instances. 

Indeed it must plainly appear to anyone experienced in these matters that 
the after-symptoms in genuine railroad injuries are remarkably out of consonance 
with the degree of mental shock experienced at the time. 

Finally there is the group of cases which are truly surgical or relate to 
actual visceral lesions and of fracture of the vertebrae, sprains, hemorrhage 
into or about the cord, myelitis and meningitis, and are directly diagnosticable. 
though in rare and deplorable instances the delayed development of organic 
disease may result in an injustice to some honest claimant. 

MOUNTAIN SICKNESS.— This is an ailment which attacks mountain 
climbers or travelers in high altitudes whose circulation is weak, who are 
unhabituated and unacclimated or are generally out of condition. 

It represents oxygen shortage in the blood due to diminished oxygen- 
tension in the pulmonary alveoli and cardiac overstrain and may last for 
a period varing from a few days to two weeks. 

No one who has visited high altitude resorts or indulged in mountain 
climbing can doubt that cardiac overstrain of itself is largely responsible for 
many such seizures. 

Symptoms. — The chief symptoms are cardiac arrhythmia with or without 
decided dilatation, dyspnea, cyanosis or cyanotic pallor, hurried respiration, 
headache, vertigo, syncopal attacks or a tendency to nausea and vomiting. 

Death occasionally occurs in coma. 

All gradations of such disability may be encountered. 

With the rapid increase in red blood cells and hemoglobin characteristic 
of high altitude acclimatization the symptoms gradually disappear. 

AVIATOR'S SYNDROME.— The European war has served to bring 
prominently into view certain disturbances related largely to rapid transition 
from low to high altitudes. 

The disturbances experienced by balloonists have long been known but 
are far less frequent and decided because of the relatively gradual ascent and 
descent and the lack of special demands upon the physical strength and 
mental alertness of the operator. 

The modern aviator, and especially he who plays his part on the battle- 
fields or in scouting expeditions, is under tremendous strain, mental, physical, 
and oftentimes, emotional. 

It follows that few or none escape symptoms referable to these factors, 
quite apart from those due to mere demands upon endurance of the effects 
of cold. 

These are chargeable only in part to mere altitude, which in itself may 



THE INTOXICATIONS 



1283 



seriously embarrass the respiration, markedly accelerate the heart or, at 
extremely high levels, produce syncope, but for the greater part, represent 
the effect of rapid rise (increased oxygen demand) abrupt descent, and the 
extraordinary nervous tension inseparable from such flights. 

Mechanical interference with the action of the diaphragm by a distended 
stomach or intestines must be a decided factor in the production of dyspnea. 

High altitude flights must involve enormous fatigue due to oxygen short- 
age and cardiac weakness even under the compensating increased pulmonary 
ventilation attained through rapid breathing, yet high altitude nights are 
repeatedly made over long distances. 

The commonest of the symptoms experienced after their return by 
army aviators would seem to be (a) profound fatigue, (b) drowsiness, suc- 
ceeded, perhaps, by high nervous tension and insomnia, (c) vertigo, (d) 
rise in blood pressure, (e) precordial oppression and palpitation, (/) headache 
of the congestive type. 



THE INTOXICATIONS 

SUNSTROKE 

(Thermic Fever, Insolation, Siriasis) 

Etiology. — Great heat with decided humidity is the chief factor in both 
heat exhaustion and sunstroke. Mere exposure to the sun does not cause it, 
the highest degrees of heat being borne in the western deserts of the United 
States with less liability to sunstroke than would be experienced at a much 
lower temperature on the seaboard or in a marshy district. Furthermore, it 
occurs both night and day, indoors and out of doors. Physical exhaustion, 
lack of food or water, an unsound heart or kidneys, the overuse of alcoholics 
and especially actual intoxication at the time of exposure, are important con- 
tributive factors. 

If one might assume that inadequate heat dissipation is associated with 
excessive heat production due to exhaustion of inhibitory centers and that at 
autopsy an extensive pulmonary, cerebral, hepatic, and renal congestion is 
present, these assumptions would suffice to explain the symptoms, but unfor- 
tunately the former remain hypothetical and the latter are inconstant findings 
at the post-mortem section. 

Symptoms. — There are preliminary vertigo and oppression with high fever 
(105 to ii2°F.) and a "burning" skin followed by sudden coma or decided 
stupor with or without a convulsion sometimes preceded by brief delirium. 
The facies is that of apoplexy without paralysis, i.e., lividity and cyanosis, 
stertorous breathing and pupils fixed in contraction until exitus approaches. 

Death may occur within a few hours or even minutes unless measures of 
relief are promptly instituted and the mortality probably exceeds 30 per cent. 
Relapses are not infrequent and the "stroke" may be followed later by men- 
ingitis. The after-effects endure for years in the shape of discomfort on 



"Sunstroke". a 
misnomer. 



Physical 
condition. 



Rational 
explanation. 



Coma. 
Hyperpyrexia. 

Facies. 

Mortality. 
After-effects. 



1284 



MEDICAL DIAGNOSIS 



¥aiike 
sunstroke. 



exposure to unusual heat and humidity or actual attacks of heat exhaustion 
or sunstroke. This acquired vulnerability is recognized by all life insurance 
companies. 

Differential Diagnosis. — The extreme high temperature at or even before 
the onset excludes even pontine hemorrhage and at once rules out uremia, 
alcoholism, diabetic coma and opium poisoning. 

Convulsions may occur and tetany or actual total paralysis may exist in 
some cases but the high initial fever and burning skin of siriasis (sunstroke) 
are sufficiently distinctive. 

It must be remembered that albumin and casts are quite commonly found. 

Warning Signals. — In countries where sunstroke is prevalent men recog- 
nize the not uncommon occurrence of certain premonitory symptoms which 
may give warning several hours at least before the actual attack. 

Among these Manson enumerates — profound general malaise, pains in the 
arms and legs, vertigo, drowsiness, mental confusion, abnormal thirst, 
anorexia, photophobia, chromatic visual aberrations, nausea, precordial 
anxiety, a sense of impending calamity, emotional instability, a hot skin and 
rapid pulse. An extremely curious and common precursor is excessive 
irritability of the bladder (Longmore). 

It is commonly believed that a sudden checking or marked diminution of 
perspiration is a warning signal. 

SUN TRAUMATISM.— The cases grouped by Manson under this head 
seem to be due probably to modified true sunstroke on the one hand, and pre- 
existing ailments of various kinds and degrees upon the other. They would 
seem to cover cases of sudden death under exposure to a hot sun in relation 
to which, diagnostically, a Scotch verdict must be rendered. 

HEAT EXHAUSTION.— This condition which is essentially a state of 
more or less complete collapse though entire unconsciousness may or may 
not be present, is characterized by a cold skin, profound pallor, a subnormal 
temperature, sweating, and is wholly unlike sunstroke. 



ALCOHOLISM 



Acute. 



Smeak 
drinkers. 



ACUTE AND CHRONIC ALCOHOLISM.— The weU-known effects of 
large potations need not be described, yet many mistakes arise in connection 
with the unconscious or stuporous stage. It should be remembered that in 
acute alcoholism the pupils are usually dilated, the individual can be partially 
roused by pinching the inner side of the upper arm or thigh, that the tempera- 
ture is normal or more frequently subnormal, the breathing deep, slow, but 
rarely stertorous. The fact that the breath is alcoholic is important, but 
far from conclusive evidence. 

The symptoms of this condition may be patent to any layman, or entirely 

i absent. The face of the sot requires no description here, but quite as great 
destruction may be going on in the tissues of one of his fellows whose habits 

' may be wholly unsuspected, even, as happens in rare instances, by his family 
members. A certain spree drinker of the author's acquaintance has for years 



ALCOHOLISM 



1285 



left home at regular intervals, gone to a hotel, quietly passed into an alcoholic 
stupor only to arise in the late forenoon of the following day, take a Turkish 
bath and proceed with the business of life. Such is the sneak drinker. 
Others drink openly and boisterously, yet others, quietly, continuously and in 
a routine way without themselves suspecting the formation of any habit or the 
creation of secondary diseases. The kind of stimulant taken is important: 
pure beer and good wines are the least injurious; absinthe, brandy, whiskey, 
and gin the most harmful. The poisonous sophisticated liquor so generally 
sold in low groggeries is peculiarly pernicious in its effects, and the drinking 
of strong or mixed liquor on an empty stomach so common in this country is 
an unmixed curse, fostered by the " treating" habit. 

Visceral Alterations. — Digestive System. — Chronic gastric catarrh fre- 
quently associated with hepatic cirrhosis is a common sequence. Gastric 
dilatation in beer drinkers, and the coated tongue and foul breath of the heavy 
drinker of stronger liquors is well known. 

In the kidneys the chief change is found in simple transient congestion, 
though interstitial nephritis is undoubtedly promoted by the drinking habit. 

The lungs seem to be rendered more vulnerable to bronchitis and tuber- 
culous processes, and the circulatory system shows a tendency to myocardial 
degeneration and arteriosclerosis. 

In the nervous system both general and local changes may occur, the morn- 
ing depression, mental irritability, impaired concentration and quickness of | 
perception, failure of memory, and a decided change in the moral character, 
being common and well-known manifestations. Recurrent or persistent 
tremor, especially marked in the morning hours, and even transient or per- 
sistent delusions may occur (Korsakoff's psychosis). 

Korsakoff's Psychosis. — This represents a curious combination of alco- 
holic polyneuritis and memory defect. 

The latter takes the form of an almost total failure to record and retain 
recent events, together with a sort of dream memory of past events which 
takes the form of pseudo-reminiscences often of a most bizarre character. 

Hallucinations may occur and the usual course is one of progressive men- 
tal defect. 

If recovery occurs the individual's true personality usually is lost or sub- 
merged even though outwardly and in casual relationships no change is 
perceptible. 

Alcoholic neuritis is described elsewhere. Alcoholic epilepsy is a curable 
form occasionally encountered and the so-called "wet brain" and its symp- 
toms have been described under "alcoholic meningitis." One of the unfor- 
tunate results of the early morning malaise, impairment of digestion and 
mental depression is the fact that it largely or wholly disappears if a brisk 
stimulant is taken and thus the vicious circle is maintained. 

Delirium Tremens {Mania a potu). — This condition is invariably as- 
sociated with chronic alcoholism; never with the spree of an habitually temper- 
ate person, however prolonged the lapsus. In the chronic drinker it may 
result either from some excess or from sudden withdrawal, and is frequent 



Unconscious 
drunkards. 



Sophisticated 
liquors. 



A vicious 
custom. 



Cirrhosis. 



Renal lesions. 



May simulate 
"paresis." 



1286 



MEDICAL DIAGNOSIS 



Tremor, 

insomnia, 

depression. 

Delirium. 



Hallucinations. 



Restraint 
required. 



Mode of death. 



A common 
error. 



Recurrence. 



in such persons following an accident, surgical operation, or some great 
emotional shock. Its association with acute disease and especially with pneu- 
monia of hard drinkers is well known to clinicians. 

Symptoms. — One of the first evidences is tremor associated with a marked 
depression, restlessness, and insomnia, which leads to increased potations. 
Within twenty-four or forty-eight hours or even less an active voluble delirium 
appears, and sooner or later the well-known hallucinations known vulgarly 
as "the horrors." Friends become enemies seeking to deprive him of life 
and liberty; the commonest noises are misinterpreted; imaginary snakes, 
rats, or other animals surround him, and he is in a constant and pitiable 
state of terror. Such patients need to be watched and usually restrained, 
though seldom dangerous save to the furniture and themselves. The tremor 
of the tongue and hands is extremely marked, there may be a fever of mild 
degree, insomnia is constant and the disease subsides by lysis in three or four 
days unless death occurs from exhaustion and heart failure. 

The frequent existence of cardiac dilatation, Bright' 's disease, or some serious 
internal injury and the tendency to the development of pneumonia in these 
cases should never be forgotten. This is particularly true of those seen in 
public service, who have been brought in by the police. 

Indeed apex pneumonias are not infrequently associated with a delirium 
closely simulating that of alcoholism. The fact that 10 per cent, or more in 
such services die, emphasizes the importance of the ailment and the frequency 
of complications alike. Recurrence follows continued excessive drinking 
and usually shows an increased severity and higher mortality. 

Morphin and Cocain Habits. — These topics have been briefly discussed 
under "Case-taking." 

CHRONIC LEAD-POISONING 

(Plumbism, Saturnism) 

Certain Etiologic Factors. — The relation of occupation to lead poisoning 
has already been discussed. 

Accidental contamination of drinking water by lead is common through 
faulty plumbing, the use of cosmetics and hair dyes and the adulteration or 
faulty preparation of foods and beverages. It is claimed that females are 
more suspectible than males, and adults more than children. Oddly enough 
a seasonal influence is noted. Not only is more water ingested during the 
summer and early autumn, but, if, as is usually the case, the community 
supply comes from peaty districts, the acid condition of the water tends to 
increase the degree of its contamination. 

Symptomatology.- — The chief lesions represent peripheral degenerative 
neuritis and, aside from rare cases of anterior cornua degeneration, the brain 
and spinal cord are spared, though marked cerebral symptoms are sometimes 
observed. Peculiar features of peripheral lead paralysis are the preservation 
of sensation and the extraordinary frequency of musculo-spiral paralysis. 
The kidney and gastrointestinal tract are also frequently affected. 



CHRONIC ARSENICAL POISONING 



1287 



The most characteristic symptoms are : (a) The "blue line" on and within 
the margin of the gums unaffected by the toothbrush and representing a black 
sulphid of lead deposited in the papilUe. It may be faint, stippled, and blue- 
black, and when present is almost pathognomic. The inner surface of the 
gums as well as the outer should be examined in all cases. 

(b) Colic. — A violent diffuse spasmodic abdominal pain unassociated 
with tenderness and relieved by pressure is a common and characteristic 
symptom. There may be associated diarrhea and persistent dull pain 
between the paroxysms. 

High-tension pulse and vomiting are sometimes observed and should 
suggest uremia from interstitial nephritis or lead encephalopathy.* 

(c) Paralysis. — If paralysis ensues, the arms are most often affected, 
usually bilaterally, occasionally unilaterally and the nerves of both arms 
and legs or of the whole body may be involved, but the tendency is to limitation 
to muscle groups. Hence we distinguish a musculospiral variety associated 
with "wrist-drop" in which the supinator longus is usually spared, a peroneal 
type (10 to 15 per cent, of cases) involving the common extensor of the toes 
and that of the big toe and associated with foot-drop and the steppage gait, 
and a brachial type bilateral, and involve the brachialis anticus, supinator, 
tongue, biceps, deltoid, and occasionally the pectoral muscles. An Aran- 
Duchenne type is interesting because of its resemblance to the first stage of 
"progressive muscular atrophy," the paralysis involving the small muscles of 
the hand and producing wasting in the thenar and hypothenar regions. 
The laryngeal form is rare and consists of an adductor paralysis. Various 
combined palsies may be noted and general paralysis may be either of a gradual 
or rapid development, in rare instances simulating Landry's disease. 

It should be remembered that sensation is usually preserved, a certain amount 
of early pain may be present, atrophy is marked, the reaction of degeneration 
present and, in the forearm, tremor is commonly encountered. 

(d) Cerebral Symptoms. — Hysterical manifestations, coma, convulsions, 
transient delirium, and temporary or permanent insanity are occasionally 
encountered usually associated with arterial hypertension. 

(e) Anemia is usually present in the form of a secondary anemia of vary- 
ing degree and basophilic degeneration of the red cells is constant in, though 
not peculiar to, lead poisoning. In no other disease, however, do they appear 
in such large numbers. Wright's staining method best shows these peculiar 
cells. 

(/) Arteriosclerosis and interstitial nephritis are common accompaniments 
of chronic lead poisoning and the examination of the urine for lead is not only 
important, but indispensable in many cases for the differentiation of the dis- 
ease. This is especially true of those varieties which exactly simulate an 
anterior poliomyelitis. 

CHRONIC ARSENICAL POISONING.— The symptoms of acute poison- 
ing are essentially the same as those of cholera morbus with excessive 
abdominal pain and are described elsewhere. 

* See also discussion under "blood pressure." 



The blue line. 



A misleading 
symptom. 



Paralysis. 



Types, 

musculospiral 
and peroneal 



Aran- 
Duchenne. 



Laryngeal. 



Motor chiefly. 



Anemia and 
basophilia. 



Renal and 
vascular signs. 



Often 
unrecognized. 



1288 



MEDICAL DIAGNOSIS 



Gastric signs 

and 

malnutrition. 



Sallowness 
a nd puffy eyes : 



Chronic poisoning possesses a complex symptomatology most baffling 
and misleading unless the case history suggests poisoning by arsenic. 

Anorexia, nausea, intermittent diarrhea, attacks of colic or abdominal 
discomfort are the usual gastrointestinal phenomena. 

Chronic bronchitis may occur, as may weakness, emaciation, and joint 
swelling. The nervous symptoms range from those of pronounced " neuras- 
thenia" to neuralgia or actual multiple neuritis. The only symptom in any 
way characteristic is the yellowish-brown pigmentation of the skin, observed 
in advanced cases, and puffiness of the eyelids. 

Arsenical paralysis differs from lead palsy only in its tendency to involve 
the legs oftener than the arms. 

PTOMAIN POISONING AND FOOD POISONING.— It is evident 
that one must distinguish between the poison inherent in the food itself, 
whether affecting all or only certain persons, and poisons introduced by 
accidental contamination in manufacturing processes, and finally, the poisons 
due to putrefactive alkaloids (ptomains). Under the first class we find 
a large number of articles which are inherently and generally injurious, such 
as that caused by certain fish in tropical countries and the mussel poisoning, 
which, however, is due to a known ptomain, mytilotoxin, which produces 
rapid pulse, dilated pupils, numbness, and a cold surface. Death results 
from collapse in about 25 per cent, of the cases. 

BOTULISM. — This type of food poisoning has assumed great prominence 
of late years and is due to a specific bacterial toxin derived probably from one 
of two strains (A and B) of the Bacillus botulinus. This microorganism was 
reported in 1896 by Van Ermengem, who described it as a large, spore-bear- 
ing, anaerobic bacillus. It measures from 2 to 6 microns in length and from 
0.5 to 1.2 microns in width. The usual arrangement is in pairs, end to end, 
but in some instances it forms chains. The ends of the individual bacilli 
are rounded and during spore formation they may be either racket-shaped or 
spindle-shaped, according to the position of the large oval spore at the end 
or in the middle of the bacillus. They are slightly motile, sparsely flagellated, 
Gram positive, and readily take the ordinary stains. 

The bacillus is readily cultivated in ordinary media and antitoxins 
have been prepared and are in use which are thought to be of value in 
treatment. 

Symptoms. — In botulinus poisoning the symptoms appear usually in 
from 16 to 48 hours after the poisonous food is ingested, though there are 
instances in which the first effects have been manifest within a much shorter 
period, this being in some cases reduced to 3 or 4 hours. 

The cases which develop early usually show profound gastrointestinal 
symptoms, namely, nausea, vomiting and purging; the last condition, 
however is likely to be followed by an obstinate constipation, and this may 
be the primary condition so far as the intestinal tract is concerned. 

If prodromal symptoms are present they are usually merely those of 
headache, vertigo, and a certain amount of gastric uneasiness or actual 
distress associated with more or less profound lassitude. 



IKc.OTISM — PELLAi;R\ 



1289 



Eye Symptoms. — The eye symptoms are of peculiar interest in that they 
may play a very important part in the symptomatology. Fundamentally 
they seem to depend upon an impairment of accommodation and an early 
attack upon the third cranial nerve. In some instances there is a complete 
paralysis of all the extrinsic eye muscles; vertigo, nystagmus and photophobia 
may be marked, and marked pupillary changes may be associated with 
ptosis of the lids. 

Throat Symptoms. — Constriction of the throat is a relatively early symp- 
tom and difficulties in speech may result both from impaired immobility of 
the tongue and a partial paralysis of the laryngeal muscles and of those of 
the pharynx. Difficulty in swallowing may be marked, and complete 
aphonia may ensue. 

General muscular weakness is usually profound but true paralysis does 
not occur. Sensation is usually unaffected throughout and the mind is 
usually clear though the patient may become apathetic and ultimately 
stuporous, or, in fatal cases, comatose. 

All secretions are usually diminished. The mouth is dry, little or no fluid 
can be ingested during the severer stages of the seizures, and the urinary 
output is usually diminished markedly. 

The temperature is seldom raised above the normal unless a broncho- 
pneumonia supervenes, and as might be anticipated, sub-normal readings are 
the rule. 

Respiratory symptoms are usually absent until a fatal termination is near, 
when there may be a very marked dyspnea or even Cheyne-Stokes breathing. 

Mortality. — It is impossible to give accurate figures with relation to 
mortality in cases of botulism as it seems to vary widely in different epi- 
demics, in some instances reaching 50 per cent, or more. 

Note. — Within the past few years several important instances of botulism 
have occurred in the United States and the mortality figures have been high. 
One of the most recent instances was that which occurred at a country club 
near Canton, Ohio. Of 200 people attending a banquet there were 14 cases 
of botulism due to the eating of infected ripe olives, and of these 14 cases, 
7 proved fatal. 

A still greater mortality ratio was reported by Sisco in 1920 as occurring 
in an Italian family in the Bronx, New York City. In this instance seven 
of eight family members ate the ripe olives and all died. 

* ERGOTISM is a well-known form due to the fungus, claviceps purpurea, 
which produces extensive epidemics due to the use of contaminated grain, 
the symptoms being either tonic, cramping, spasms, enduring hours or days 
and characterized by flexion of the arms, extension of the legs. Marked 
mental symptoms amounting to actual insanity and epilepsy may terminate 
the convulsive attacks. A second form is characterized by gangrene of the 
toes, fingers or, more rarely, nose and ears, preceded by muscular spasm of 
lesser degree, anesthesia, paresthesia, and pain. 

PELLAGRA. — This disease of the country rather than the city has been 
recognized for more than two centuries in Southern Europe and occurs also 



An ancient 
disease. 



1290 



MEDICAL DIAGNOSIS 



in Egypt, Algiers, and Mexico. It is probably an infection, though formerly 
held to be caused by a poison contained in decomposed or fermented corn 
(maize) whether used as a food or in the form of a stimulant of which it is 
the basis. Both the nature of the infective or toxic agent and its exact mode 
of origin and development are as yet unknown. 

Of late the disease has been steadily extending its area of incidence and 
many thousands of cases have been reported from the southeastern portion 
of the United States* together with lesser groups of isolated cases in widely 
separated localities. 

Recently it has been estimated that between the years 1902 and 1920 
500,000 cases with 50,000 deaths have occurred in the United States. 

Adults between the ages of twenty-one and forty-five are chiefly affected 
and negroes are especially susceptible. 

Symptoms. — The primary symptoms comprise general malaise, constant 
cerebro-spinal pain, mental dulness, pallor, a peculiar staring facies, progres- 
sive emaciation, irritability and insomnia, together with a patchy and varying 
erythema lasting for a few weeks only to disappear and leave behind a rough 
skin stained light sepia. The other symptoms last through the winter, while 
the spring is associated with the full development. 

This takes the form of marked dyspepsia, both gastric and intestinal, 
more or less severe diarrhea or actual dysentery and a peculiar remitting .but 
progressive erythematous rash affecting the exposed surfaces of the body 
and followed by desquamation. This dark red rash is particularly well 
marked on the neck and hands and blanches under pressure. 

The palms of the hands are usually free and as the period of desquamation 
approaches the deep red becomes gradually a livid blue. 

The skin finally becomes thinned and lifeless and the course of the 
eruption may be varied by vesiculation, suppuration, fissures, or the forma- 
tion of crusts, or take on a macular form. 

Summer brings a remission, the following spring or, in our own country, 
the fall, a relapse, and finally a cachexia appears, associated with disorders 
of the special senses and of the mind, spastic paralysis of the legs associated 
with atrophy and contracture, normal superficial reflexes and increased knee- 
jerks. 

Cerebrospinal pain is intense, associated with troublesome paresthesia 
and maddening hyperesthesia. Anemia and emaciation are profound. 

Diagnosis. — The combination of the skin lesions, gastrointestinal dis- 
turbances and seasonal variations make a striking combination. An acute 
form is rarely observed which may simulate typhoid fever or meningitis. 

Prognosis. — The disease lasts for a decade or more and furnishes a con- 
siderable proportion of the cases of insanity encountered in Italy. As might 
be expected the autopsy often shows chronic exudative meningitis, and occa- 
sionally, hemorrhagic sclerosis of the posterior and postero-lateral columns, 
and degeneration of the peripheral nerves. 

* Alabama, Mississippi, South Carolina, Tennessee and Texas have shown a heavy- 
death rate. 



MALINGERING 



1291 



BERI-BERI. — This peculiar endemic epidemic neuritis causes a large 
mortality in Asiatic countries, is especially prevalent in the Malay Archi- 
pelago and a few important cases are encountered in this country usually 
from South American and West Indian ports or among fishermen on the 
Newfoundland banks. The specific cause is unknown, but Baron Takaki, 
Japanese Surgeon-General, found that a marked diminution in the incidence 
of the disease followed the withdrawal of raw fish from the diet, and the sub- 
stitution of unshelled for shelled rice.* 

The Vitamin Doctrine. — A vitamin is a substance belonging to a 
chemical group of unknown composition "present in small quanities in 
certain foods and essential to normal metabolism." 

In rice, for example, in the process of removing the husk and polishing 
the grains the pericarp is removed and with it a part of the alurone 
layer. It would seem to be established that this process involves the loss 
of a vitamin, indispensable to the entire prevention of Beri-beri in a popu- 
lation depending largely upon rice for food. 

Symptoms. — The symptoms are chiefly those of neuritis of greater or less 
severity. Edema is an important symptom varying from that of the slightest 
degree to a general anasarca. Palpitation and dyspnea are also marked symp- 
toms, varying greatly in severity. A somewhat arbitrary classification is 
based upon the factors above named, there being a "mild form," in which all 
symptoms are slight, a "wet or dropsical" variety in which edema is the pre- 
dominant symptom, a "dry form" characterized by predominant paralysis 
and relatively slight edema and a "pernicious form" in which extreme 
cardiac decompensatory symptoms predominate. 

MALINGERING 

Until medicine becomes an exact science the physician will do well 
to give the benefit of any doubt to the supposed malingerer and avoid meas- 
ures savoring of harshness or cruelty, or the giving of injurious testimony 
in a court of law, save when the case is cleai and the imposture of a particu- 
larly barefaced or injurious nature. 

The chief sufferers from feigned diseases are railway, street car, and 
accident insurance companies, but the evil extends to the army and navy 
pension bureaus, and even to the home, and every physician must meet with 
numerous cases whatever may be his line of practice. 

No one class of diseases has any monopoly of this form of deception, 
though the nervous system lends itself most readily to the needs of the im- 
postor, while, on the other hand, presenting more traps and pitfalls and, 
in certain directions, more difficulty in simulation than general diseases. 

The basis of the most serious types of malingering or imposture is the 
dollar and the lengths to which people will go in their attempts to defraud 

* Shortly after the Russo-Japanese war Baron Takaki stated to the author that the 
mortality and incidence of this disease in the fighting forces was thus reduced to an almost | 
negligible factor. 



Baron Takaki's 
work. 



"Mild", "wet," 

"dry" 

and pernicious 

forms. 



1292 



MEDICAL DIAGNOSIS 



Malingering 
extraordinary. 



Suggestive 
facts. 



accident insurance companies especially is almost incredible. For many 
years these companies paid a large indemnity for the loss of the left hand and 
the number of claims incurred was so great as to lead to a reduction of the 
indemnity by one-half, following which the claims of this class fell off over 
80 per cent. 

Men will deliberately shoot themselves or place a hand or foot under the 
wheels of a moving train for the sake of the small amount of money repre- 
sented by accident indemnity and similar examples of self-mutilation are 
found in the countries where military service is compulsory or in the case of 
soldiers tired of service and desiring a discharge; the common form being 
formerly the mutilation of the trigger finger as furnishing the readiest and 
slightest injury incapacitating for active service. 

The minor frauds in this connection are consequently encountered by 
every physician and the unscrupulous man with an unrecognized but readily 
sprained flat-foot or the still more fortunate possessor of a shoulder or hip 
that he can dislocate at will is reasonably sure of realizing something from 
his infirmity. 

Furthermore, as is now well known, certain outlaw attorneys and equally 
unscrupulous physicians of the large cities form a criminal class known 
as " ambulance chasers." Such scoundrels will not only follow up cases of 
injury and suggest lawsuits, but will furnish witnesses ready made, sworn 
physicians' statements of any desired character, and any other bit of crim- 
inal machinery needed in the given case. 

A Curious Case of Simulated Injury. — Among the many instances of 
professional malingering one will suffice for illustration. A certain individual, 
following the usual custom of the expert criminal, took one special fine as his 
own and the street car companies as the objects of his attack. His pro- 
cedure was simplicity itself; he would enter a street-car carrying a cane which 
bore on its tip a screwdriver and while sitting in the car would quietly elevate 
a floor screw of the seat in front of him. Thereupon he would rise hastily to 
leave the car, ostensibly trip over the screw-head, and in falling receive an 
apparently severe and painful injury. He would then summon a carriage and 
be driven rapidly home where he would take a tack-hammer and after cover- 
ing the knee, elbow or ankle-joint with a few layers of cloth would pound the 
point selected until he had produced the necessary appearance of a severe 
joint injury, after which he summoned a physician. It is said that this went 
on for years and that the man received in damages from different corporations 
a very decent fortune. As regards deliberate mutilations of the more serious 
type, it should be remembered that the victims are usually urgent in their 
demands for amputation, frequently suggesting it and often insisting upon it. 
Such are usually holders of recently issued accident policies, and the mutila- 
tion is ordinarily just sufficient to come within the terms of the contract and 
seldom involves the most useful member; the left hand or foot being usually 
selected. 

Classification. — Disease or injury may be (a) wholly spurious and non- 
existent, or (b) actual, but either self-produced, factitious or deliberately exagger- 



FEIGNED STATES 1 2 93 

ated or aggravated, (c) the deception may be an innocent one due to a genuine 
belief in its serious nature on the part of the patient, which opinion is usually 
fostered by friends and family and too often by an over sympathetic physician or 
a shyster lawyer. 

SOME OF THE COMMONER FEIGNED STATES 

Anemia. — By taking a nauseating substance pallor is readily achieved, 
but the absence of anemia is readily demonstrated by testing the blood. 

Angina pectoris can be successfully simulated by one familiar with the 
subjective symptoms by taking drugs which produce a disturbed heart 
rhythm, swallowing tobacco to produce pallor and clammy skin, and then 
simulating the paroxysmal seizures. It requires, however, a good actor to 
deceive one who has seen the genuine attacks. The tobacco or other drugs 
may be taken by the rectum and palpitation may be caused by extreme 
compression of the abdomen; indeed, Herold states that hypertrophy may 
thus be induced, which statement we would beg leave to doubt. A normal 
or but slightly raised blood pressure would at once arouse suspicion of simu- 
lation. In nearly every case of true major angina pectoris so far tested by 
the author the arterial pressure has been very high. 

Most frauds of this type throw themselves about and produce a clinical 
picture which is the exact antithesis of the genuine one. 

Aphonia. — Here the one reliable test is the volubility of the patient 
during the stage of excitement or the after stage of recovery from an anes- 
thetic. No condition is more readily simulated. 

Asthma of the spasmodic type cannot be successfully simulated nor can 
the severer forms of dyspnea because of the absence of persistent cyanosis 
and the characteristic physical signs. 

Atrophy of the Extremities. — A certain amount of atrophy may be 
induced by long periods of splinting or disuse and increased by the use of 
tight bandages. 

Blindness. — Amaurotic blindness is easily feigned by instilling atropia and | 
is difficult to detect unless the patient can be thrown off his guard and care- 
fully observed for a considerable period. Simulation of blindness, however, 
usually involves one eye and is oftentimes a mere exaggeration of an existing 
though trivial defect in refraction. A pupil reacting normally to light ex- 
cludes most forms of blindness, but in all, the testing of the visual field will 
often reveal deliberate deception and a simple test consists in holding a 
pencil close to the sound eye and asking the patient to say when its tip is lost 
to his vision; he may still see it after it is passed well beyond the nose or deny 
seeing it while it is manifestly in the range of the normal eye. If asked to 
look at an object held in his own fingers a malingerer feigning total blindness 
will often pretend that he cannot get the direction of the object, while those 
actually blind will look at it, judging its position without hesitation. If a 
pencil is held between a book and the eye and double vision exists it does not 
interfere with the reading, but if only one eye is competent reading is impos- 
sible as certain words will be cut out. This is an excellent test because the 



1294 MEDICAL DIAGNOSIS 



pencil can be thus used without attracting the attention of the malingerer. 
It must of course be held close to the eye and motionless. Lenses make still 
more difficult any fraud in connection with unilateral blindness. If, for 
example, a strong prism is placed in front of a sound eye, base up, and brought 
gradually in front of the eye from below upward, double vision will occur 
before the base reaches the pupillary center, one image directly transmitted, 
the other refracted. This being admitted by the patient, the prism is 
gradually pushed upward so as to obscure the pupil, producing a single image 
for that eye, but if both eyes are competent a double image because of the 
different levels. If, therefore, a double image is still admitted, as is almost 
invariably the case, it proves vision in both eyes. Another test consists in 
using a 6 D convex glass upon the sound eye, thus reducing the range of vision 
and making reading possible only at 17 cm. or less. The patient is asked to 
read and the book gradually removed, when it will be found ordinarily that 
the range is greatly exceeded or variable. Still another test consists in intro- 
ducing a red glass before one eye and a green one in front of the other; the 
patient is then asked to look at Snellen's colored test types. Only the colored 
letters that correspond to the color of the glass in front of the eye can be read 
by that eye, and if one is blind unilaterally he will not even suspect the exist- 
ence of letters other than those read by the supposedly sound eye. This test 
may also be made by using an ordinary pencil and a red pencil to make the 
I written characters of the two colors.* 

Cancer. — By severe irritation of an existing sore in certain regions, such 

' as the breast or lip, or by attaching to the skin a section of the spleen a 

passable imitation of cancer may be attained, but the success of such impos- 

! tures seems incredible if any examination be made and the patient under 

proper observation. 

Catalepsy. — This is imperfectly simulated, as the maintenance of the 
forced postures characteristic of the true state is impossible, the arm or leg 
if extended soon tiring and dropping to the normal position. 

Cerebral Concussion. — This condition is often feigned, but it is only 
necessary to remember that the genuine lesion is associated with superficial 
respiration, pallor and moist skin and usually with nausea or vomiting. 

Chorea is in itself difficult to simulate and readily detected if the subject 
can be observed when awakened from a sound sleep, in which case he will 
for a moment forget his role. 

Consumption. — Only the stethoscope can unmask the skilful malingerer 
who chooses this ailment, and if, as frequently happens, there is actual 
bronchitis the exposure depends upon the absence of physical signs of infiltra- 
tion or cavity formation and of fever or bacilli in contrast to the patient's 
apparent condition, which is usually pitiable. The common method em- 
ployed consists of feigned cough, bloody sputum, obtained by pricking the 
gums or when opportunity offers (as in hospitals) mixing ordinary sputum 
with blood or pus, and emaciation, produced by abstinence from food, drink- 

* These tests are for the most part derived from Fuch's "Text Book of Ophthal- 
moscopy." 



FEIGNED STATES 1 295 



ing quantities of vinegar or chewing and swallowing large quantities of 
tobacco. 

Contractures. — Joint diseases with contracture or ankylosis offer an 
inviting field for the malingerer, but the joint in such cases is normal or 
becomes so if the patient is kept under observation and lacks implements and 
opportunity for producing fictitious lesions. Pain is frequently associated 
with the lesion and is often of such a nature as to at once expose the attempted 
deception. Muscular atrophy save that of disuse is lacking, the patient re- 
sists by evident muscular contraction attempts to move the joint and an 
anesthestic reveals motility and exposes the fraud. One simple method is 
often effective with this class, viz., having the patient stand and then sud- 
denly pushing him off his balance when the supposed crippled leg will 
usually be extended for support. Another method is to place the patient, 
standing on one leg, upon some high object, as a stepladder, the sound limb 
being slightly flexed; muscular fatigue will often force the patient to bring 
down the affected leg for support. Yet another consists in suspending a 
heavy weight over the contracted limb, and it soon yields to the steady pull. 
Another old procedure involves the use of an Esmarch's bandage, which, being 
tightly applied, prevents the muscular action which maintains the false 
contracture. 

Convulsions. — It is physically impossible to maintain for a long period 
the more violent convulsive movements and difficult to simulate correctly 
and in proper sequence those of the well-known types. Nevertheless, even 
epilepsy may be exactly simulated by one having a thorough knowledge 
of the true disease and willing to go to the extent of biting the tongue and 
passing urine during the paroxysm. 

Cutaneous Lesions. — These are readily simulated in many of their forms 
A simple mustard plaster will produce erythema and may be cut in any form 
desired; pustules may be caused by croton oil; blisters by cantharides. Ur- 
ticaria may be deliberately produced by eating certain substances known to 
produce them in the given individual (shell fish, strawberries, etc.). Pruritus 
offers no difficulties to the malingerer. Dermatitis and ulcer may be pro- 
duced by acids or caustics; gangrene, or the appearance of it, by constricting 
bands, and indeed nearly every skin disease, including alopecia, bromidrosis 
and chromidrosis, may be accurately feigned, but are of little consequence. 
Detection of most of them is easy if a fixed plaster-of-Paris dressing can 
be applied, the patient being then unable to keep up the necessary irritation, 
and in the case of simulated gangrene, stripping the patient will disclose the 
cause and close confinement and observation will result in a disappearance 
of the lesion. 

Diarrhea and dysentery both may be simulated, most commonly by mix- 
ing the fecal discharges with urine and adding blood from the finger or gums. 
Soap may also be employed and iron and bismuth taken by the mouth may 
add to the apparent abnormality. Such impostures ought never to be suc- 
cessful if a patient can be watched, as the evacuations can be received in a 
pan and directly inspected. 



1296 MEDICAL DIAGN 



Dropsy, Edema, Ascites. — Edema may be produced in an extremity 
by the use of a concealed ligature which, however, will leave its mark. 
It is even said that water has been injected directly into the peritoneal 
cavity. 

Dyspepsia. — Xo disease is more easily simulated, because of the pre- 
dominance of subjective symptoms in the real disease. The introduce 
of a stomach tube after a test meal, if accompanied by a positive statement 
as to the certainty of its findings, may reveal the imposture,, unless the simu- 
lator knows much of the vagaries of the disorders of digestion. Another 
successful method is the buttermilk cure with absolute rest in bed. and with- 
out means of diversion. 

Dyspnea on exertion can be clumsily simulated, but with normal heart, 
blood, lungs, and kidneys is disproved. 

Calculi and gravel are frequently simulated, most commonly by urinary 
sediments, which are usually readily proven to be street gravel, brick dust, 
cinders, or bone. In the female these substances are not infrequently actually 
introduced into the bladder or stored away in the vagina and used as occasion 
offers. 

Epilepsy. — As before stated, this disease can be, but is with difficulty 
simulated. It is employed by professional thieves and beggars, as it draws 
a crowd, diverts attention and excites sympathy. T;:e use of a \ 
snuff often suffices to expose the fraud, as will the injection of apomorphia 
and occasionally the actual cautery or a threatened operation. Marl 
improvement under the administration of sodium chloride, the patient think- 
ing that he is taking sodium bromide, may expose the supposed victim of 
chronic seizures. 

The Eye. — Diseases of the eye. aside from the blindness already mentioned, 
are readily simulated, a great number of irritants being ready to hand. 
In these cases the rapid onset of inflammation and its prompt subsidence 
after the withdrawal of the irritant exposes the fraud. Chronic inflammation 
as induced by beggars may be extremely difficult to detect and is often carried 
to the point of ulceration of tissue. 

Feigned Sleep. — It is said that in genuine sleep if the eye be suddenly 
opened, even in the presence of a bright light, there is transient primary 
dilatation of the pupil. 

Fever. — Save in actual hysteria, the simulation of fever is unsuccessful 
in the light afforded by clinical thermometers, but nothing is commoner than 
the use of the hot-water bag or a hot drink for the purpose of raising the 
temperature. Fever readings of any height are easily produced thus or by 
friction applied to the thermometer.* Chill is sometimes feigned, but the 
malingerer is found hot and sweating under his blankets from the warmth 
and from his own exertions. 

Fistula. — Anal fistula is readily and often successfully simulated by 
making a cut and treating it with some irritant, such as carbolic or one of the 

* In a recently observed private case a much-desired winter trip to the South was 
obtained bv this means. 



FEIGNED STATES 1 297 



strong mineral acids, but usually it is clumsily done and the imposture 
detected. 

Fictitious Wounds. — Aside from mutilation under accident policies, 
fictitious wounds are not uncommon in connection with false charges of 
assault or in the case of those who seek to disguise their own theft by the 
pretense of attack and injury at the hands of burglars. They are also em- 
ployed as a means of establishing self-defense in cases of actual or attempted 
homicide. The most significant factor in their detection is in the. com- 
paratively trivial nature of the injury, the fact that knife wounds are inflicted 
in the region most accessible to the hand commonly used by the individual, 
or, as is often the case, such cuts and gunshot holes are made in the clothing 
to intensify the appearance of a struggle, as should manifestly have involved 
the skin or body but do not. Attempted suicide by throat cutting with the 
razor or knife may be denied or concealed, but the characteristic incision 
obliquely downward and forward from the angle of the jaw on the side 
opposite the arm commonly in use is usually sufficiently characteristic. 

Fractures. — Simulated fractures can impose only upon ignorance and 
are absolutely exposed by the X-ray. 

Headache. — Feigned headache can hardly be detected with certainty, 
though close observation by the physician or nurse and the readiness with 
which sleep is produced may in some cases be important. 

Heart. — Save in the rare instances of inhibition of the heart action, cardiac 
ailments are simulated only by producing palpitation and changes in the 
pulse rate. Sly compression of an axillary artery or the use of a concealed 
ligature may produce unilateral weak pulse. Digitalis in full doses may pro- 
duce an apparent bradycardia, or, if pushed still further, an irregular and 
tumultuous heart action. Cardiac dilatation or hypertrophy, valvular 
murmurs and abnormally accentuated heart so unds are not readily 
simulated. 

Hemorrhages. — The commonest are those simulating hemoptysis, 
hematemesis, and hemorrhoids. The saliva may be clumsily covered with 
dyes, brick dust, etc., or, more commonly, mixed with genuine blood obtained 
by pricking the gums or fauces. If the symptoms of tuberculosis are absent, 
both as to fever and physical signs, a solution is relatively easy. 

Hematemesis may be simulated by pricking the gums and swallowing the 
blood which is afterward vomited, and constitutes one of the most difficult of 
all impostures for the medical examiner, particularly if associated with 
feigned pain by one having a knowledge of gastric ailments. The sources 
of anal hemorrhage are readily detected by local examination, further they 
result from cutting or pricking the parts or from the introduction of blood, 
the lesion being evident upon removal of the blood which shows no possible 
source for the hemorrhage. In some instances substances, such as inflated 
fish bladder, have been introduced to simulate hemorrhoids. They are 
readily detected by local examination. 

Hernia. — Inflation of the cellular tissue of the scrotum and in some in- 
stances voluntary retraction of one testicle have been employed, but the fraud 



1298 MEDICAL DIAGNOSIS 



is readily detected by the behavior of the supposed intestinal coil under 
manipulation or the absence of one testicle. 

Hydrocele. — Attempts to simulate this lesion by injecting water into the 
tissues of the scrotum are clumsy and unsuccessful and in any event readily 
detected by drawing off a portion of the fluid. 

Hydrocephalus. — Pseudo-hydrocephalus has been produced by the injec- 
tion of air into the cellular tissue of the scalp. The crackling on palpation 
and peculiar fascial distribution should at once excite attention. 

Hydrophobia is frequently simulated, but is usually greatly overdone and 
readily detected. 

Hysteria may of course be readily simulated, but is an absurdity. 

Incontinence of Urine. — This is oftentimes extremely difficult to detect, 
but it is frequently possible to make the circumstances surrounding it so 
embarrassing as to expose the deception'. The steady drip of overflow 
incontinence cannot be simulated if the patient is closely observed. 

Insanity.^— The following points may be of service in this frequently 
feigned disorder: Melancholia. A sudden onset with loss of memory and 
dementia at once proves the ailment spurious. Mania. A sudden onset 
lacking all relation between the surrounding and the patient's ideas, the 
relatively easily induced fatigue and natural sleep proves the falsity of 
the ailment. Maniacal Frenzy. Absence of a preliminary period of depres- 
sion and loss of memory of events just prior to the attack are the two chief 
signs of fraud. Paranoia. The feigned disease is indicated by the obtru- 
siveness of the assumed delusions, the usual evidence of a capacity to weigh 
and judge the effect of statements made and the lack of elaborately sys- 
tematized delusions. Paretic Dementia. A sudden onset, the absence of eye 
symptoms, the lack of true speech defects of the well-known type are sufficient 
to establish the deception. Loss of Memory. The radical error of impostors 
is their failure to observe the fact that in all forms of dementia the loss of 
memory is of the senile type affecting recent events, but not necessarily re- 
mote ones, often seeming to intensify those dating back to childhood and 
youth. In the less extreme form of genuine amnesia the memory remains 
for striking events, the very ones in fact that a criminal seeking to escape 
punishment will forget. 

Insanity is, moreover, extremely difficult to simulate and demands a 
knowledge of the various types, possessed by few. Not only is failure of 
memory usually exaggerated and often intermittent and inconsistent, but 
the facial expression is difficult to assume and the demands upon the simu- 
lator for deviations consistent in speech and action are seldom met. The per- 
son feigning dementia almost invariably pretends to have forgotten all events. 

Jaundice cannot be successfully simulated because of the impossibility of 
maintaining the yellow discoloration of the conjunctiva when supplies are 
cut off. Turmeric has been used to color the skin, HC1 added to the stools 
to make them clay-colored, rhubarb ingested to give the urinary color, and 
sometimes the eyes are deliberately inflamed to hide the deficiency in that 
region. 



FEIGNED STATES 1 2 99 

Joints. — See "Contractures," "Rheumatism" and "Limping." 

Limping. — Careful observation of a person using a cane or crutch may 
establish the fact that it is not being made a genuine support. Pretended 
fixation of joints is revealed by the use of an anesthetic and the absence 
of all inflammatory signs, joint crepitation, etc. ; will usually suffice to 
detect fraud. 

Lumbago may be successfully simulated and is the favorite form; fortu- 
nately the treatment ordinarily pursued is sufficiently heroic to make it of 
short duration. 

Ozena is said to have been feigned by the introduction of ripened, highly 
odorous cheese into the nostrils. 

Pain and Tenderness. — These are extremely difficult symptoms to 
detect the falsity of, being wholly subjective, yet if the patient be under close 
observation it is seldom difficult to expose the fraud. Few can carry on a 
conversation while the physician is examining the body and still be prompt to 
respond to pressure made with one hand over the supposed tender area while 
a more vigorous and obtrusive procedure is being carried on elsewhere with 
trie other hand. Furthermore, the administration of morphia may suggest 
fraud, either by the relief of pain afforded by a small dose or a spurious one 
or by the assertion of persistence of pain or tenderness after the administra- 
tion of full doses. Nearly all cases of this kind are overdone and the pain is 
referred to vague, indeterminate, shifting, or unusual locations. If, more- 
over such a patient can be examined during sleep, such as that produced 
by sulphonal or some other pure narcotic in moderate dose, it will be found 
that the tender areas do not exist and that the pain which should prevent 
sleep does not affect it. 

Exaggeration is usually so great as to reveal the imposture. 

Paralysis. — This condition can hardly be feigned with success if the 
examination be thorough and in competent hands. Its description would 
involve a rehearsal of the signs and symptoms of the paralyses resulting from 
the lesions of individual nerves or nerve groups and the different areas of the 
brain and cord, as well as the phenomena of hysteric paralysis. It may be 
well to remind the reader that in the last-named disturbance loss of sensation 
in the extremities stops sharply at the junction of the limb with the body, 
and if unilateral and of the trunk, is sharply limited by the median line and is 
likely to affect the entire side, including the face and scalp. Furthermore, 
the reflexes in this condition are likely to be bilaterally increased even though 
the paralysis is unilateral. Feigned anesthesia is best detected by the unex- 
pected application of the electric brush and it is impossible for a malingering 
patient to maintain the fixed boundary line of a true anesthetic zone, as first 
defined by a skin pencil according to his own responses, repeated examinations 
revealing marked variations. So also partial general anesthesia will almost 
invariably unmask feigned paralysis. 

A very simple device often successful when unilateral involvement of the 
extremities is asserted consists in pricking first one limb and then the other 
demanding that a prompt "yes" or "no" be given with respect to sensation. 



13OO MEDICAL DIAGNOSIS 



The unwary malingerer will answer "no" when the supposedly anesthetic 
limb is touched forgetting that he can feel nothing on that side. 

Peritonitis is often simulated, but seldom successfully; one of the most 
common lapses being a restlessness on the part of the patient, sharply in 
contrast with the fixed position assumed in true peritonitis; the true facies 
and pulse cannot well be simulated. 

Rheumatism can only be successfully feigned in its acute form by pound- 
ing the joints, and this is seldom carried to the point of producing any 
misleading resemblance. The fever and peculiar sweating are beyond the 
patient's resource if he is under observation, and the lesions rapidly fade. 

Retention of Urine. — This cannot be simulated if the patient is carefully 
watched. 

Sciatica. — This frequently feigned disorder is oftentimes readily detected 
by the clumsily described referred pain and points of tenderness. Few 
genuine cases lack maximum tenderness midway between the sciatic notch 
and the knee, even though the other points are insensitive. In the genuine 
disease, moreover, if the extended leg is flexed upon the pelvis, the pain is 
severe though the opposite movement causes little distress. In spurious 
cases the patient may walk upright though limping and feigning great pain 
and distress, whereas in the true sciatica the thigh is always more or less 
flexed and the body inclined forward. 

Scoliosis. — Feigned scoliosis is almost invariably dorso-lumbar, the spinal 
axis is not changed as in the true ailment, the skin is more markedly involved 
and the secondary compensatory curve is absent. 

Scurvy cannot be simulated except by deliberately taking mercury to the 
point of excessive salivation, and swelling of the gums otherwise seldom or 
never will be encountered. 

Unconsciousness. — Aside from ovarian and supraorbital pressure in the 
hysterical cases, the application of a sharp electric current, and similar drastic 
measures, the best procedure by far is that of administering ether, when 
the patient will invariably struggle and probably talk during the stage 
of excitement, unless the unconsciousness is real, when there will be no 
response. 

Venereal Diseases. — Such simulation is not infrequent in connection with 
blackmail. Artificial eruptions are as readily produced on the genitalia as 
elsewhere and a fair imitation of gonorrhea can be produced by the use of 
caustics or other irritants, whether in the female or in the male, but the ab- 
sence of the gonococcus is readily established and the peculiar characteristics 
of a primary sore are not easily simulated. 

Vertigo. — It may be impossible to detect spurious vertigo, though here 
as elsewhere close observation may result in catching the patient off guard. 

Vomiting. — This may be a very difficult form of malingering to detect, 
but is usually so causeless or so directly and immediately related to the taking 
| of bland substances as to expose its real nature. It may often be detected 
by making the circumstances under which it would occur particularly em- 
barrassing to the impostor. In a case of persistent habital vomiting observed 



CONDITIONS SIMULATING DEATH 130I 



by the author a cure was effected by forcing the patient to go to the theatre 
for an evening. 

Wry Neck. — This is usually readily detected by the muscular rigidity 
which follows any attempt on the part of the physician to correct the 
deformity. Furthermore, the associated unilateral atrophy cannot be 
simulated and the condition disappears during sleep or anesthesia. 

Comment. — hi conclusion one may say that in all simulated diseases detec- 
tion depends upon (a) the incongruity and lack of proper sequence in the symp- 
toms presented; (b) the presence of a motive for simulation; (c) the patient's 
actions and the course of his ailment when under close observation and control 
or twhen exposed to shock, surprise or suggestion; (d) the use of drugs and anes- 
thetics; (e) the absence of physical signs of the disease or symptom simulated. 

By far the most difficult cases are those occurring in the domestic circle 
where the physician must use great tact and judgment and is usually obliged 
to make the patient expose himself. It may be added that the ruse so often 
suggested of allowing patients to overhear conversations calculated to pro- 
duce absolutely spurious symptoms is successful only in the case of stupid 
and ignorant patients, the brainy impostor being ordinarily prepared for such 
maneuvers. On the other hand, in many instances the simplest of measures 
suffice for exposure if the patient is under control, among the commonest 
being the mere threat of operation, the administration of nauseating drugs, 
or the establishment of an attenuated or unpleasant dietary and irksome 
restraint. Confinement to bed, a diet of milk or buttermilk and a mixture 
of nux vomica and asafetida t.i.d. proved of sovereign virtue in a certain 
public service infested by clumsy malingerers suffering, actually, from 
antipathy to honest labor. 

CONDITIONS SIMULATING DEATH.— Asphyxia.— In drowning espe- 
cially, death is often only apparent and resuscitation possible after long periods 
of submersion (one hour or even more).' The same is true of infants appar- 
ently born dead. Efforts to restore life in such cases should therefore be 
carried out for a long period before hope is abandoned. 

Catalepsy. — In this condition the simulation of death is not ordinarily 
sufficient to lead to error, although both respiration and circulation may be 
but faintly indicated, superficial reflexes lost, analgesia and anesthesia present. 
and the temperature decidedly low. In the "trance state" the simulation of 
death is much more perfect, the limbs being flaccid or showing a rigidity 
simulating rigor mortis, the face pale, and the pupils often fixed in dilatation. 
In these cases the question of voluntary temporary but decided partial 
inhibition of the heart action and respiration is interesting, and there can 
be little doubt that certain of the East Indian fakirs possess this power. In 
the case of Colonel Townsend, as described by Cheyne, the mirror test and 
stethoscope failed to reveal any sign of respiration or heart action for fully 
half an hour. 

Syncope (Fainting). — As this represents a temporary failure of respira- 
tion and heart sounds and is associated with complete unconsciousness and 
pallor, it perfectly simulates death, but lasts ordinarily but a few seconds. 



1302 MEDICAL DIAGNOSIS 



Signs of Life in Persons Apparently Dead. — This title seems to the 
author more appropriate than the usual one, viz., "Signs of Death." In 
the trance state or in those who can voluntarily inhibit heart action the pulse 
may be absent and the heart sounds inaudible, but the following signs will 
be present if the patient is living. 

1. A deep red or purple color in the finger tips will become evident gradually 
if a firm ligature be applied to the digit. If applied to the wrist, prominence 
of the veins on the dorsum of the hand indicates life. The ligature must 
not be so tight as to completely cut off the circulation. 

2. Several hours after a supposed death blood will flow persistently from a cut 
artery. A small artery should be chosen, not mere wet cupping or haphazard 
puncture. 

3. If a needle thrust into the tissues and left for a time becomes oxidized, 
life is present. 

4. // any cloud repeatedly appears upon an ice-cold mirror held close to 
the mouth, there is respiration, but its absence does not alone suffice to prove 
death. 

5. If a powerful vesicant produces redness or blisters, there is life. 

6. // a body fails to take approximately the temperature of its environment 
forty-eight hours after apparent death there is life. 

7. Pupillary response to light shows life, its absence does not prove death. 
Several hours after death it is affected neither by atropin nor eserin. 

8. Persistence of the red in, and visibility of the arteries of the optic disc are 
signs of life, as is also persistent clearness of the media, six to eight hours after 
apparent death. 

9. A sensitive cornea is a sign of life, absence of the corneal reflex is not a 
sign of death. 

10. Presence of electric excitability in all muscles twenty-four hours after 
apparent death indicates life. (Usually lost in from three to six hours, but 
retained for from ten to fifteen in certain cases.) 

A BRIEF SUMMARY OF THE SYMPTOMS AND TREATMENT OF 

ACUTE POISONING 

ACIDS, MINERAL.— (HNO3, H 2 S0 4 , HC1.) 

Symptoms. — Burning pain in the mouth, esophagus and stomach, vomit- 
ing of grumous liquid containing shreds of tissue; mind clear, intense thirst, 
dysphagia and usually dyspnea or actual suffocation, scanty or suppressed 
urine, constipation and profound shock. 

Acid Stains on Mucous Membranes. Sulphuric: White turning to dark 
brown or black. Nitric: White, then orange, then brownish -red. Hydro- 
chloric: White or gray. Duration of fatal period: Several hours or months, 
depending upon amount taken, etc. 

Treatment.— Cardiac stimulants, morphia to relieve pain, baking powder 
or bicarbonate of soda in milk, egg albumin, carbonate of magnesia, calcined 
magnesia, mucilaginous liquids, sweet oil, olive oil, chalk, whiting, soap and 



TREATMENT OF ACUTE POISONING I303 

water; the stomach tube or pump being barred. All treatment fails if pure acid 
has been swallowed in quantity. 

ACONITE. — (Aconitum Na.pellus, monkshood, wolfsbane. Fatal dose, 
80 minims of the tincture; maximum medicinal dose, i to 5 minims.) 

Symptoms. — (Usually come on in a few minutes or may be delayed one 
hour or more.) Pallor, dryness and tingling of lips, tongue, pharynx, then 
of extremities and finally of whole body, nausea, perhaps vomiting, pharyn- 
geal constriction (subjective); slow, weak, later rapid and irregular pulse, 
subnormal temperature, slowed, shallow and irregular respirations, vertigo, 
dimness of vision, tinnitus aurium, clammy anesthetic livid skin, dilated 
pupils if convulsions are present, profound prostration and death. Fatal 
period from thirty minutes to five hours. 

Treatment. — Absolute rest. Evacuation of stomach by tube or stomach 
pump if condition permits, elevation of foot of bed, external heat, cardiac 
stimulants, artificial respiration, hypodermoclysis, hot rectal enemata. 
Tannin and charcoal may be given, but are probably of little use. Large 
doses of digitalis seem effective (m xx-3i). 

ARSENIC— (Fatal dose, 1 to 2^ grams, retained.) 

Symptoms (After half an hour or more). — Thirst, epigastric pain and 
tenderness, nausea, vomiting, purging with tenesmus, muscle cramps, rapid 
labored respiration, incessant and violent retching, pulse weak and rapid, 
urine scant or suppressed, cold wet cyanotic skin, perhaps paralysis, 
convulsions, and coma. 

Variations. — Cerebral symptoms may predominate, pain and vomiting 
may be absent or gastro-enteric symptoms be exceptionally violent. The 
usual picture is that of cholera morbus. Average duration in fatal cases 
between eight and seventy-two hours, shortest seventeen minutes. 

Treatment. — Evacuation of stomach, bland and mucilaginous drinks, 
ferric hydroxide (ferric chloride precipitated by any alkali) in milk, barley 
water, etc., followed by castor oil. 

ATROPIN.— (Belladonna. Fatal dose of atropin Y 2 grain.) 

Symptoms (After one-half to two hours). — Dry hot throat, dysphagia, 
vertigo, dilated pupils, blurred vision, flushed face, brilliant eyes, rapid pulse 
and respiration, active or even maniacal delirium, hallucinations, nausea, 
vomiting, scant, bloody, or suppressed urine, sometimes strangury and 
priapism; scarlatiniform rash on face and neck, sometimes general; stupor 
and death. It should be remembered that 10 to 15 drops of the urine in 
such a case will dilate the pupil of any animal except birds and monkeys. 

Treatment. — Evacuation of the stomach and bladder, morphin, pilo- 
carpin, tannic acid, cardiac stimulants. 

CANTHARIDES. — (Fatal dose, 24 grains or 1 ounce of tincture.) 

Symptoms. — Abdominal pain, vomiting, dysenteric purging, dysphagia, 
loin pain, dysuria, strangury, and frequently priapism in the male, hot and 
swollen labia in the female, or actual frenzied eroticism. 

Treatment. — Evacuation of stomach, cathartics and bowel flushing, opium, j 
cardiac stimulation, demulcent drinks but no oils, chloroform inhalations. 



1304 MEDICAL DIAGNOSIS 



CARBOLIC ACID.— (Fatal dose usually 5 to 5 i, but less would probably 
suffice, depends largely on dilution and stage of digestion.) 

Symptoms. — Odor of acid on breath, whitened mucous membranes from 
contact. Burning pain throughout affected tract, vomiting, retching, con- 
tracted pupils, insensitive cornea, dyspnea, respirations rapid and shallow, 
stertor, collapse, coma and perhaps convulsions. Urine scant or suppressed, 
smoky, sometimes black or bottle-green. Fatal period, few minutes to 
several hours. 

Treatment. — Dilute alcohol, whiskey, brandy in quantity, then evacuation 
of stomach; epsom salts, saccharated lime, soap and water may be used and 
demulcent drinks. 

CAUSTIC ALKALIES. — (Sodium and potassium hydrate, ammonia.) 

Symptoms. — Same as corrosive acids except that there is dysenteric 
purging. 

Treatment. — Oils, dilute vinegar, lemon juice, cardiac stimulants, 
morphia, milk, mucilaginous drinks. Stomach tube contraindicated. 

CHLORAL HYDRATE.— (-Knock-out drops," etc.) 

Symptoms. — Stupor or coma, pallor, either slow or rapid feeble pulse, 
slow respiration, pupils hrst contracted, later dilated, marked muscular 
relaxation, cardiac failure. 

Treatment. — Cardiac stimulants followed by hot packs and brisk friction, 
artificial respiration, hypodermoclysis. 

COCALK 

Symptoms. — Nausea, vomiting, mental excitement, delirium, rapid pulse 
and respiration, dilated pupils, fever, convulsions, stupor, coma. 

Treatment. — Cardiac stimulants, inhalations of chloroform to control 
convulsions, evacuation of stomach, morphia. 

COLCHICUM— (Fatal dose. % ounce of wine or less.' 

Symptoms. — Those of a violent gastrointestinal irritation with dilated 
pupils, cramps, perhaps delirium or convulsions, collapse, urinary suppres- 
sion, partial or complete. Fatal period, a few hours to several days. 

Treatment. — Cardiac stimulants, hypodermoclysis, morphia. 

CROTON OIL. — (Fatal dose, 30 minims.; Typical choleriform symp- 
toms, ccllapse. 

Treatment. — Symptomatic. 

CASTOR OIL. — Same symptoms. 

Treatment. — Symptomatic. 

CORROSIVE SUBLIMATE.— (Mercuric chloride. Fatal dose, 3 grains.) 

Symptoms. — Immediate choking, burning pain in epigastrium and 
esophagus, metallic taste, nausea, vomiting, persistent retching, dysenteric 
purging, distended tender abdomen, shock, dyspnea, muscle cramps, syn- 
cope, stupor, convulsions. Salivation not immediate and sometimes absent. 
Poison has an acrid coppery taste as compared with arsenic and, in the case 
of the latter, symptoms are delayed and the stools are less often bloody. 

Treatment. — Evacuate stomach, morphia, cardiac stimulants. Give 
white of egg in milk in quantity or rlour paste. 



TREATMENT OF ACUTE POISONING 1305 

FORMALDEHYDE. — This produces intense abdominal pain, lachryma- 
tion and nasal irritation (fumes), cyanosis and cardiac failure. The odor of 
the breath is characteristic. 

Treatment. — Evacuation by stomach pump if apomorphia fails, ammonia 
by inhalation and the same drug (dilute) by the mouth if possible; morphin, 
cardiac stimulation. 

GELSEMIUM— (Fatal dose, 3i of fluid extract or 3iv. of tincture.) 

Symptoms. — Extreme muscular weakness. Oculo-motor paralyses chiefly 
ptosis, blurred vision, fixed and dilated pupils, jaw-drop, face pallid and 
congested, livid cold sweat, impaired speech, dyspnea (respiration 
slow), partial paralysis of extremities, marked cardiac depression, occa- 
sionally pharyngeal spasm or general convulsions. Fatal period, one to 
several hours. 

Treatment. — Evacuation of stomach, morphin freely, cardiac stimulants, 
hypodermoclysis. 

HYDROCYANIC ACID.— (Prussic acid. Fatal dose, about 5i of official 
preparation or 1 grain of anhydrous acid.) 

Symptoms. — Immediate in large doses, vertigo, muscular relaxation 
(patient falls), protruding eyes, locked jaws, slow gasping respiration, 
dilated pupils, insensitive conjunctiva, pulse feeble, extremities cold, convul- 
sions may occur, the face is livid and bloated, the lips foamy, the breath car- 
ries the distinctive odor of bitter almonds and death occurs in coma with 
stertorous breathing or convulsions. 

Fatal Period. — A few minutes. Death is not instantaneous as is commonly 
believed. 

Treatment is usually futile, impossible or unnecessary, the patient being 
dying, dead, or out of danger in a few moments. 

LEAD ACETATE.— (Maximum fatal dose, about 1 ounce.) 

Symptoms. — Sweet metallic taste, violent vomiting and a particularly 
intense abdominal colic with a rigid retracted abdomen, intense thirst and | 
obstinate constipation, or, more rarely, a diarrhea with black stools, vertigo, 
convulsions and stupor or coma. The blue line may be present even in acute 
poisoning. Fatal period, a few hours to several days. 

LOBELIA. — (Indian tobacco. Fatal dose, 5i of leaves.) 

Symptoms. — Nausea, vomiting, perhaps purging, cold sweats, con- 
tracted pupils, collapse, coma. 

Treatment. — Evacuation of stomach. External heat, cardiac stimulants, 
morphia, tannic acid. 

MUSHROOM POISONING.— (Usually Agaricus muscarius or vernus.) 

Symptoms. — Violent abdominal pain, vomiting, purging, mental and 
nervous excitement, dyspnea, stertor, collapse. 

Treatment. — Large doses of atropia* hypodermoclysis, external heat, 
cardiac stimulants. Empty stomach if necessary. 

*This treatment was first successfully applied by Dr. Jacob E. Schadle, of St. Paul, 
who in a personal communication states that the dose should be 3^0 grain repeated 
as necessary and that 3^ grain may be required during twenty-four hours. 



1306 MEDICAL DIAGNOSIS 



OXALIC ACID. — (Frequently taken for epsom salts.) Fatal dose, 3iv. 

Symptoms. (Immediate). — Violent vomiting often bloody, or acute pain 
in head, neck, back and limbs with tingling or numbness, tetanic spasms or 
convulsions, aphonia and marked cardiac weakness or collapse. Usually 
fatal within one hour, perhaps in a few minutes. 

Treatment. — Never give potassium or sodium salts, but rather chalk and 
magnesia in milk, oils, lime-water, morphin and cardiac stimulants. 

OPIUM. — (Fatal dose 4 to 5 grains; laudanum 5i, or their equivalents. 
In children trifling doses have caused death. Habitues may use several 
hundred grains daily.) 

Symptoms. — (Usually within from three to thirty minutes.) Somnolence, 
vertigo, stupor, coma, according to dose, the pupils are contracted ("pin- 
point") and almost invariably equal, pulse slow and full, later weak and 
compressible. Respiration slow and stertorous, skin at first flushed and 
warm, later clammy, with diminishing respiratory rate. Pupils may dilate 
as death approaches. The fact that contracted pupils may occur in pontine 
hemorrhages and uremic poisoning (Reese) must not be forgotten. 

Duration of Fatal Period. — Seven to twelve hours. 

Treatment. — Evacuate stomach (apomorphia 1 to 10 grains, stomach 
pump, etc.). Hypodermic injections of atropin, administer strong coffee; 
exercise mild cases and dash cold water over chest to excite respiration. Use 
artificial respiration and cardiac stimulants. Administer 10 grams of potas- 
sium permanganate in 6 to 8 ounces of water. Empty bladder, use hypoder- 
moclysis. In doubtful cases note odor of breath (laudanum) and search for 
hypodermic punctures, old or recent. Cocain and adrenalin have been 
recommended and repeated lavage is valuable. Death occurs from respira- 
tory failure indicated by increasing lividity and irregularity and slowness of 
respiration. 

PHOSPHORUS.— (Fatal dose, 1 to 10 grains have killed.) 

Symptoms. — (Usually delayed several hours.) "Garlicky" breath, 
nausea, violent vomiting, abdominal pain, either diarrhea or constipation, 
dilated pupils, cardiac depression. Vomited matter is green and is luminous 
in the dark; in protracted cases jaundice and hemorrhages from mucous mem- 
branes (especially hematemesis), or under skin. Urine scant and albumi- 
nous or suppressed. 

Treatment. — Ordinary oils must not be used. Evacuate stomach by use of 
copper sulphate, purge freely and repeatedly; give old oil of turpentine in 
emulsion, albuminous and mucilaginous drinks (barley water, milk, flaxseed 
tea, egg albumin, etc.).* 

POTASSIUM NITRATE.— (Niter, saltpeter.) 

Symptoms. — Same as caustic alkalies, but less marked, with tremor and 
perhaps convulsion and delirium. 

Treatment.' — Evacuate stomach and give milk, barley water, flaxseed tea, 
cardiac stimulants, and morphia. 

*H. C. Wood states that American oil of turpentine is valueless in this condition. 
Crude French oil is undoubtedly best. 



TREATMENT OF ACUTE POISONING C307 



POTASSIUM CHLORATE. 

Symptoms. — Vomiting, purging, asthenia, delirium, spasm or convulsions, 
acute nephritis. 

Treatment. — Same as preceding. 

STRAMONIUM AND HYOSCYAMUS.— Same as belladonna. 

STRYCHNIN (Nux vomica).— Fatal dose, Y 2 grain. 

Symptoms (After fifteen to thirty minutes). — Constriction oj the throat or 
subjective dyspnea, muscular twitching of the face, followed by jerking of the 
head and extremities, and violent tetanic spasm (usually opisthotonos) 
associated with lividity. Contraction of the facial muscles produces the 
''risus sardonicus," there may or may not be locking of the jaw (if so, it 
comes on last and relaxes first in the spasms) , and, as in hydrophobia, spasm 
may be induced by attempts to administer water. Relaxation follows in 
from one-half to five minutes and there is marked exhaustion and profuse 
perspiration. After a few minutes the spasm recurs and they increase in 
frequency and severity until death ensues from exhaustion or asphyxia. 
The special senses are exquisitely acute and a noise, draught of air, or sudden 
bright light may induce spasm; vomiting is usually absent. It should be 
noted as separating this condition from hysteria, that the eyes are opened and 
the mind clear until the last or until the supervention of asphyxia if the case 
thus terminates. Unlike trismus proper, the jaw muscles are involved late 
and the convulsions are intermittent with periods of complete relaxation. 
Fatal period, five minutes to several hours. 

Treatment. — Absolute quiet in a darkened room, evacuation of stomach 
after chloroform inhalation has been started, bromides and chloral, atropin. 

TARTAR EMETIC— (Fatal dose, }i to 40 grains.) 

Symptoms. — Almost exactly as in arsenic poisoning with profound 
cardiac depression. 

Treatment. — Same as arsenic, save that tannic acid, not iron, is the anti- 
dote (strong green tea, etc.). Morphia and cardiac stimulants are indicated. 

TARTARIC ACID.— (One ounce has proved fatal.) 

Symptoms. — Violent gastrointestinal irritation. 

Treatment. — Sodium bicarbonate, magnesia, chalk, best administered 
through stomach tube which permits emptying stomach of contents and 
generated gas. 



i 3 o8 



MEDICAL DIAGNOSIS 



TABLE OF (APPROXIMATE) METRIC EQUIVALENTS 


Grains or 


Grams or 


Grains or 


Grams or 


Minims 


(c.c) 


Minims 


(c.c) 


/^00 


= o . 0003 


IO 


= 0.6 


Moo 


= . 0006 


12 


= 0.8 


Y64 


= O.COI 


15 


= I .O 


YZ2 


= 0.002 


20 


= 1.2 


He 


= . 004 


30 


= 2.0 


Yl2 


=0.005 


60 


= 4.0 


y 8 


= 0.008 


I20 


= 8.0 


% 


= 0.01 


240 


= I5.O 


y± 


=0.015 


480 


= 30. C 


Yz 


= 0.02 


Ounces 




i 


= 0.06 


2 


= 60.O 


2 


= 0.12 


4 


= II5.0 


3 


= 0.2 


6 


= 170.0 


4 


=0.25 


8 


= 230.0 


5 


=0.3 


10 


= 28o.O 


6 


=0.4 


IS 


= 420.0 


8 


=0.5 


20 


= 568.0 



CENTIGRADE AND FAHRENHEIT SCALES 

To convert Fahrenheit into Centigrade, subtract 32, multiply the remain- 
der by 5, and divide the result by 9. 

To convert Centigrade into Fahrenheit, multiply by 9, divide by 5, and 
add 32. 

The following table shows the relation of degrees Fahrenheit to 
Centigrade. 



Centigrade 


Fahrenheit Centigrade 


Fahrenheit 


Centigrade 


Fahrenheit 


Centigrade 


Fahrenheit 


no 


230 


45 -o 


113. 


37-0 


98.6 


IS 


59-0 


100 


212 


44.0 


III. 2 


36.5 


97-7 


10 


50.0 


95 


203 


43 -o 


IO9.4 


36.0 


96.8 


+ 5 • 


41 .0 


90 


194 


42.0 


IO7.6 


35-5 


95-9 





32.O 


85 


185 


41.0 


IO5.8 


35-0 


95.o 


- S 


23.O 


80 


176 


40.5 


IO4.9 


34-0 


93-2 


— 10 


14.O 


75 


167 


40.0 


IO4.O 


33-o 


91.4 


-15 


+ S-o 


70 


158 


39-5 


IO3. 1 


32.0 


89.6 


— 20 


-4.0 


65 


149 


39-o 


I02.2 


31.0 


87.8 


-17.8 




60 


I40 


38.5 


IOI.3 


30.0 


86.0 






55 


131 


38.0 


IOO.4 


25.0 


77.0 






5c 


122 


37.5 


99-5 


20.0 


68.0 







SYMPTOM INDEX 



Absent-mindedness, in petit mal, 1272 
Acetonemia, 249 
Acetonuria, 228, 229 

in diabetes mellitus, 1166 
Achromia, in chlorosis, 150 
Achylia, 879, 880, 934 

accompanying menstruation, 880 
diarrhea, 880 

age incidence of, 883 

asthenic dyspepsia, 880 

differential diagnosis of, 883, 884 

functional, 852 

gastrica, 862, 863, 867, 870, 879, 922' 

in anemia (pernicious), 883 

in carcinoma (gastric), 928, 935 

in congenital asthenics, 880 

in emotional crises, 880 

in gastritis, 906 

in malignant disease of stomach, 884 

pancreatica, 881 

persistent, 882 

senile, 883 

stomach findings in, 881, 934 

simple, 880 
Acidosis, 3. 228, 1 164 

diabetic, 82, 1164 

in cholera (Asiatic), 1032 

in chloroform anesthesia, 229 

in cardiac decompensation with dropsy, 230 

in delirium (low), 230 

in fever (typhoid), 230 

in hypertension, 480 

in locomotor ataxia, 229 

in malignant growths (gastric or intestinal), 
229 

in melancholia, 229 

in non-diabetics, 229 

in stuporous states, 230 

ketone, in diabetes mellitus, 1163 

tests for, 229 
Achoria, 871 

Adams-Stokes syndrome, 570 
death during, 570 

in anemia (cerebral), 565 

in arterial tension (high), 480 

in angina pectoris, 769 

in coronary sclerosis, 769 

in heart block, 466, 565 

suggesting status epilepticus, 570 
Affliction, in pericarditis, 793 
Agraphia, 14, 1204, 1210 

in brain tumors, 1244 
Albuminuria, 6, 215 

accidental, 215 

affected by posture, 217 

after manipulation of kidney, 267, 814 

and asthenia universalis congenita, 217 

cyclic, 216 



Albuminuria, febrile, 254 107 t 
following cold baths, 216 

emotional disturbances, 216 

exhausting exercise, 216, 217 

infections, 216, 217 

ingestion of excessive amounts of nitro- 
genous food, 216- 
from retention of chlorides in tissues, 213 

septic foci, 217 
in acute cholecystitis, 976 

congestion and nephritis, 257 

glomerulonephritis, 258 

interstitial nephritis, 258 

rheumatism, 1153 

yellow atrophy, 1037 
in alcoholics, 241, 255 
in amyloid kidney, 266 
in Asiatic cholera, 1032 
in biliary cirrhosis, 973 

colic, 978 
in Bright 's disease, 213 
in caisson disease, 1239 

heart disease, 648 
in cholera infantum, 944 
in chronic interstitial nephritis, 202, 215, 255 
258, 264 
parenchymatous nephritis, 260 

mixed nephritis, 260 

passive congestion of kidney, 253 
in cold weather, 217 
in colic (abdominal) , 90 
in congenital asthenics, 217 
in cystic degeneration of kidney, 272 
in cystitis, 273 
in dengue, 1035 
in diabetes insipidus, 11 69 
in erythremia, 163 
in fever, Rocky Mountain spotted, 1056 

scarlet, 484, 107 1 

trench, 1065 

yellow, 1036, 1037 
in glomerulonephritis (acute), 258 
in gout, 1 173 
in influenza, 1020 
in jaundice, 19 
in malaria, 1045 
in measles, 1067 
in meningitis, 1080 
in nephritis, 202, 215, 217, 253, 255, 257 

258, 259, 260, 262, 264, 266 
in pachymeningitis, 1238 
in phosphorus poisoning, 1306 
in pneumonia, 389. 393 

(broncho), 397 
in pregnancy, 253, 254 
in renal colic, 86 
in renal infarct, 270 
in Rocky Mountain spotted fever, 1056 
in scarlet fever, 484, 107 1 
in serum disease, 993 



1309 



i ;io 



SYMPTOM IXDEX 



Albuminuria in small white kidney. 260 

in smallpox, 1098 

in sunstroke, 1284 

in syphilitic cirrhosis, 973 

in tonsillar infection, 341 

in trench fever, 1065 

in trichiniasis, 1138 

in Weil's disease, 975 

in whooping cough, 1104 

in yellow fever, 1036, 1037 

intermittent, 217, 247 

minima (transient), 217, 240 

orthostatic. 217 

physiologic, 250 

retinal hemorrhage in, 1220 

significance of. '2 16 

tests for. 217. 218, 219, 220, 221, 222 

toxic, 254 

transient, 215, 216, 814, 1067 
gouty, 1 1 73 
Albumoses (albumosuria"!. 215 

:r. e~rye~a 5 "_ 

in septic processes, 215 

secondary, 215, 216 

significance of, 215 

test for, 216 

with leucocytosis, 215, 374 
Alcaptonuria, 192, 194 
Alexia, 1203 
Alkaline tide, effect of diet upon, 197 

significance of, 197 
Allochiria, 1204 
Alopecia, syphilitic, 13 
Alternating pulse, 558, 561 

Alvarenga Duroziez murmur. iSee Murmurs.) 
Amaurosis, 248, 1225. (See Blindness.) 
Amblyopia, 1225 
Amimia, 14, 1203 
Amnesia, 14, 15, 1201, 1203 

in hysteria, 1279 

memory in, 1201, 1298 

simulated, 1298 
Anachlorhydria as a symptom, 870 

in achylia gastrica, 870 

in asthenics, 870 

in anemia (pernicious), 870 

in carcinoma, 870 

in gastritis, 870 
Anacidity, 860, 873. 874 
Analgesia, 1209 

in locomotor ataxia, 1255 
Anarthria, 14, 1202. 1204. 1213 

in multiple sclerosis, 1240 
Anasarca, 13, 20. (See also Edema.) 

in heart disease, 51 

in myeloid leukemia. 157 

in nephritis, 259, 260 
and hydrothorax, 383 
Anemia, 60, in, 124, 144 

Addisonian pernicious, 151 

and hydrothorax, 382 

and infantile Kala azar, 1061 

and use of stomach tube, 849 

aplastic pernicious, 154 

arterial, 558 

in pulmonary insufficiency, 731 

blood pressure in, 479, 481 

causes of, 147 

cerebral, 565, 1241 



Anemia, chlorotic, 148, 162, 883 
cord symptoms in, 1254 
differential diagnosis of, 160 
diseases associated with, 164 
etiologic factors in, 147 
feigned. 1293 
general considerations in, 145 

nutrition in, 147 
in achylia gastrica, 883 
in acute rheumatism. 44, 147, 1152 

--.idison's disease, 174 
in Arctic explorers, 147 
in arthritis deformans, 44, 1157 
in atrophy (gastric), 160, 161 
in auto-intoxication, 147 
in Banti's disease, 155 
in bothriocephalus infection, 127, 153, 160, 

"35 
in Bright 's disease. 147 
in carcinoma, gastric, 147, 153- 160. 932, 933 

of pancreas, 964 
in chloroma, 161 
in chronic parenchymatous nephritis, 254 

lead poisoning, 1287 
in colic (abdominal), 90 
in congenital hemolytic jaundice, 156 
in diphtheria, 1076 
in filariasis, 1144 
in fever, Malta, 1054 

Oroya, 1062 

Rocky Mountain spotted, 1056 

typhoid, 1007 
in Gaucher's disease, 155 
in heart disease, 434 

fatty. 670 
in Hodgkin's disease, 164, 166 
in hyperchlorhydria, 868 
in hyperemia of liver, 967 
in intestinal parasites, 147 
in leukanemia (myeloid), 157 

lymphatic, 159. 160 
in leishmaniasis, 1060 
in leprosy, 147 
in malaria, 147. 1048 
in malignant disease of stomach, 153 
in Malta fever, 1054 
in nephritis (acute), 256 

(parenchymatous), 259 
in Oroya fever, 1062 
in pellegra, 1290 
in poisoning (mineral), 147 
in post-stenotic ectasia, 901 
in primary combined sclerosis, 1256 
in rheumatism, 44, 147, 1152 
in Rocky Mountain spotted fever, 1056 
in scorbutus, 171 
in splenomegaly with hepatic cirrhosis, 155 

of Gaucher type, 155 
in sprue, 1063, 1064 
in Still's syndrome, 161 
in syphilis, 147 
in tapeworm infection, 1135 
in tonsillar infection, 341 
in trematoda infection, 1133 
in tricuspid stenosis, 728 
in tuberculosis, 147, 400, 410 
in typhoid fever, 1007 

in ulcer, gastric and duodenal, 87,^907, 9io t 
915. 919, 920 



SYMPTOM INDIA 



I3II 



Anemia in uncinariasis, 1139 

in valvular lesions. 743 

murmurs associated with, 451, 452, 743 

myelocytic, 161 

of ear, 33 

of fingernails. 42 

of lips, 34 

outward signs of, 145 

pernicious, 151 

progressive, from hemorrhages, 147, 915 
in carcinoma, gastric, 147, 915, 932, 933 
in hemorrhoids, 147, 942 
in ulcer, gastric and duodenal, 147, 840, 
915. 920 

pulse in, 494. 495 

secondary, 147, 174 

splenomegaly with, 155 

types of. 144 

with splenic enlargement, 154, 155, 1048, 
1054, 1056, 1060 
Anesthesia, 1204, 1208 

bilateral, 1209. 1213 

dissociated, 1260 

dolorosa, 1209 

feigned, 1299 

general and local, surgical, 483, 647, 816, 826 

hysterical, 1259, 1280 

in auditory nerve lesions, 1234 

in caisson disease, 1239 

in facial nerve lesions, 1233 

in glosso-pharyngeal nerve lesions, 1235 

in hematomyelia, 1239 

in hysteria, 1279 

in injuries to spinal cord, 1262 
tumors of spinal cord, 1262 

in leprosy, 1121 

in musculo-spiral paralysis, 1268, 1287 

in myelitis, chronic, 1262 

in neuritis, 1267 

in pachymeningitis, 1238 

in polyneuritis, 1268 

in primary combined sclerosis, 1256 

in spinal accessory nerve lesions, 1236 

in syringomyelia, 1260 

in trifacial nerve lesions, 1232 

in uremia, 247 

in vagus nerve lesions, 1236 

intestinal, 950 

laryngeal, 1236 

locomotor ataxia, 1255 

muscular, 11 21 

patchy, 1208, 1212 

"stocking anesthesia," 1279 
Angio-neurotic Edema. (See Edema.) 
Anidrosis, 20. (See also Dryness of skin.) 
Anisocytosis, 152 

in Addisonian, pernicious, 152 

in aplastic pernicious form, 154 

in chlorosis, 150 
Anorexia, 871 

and use of duodenal tube, 856 

hysterical or psychasthenic, 871, 1281 

in anemias, 146 

in ascaris infection, 1137 

in arsenical poisoning (chronic), 1288 

in carcinoma (gastric), 932, 934, 935 

in cardiac disease, 648 

in cirrhosis of liver, 97 1 

in catarrhal jaundice, 977 



Anorexia in chlorosis, [49 

in congenital asthenia, 871 

in fevers, 75. B? I 
(.typhoid), 1005 

in gastric carcinoma, 932, 934. 935 
and duodenal ulcer, 919 

in gastritis, 905 

in gout, 1 172 

in hysteria (traumatic), 1280 

in jaundice (catarrhal), 975 

in influenza, 1032 

in lethargic encephalitis, 1087 

in meningitis, 1079 
(syphilitic), 1084 

in poliomyelitis, 1093 

in poisoning (chronic arsenical), 1288 
(meat), 1132 

in tuberculosis, 871 

in ulcer (gastric and duodenal), 919 

nervosa, 879, 913 

preceding sunstroke, 1284 

psychasthenia, 871. 1281 
Anuria, 191 

m Asiatic cholera, 1032 

in hysteria, 191, 1279 

in poisoning (phosphorus), 191, 1306 
Apex beat. (See Pulsation.) 
Aphasia, 14, 1203, 1204, 1210, 1211, 1212 

and hemianopsia, 1225 

and hypertension, 478 

auditory, 1204 

in ascaris infection, 1137 

in apoplexy, 401 

in brain tumors, 1244 

in cerebral hemorrhage, 401, 1246, 1248 

in epilepsy, 1272 

in hemorrhage (cerebral), 1246, 1248 

in migraine, 93 

in meningitis (syphilitic), 1085 

m pachymeningitis, 1238 

in tumors of brain, 1243 

motor, 14, 1203, 1204, 1244 
in pulmonary congestion, 401 

sensory, 14, 1203, 1204. 1211, 1244, 1246 

true, 14 

visual, 121 1 
Aphemia, 14, 1204 
Aphonia, 14, 1204 

feigned, 1293 

in aneurysm (aortic), 776, 777 

in botulism, 1288 

in edema of glottis, 343 

in hysteria, 1279 

in laryngitis (tuberculous). 344 

in paralyses (segmental), 12 15 

in paralysis (adductor), 1236 

in poisoning (oxalic acid), 1306 
(botulism), 1288 

in trichiniasis, 1138 

in tumors of larynx, 344 
Apnea, 436 

Biot's periodic, 436 

in Cheyne-Stokes breathing, 108 
Appetite. (See also Anorexia.) 

excessive, in diabetes, 1166 

gluttonous, in paretic dementia/ 1253 

loss of. (See Anorexia.) 

ravenous (in tapeworm infection), 1135 . 
Apraxia, 14, 1203 



1312 



SYMPTOM INDEX 



Apraxia, tests for, 1204 

Argyll-Robertson pupil in locomotor ataxia, 
1254 

in paretic dementia, 1252 

in syphilis of nervous system, 1252 
Arrhythmia. (See also Pulse.) 

analysis of, 543 

blood pressure in, 487 

classification of, 543 

in auricular fibrillation, 554, 555 

in cardiovascular insufficiency, 650 

in childhood and youth, 563 

in diphtheria, 1075 

in endocarditis, 675 

in hysteria (traumatic), 1281 

in mountain sickness, 1282 

in neurasthenia, 1183 

in pericarditis, 787 

in pneumonia, 393 

in traumatic hysteria, 1280 

indicated in electrocardiogram, 527. 562 

indicated in polygram, 507, 51 1 

perpetua, 543 

sinus, 562, 563 

toxic, 589 

vagus, in neurasthenia, n 83 
Ascites, 21, 23 

and abdominal examination, 24 

associated with fatty heart, 785 (Fig. 359) 

character of, 25 

chyliform (fatty), 25 

chylous (milky), 25 

differentiation of, 24, 817 

examination for, 24, 25, 439 

fatty, 25 

forcing liver upward, 810 

in abdominal distention, 439, 805, 806, 810, 
812 

in Banti's disease, 155 

in Bright's disease, 23 

in carcinoma of pancreas. 965 

in cirrhosis (of liver), 28, 970, 971. 972, 973 

in emphysema, 24 

in fibroid lung, 24 

in heart disease, 23, 436, 439 

in hepatic cirrhosis, 25 

in hepatic hyperemia, 968 

in "nutmeg liver," 972 

in peritonitis, 24, 25 
(tubercalosis), 25, 963 

in polyserositis, 796 

in portal phlebitis, 24, 972 

in splenomegaly with hepatic cirrhosis and 
anemia, 155 

in syphilitic cirrhosis, 973 

in thrombosis (portal ) : 25 

in tricuspid insufficiency, 703, 706 

in tuberculosis peritonitis, 963 

in uncinariasis, 1139 

lactescent (milky), 25 

lung borders in, 296 

massive, 28 

(Grocco's triangle in;, 367 

orthopnea in, 50 

"poached egg" belly, 25 

rapid onset, in portal phlebitis, 972 

recurring, 972 

simulated, 817. 1296 

with emaciation, 25 



Asphyxia, 130 1 

bradycardia in, 563, 564 

blood pressure in, 480, 481 

in dermatomyositis, 1159 

in croup, 343 

in heart lesions, 485 

in poisoning (strychnin), 1307 
(trench gas) , 348 

in serum disease, 993 

in tricuspid insufficiency, 703, 706 
stenosis, 728 
Asthenia (congenital.) (See Exhaustion.) 

and Hood pressure in, 482, 486 

and cardiac outline, 589, 592 

and chest outline, 284 

and "drop heart," 428, 449, 594, 598, 
605 

•and heart disease, 437, 592 

and heart murmurs, 452 

and movable kidney, 267 

and renal tuberculosis, 269 

and tuberculosis, 403, 404 
Ataxia, 49, 1207, 1208, 1212, 1213 

in brain tumors, 1245 

cerebellar, 49, 1207. 1212, 1257 

Friedreichs's, 1256, 1257 

gait in, 52 

in hydrocephalus, 1242 

in malaria, 954 

locomotor, 1254 

Marie's, 1257 

paretic, 1207 

static, 1207 

tests for, 1207 
Atrophy, ataxic paraplegia, 1256 

brown, in myocarditis, 590 

cerebral, in pachymeningitis. 1238 

disuse, in hysteria, 1279 

feigned, 1293 

fiber, in paretic dementia. 1252 

hemiatrophy, 31 

in acute myelitis, 1261 

in Addison's disease, 174 

in amyotrophic lateral sclerosis, 1264 

in apoplexy, 1248 

in coma, 81 

in cranial nerve lesions, 12 19 

in disease of anterior horns, 11 89 

in facial hemiatrophy, 1269 

in gonorrheal arthritis, 115S 

in Landry's paralysis, 1263 

in lead poisoning, 1287 

in leprosy, 1121 

in locomotor ataxia, 1255 

in motor lesions, 1192 

in muscular dystrophy, 1265 

in myxedema and cretinism, 177 

in neuritis, 98, 1267 

in orchitis following mumps, 1069 

in poliomyelitis, 1092 

in primary lateral sclerosis, 1257 

in syringomyelia, 1260 

in wry neck, 46, 1301 

muscular, 1200, 1219. 1238, 1256, 1263, 
1264, 1265, 1266, 1287 

of arm, 1216, 1219 

of bone, in arthritis deformans, 115 7 

of cortical centres, 1191 

of joints, 43 



SYMPTOM INDEX 



1313 



Atrophy of leg, in Madura foot, 1130 

in pellagra, 1290 
of little finger, 12 19 
of liver, in sprue, 1063 

locomotor ataxia, 1256 
of lungs, in emphysema, 352, 354 

atelectasis, 399 
of mucous membranes, in bronchitis, 345 
of muscles, in arthritis deformans, 1156, 1157 
of nerve fibers, 1190 
of thumb, 1 2 17 

of thyroid, in myxedema and cretinism, 177 
of tongue, 14, 37. 1215 

in bulbar palsy, 1264 
of ventricle, in mitral stenosis, 577 
optic, in amaurotic family idiocy, 1259 

hereditary ataxia, 1257 

locomotor ataxia, 1255 

multiple sclerosis, 1240 
peroneal muscular, 1265 
pigment, 174 
progressive muscular, 1263, 1265, 1266, 1287 



B 



Backache, 96, 99 

in anthrax, 11 23 

in chickenpox (varicella), 1103 

in fever (trench), 1065 
(typhus), 1052 

in flat-foot, 99 

in influenza, 1019 

in meningitis, 1079 

in pelvic disease, 99 

in poisoning (oxalic acid), 1306 

in renal disease, 99 

in smallpox, 1095 

sacro-iliac, 96—99 
Bacteriurea, 236 
Barrel-chest, 352 
Basophilia, 125 
Belching, 871 

in gastritis, 905 
Blebs. (See also Rash.) 

in erysipelas, 11 18 

in herpes zoster, 95- 1163, 1269 

in Raynaud's disease, 1270 
Blindness, 1223, 1225 

color-, 1224 

feigned, 1293, 1294 

in amaurotic family idiocy, 1259 

in hysteria, 1280 

in idiots, 1259 

in locomotor ataxia, 1255 

in meningitis (infantile), 1086 

in neuralgia (ophthalmic), 94 

in uremia, 248, 263 

mind-, 4, 14, 1204, 1211, 1225, 1244 

night-, 1224 

testing for, 1225 

transient, 94 

word-, 14, 1225, 1244 
in tumors of brain, 1244 
Blood pressure. (See also Hypertension and 
Hypotension.) 

age and sex, effect of, 476 

attitude and exercise, 474 

basic factors, 471 

bradycardia, in acute hypertension, 492 

83 



Blood pressure, determination of, 47 2 
diastolic pressure, 473, 474 
"high," discussion of, 478 
important points, 485, 486 
in acute infections, 481 
in alcoholism, 483 
in amyloid kidney, 266 
in anemia, 481 

in anesthesia (general surgical), 483 
in angina pectoris, 480, 485 
in aorta, 713 
in aortic aneurysm, 482 

in aortic regurgitation (high "systolic"), 479 
in arrhythmias, determination of pressure, 

487 
in arteriosclerosis, 479 
in arteriosclerotic kidney, 261 
in asthenia, 482 
in asthma, 481 
in brachial artery, 472 
in capillaries, 471 
in cardiorenal cases, 486 
in cerebral arterial crises, 478 
in cholera, 481 
in colic (abdominal), 485 
in congenital asthenia, 482 
in cystic degeneration of the kidney, 272 
in danger line in hypertension, 486 
in diphtheria, 480, 481 
in dysentery, 481 
in eclampsia, 479 
in epilepsy, 480 
in erythremia, 160, 480 
in gout, 478 
in heart lesions, 485 
in hemorrhage, 480, 481 
in hypotension, excessive, 480, 481 
in hypotension following paracentesis, 484 

thoracentesis, 484 
in intracranial pressure, 479 
in lead poisoning, 478 
in lesser arteries, 472 
in locomotor ataxia, 480 
in malaria, 484 
in mesaortitis, 752 
in middle age. 479 
in morphinism, 483 
in myocarditis, 478 
in nephritis (acute), 256, 478, 492 

(chronic), 487 

(interstitial;, 262, 265, 460, 478, 480 

(parenchymatous), 478 
in normal individuals, 475 
in pericardial effusions, 482 
in pleurisy with effusion, 481, 484 
in pneumonia, 481 
in pneumothorax, 482 
in pregnancy, 254, 485 
in scarlet fever, 484 
in spastic splanchnic crises, 480 
in stasis, 480 
in syphilis, 482 
in tuberculosis, 482 
in typhoid fever, 483, 484 
in uremia, 248, 249, 479. 492 
in veins, 472 
Koratkow's method, 474 
"low." discussion of, 480 
"mean" pressure, 474 



i3 x 4 



SYMPTOM INDEX 



Blood pressure, normal readings, 476, 478 
prognostic data, 484, 485. 486 
"pulse pressure," 472, 474 
sphygmomanometer. 472 
systolic pressure, 4 7 5 
Blue line on gums, in lead poisoning, 1287 
Borborygmi, in asthenia (congenital), 897 
in abdominal examination, 806 
in diaphragmatic hernia, 381 
in gastroptosis, 884 
in intestinal neuroses, 949 
Bradycardia, 491, 563 

abrupt occurrence of, 492, 563 

and nodal rhythm, 569 

contraction of heart in, 546 

diseases accompanied by, 491, 564 

in angina pectoris, 769 

in apoplexy, cerebral, 1247 

in arterial tension, rapidly induced, 492 

in brain tumor, 1243 

in drug poisoning, aqi, 564 

in ectasia (post-stenotic), 900 

in fever (pappataci), 1059 

in heart block, 564, 568 

in influenza, relative, 1020 

in jaundice, 490 

in lead poisoning, 479 

in meningitis (tuberculous;, 491 

cerebrospinal, 1079 
in myelitis (acute), 1262 
in pappataci fever, 1059 
in pneumonia, relative, 491 
in poisoning (drug), 491 

(lead), 479 
in simple, 563, 569 
in simulated, 1297 
in suspicious, 568 

in toxemia (jaundice, certain acute infec- 
tions), 492 
in typhoid fever, relative, 491 
Breath, 34, 82 
foui, 34, 336 

"fruity," of diabetes, 34, 82, 249, 1166 
"garlicky," in phosphorus poisoning, 34, 

1306 
holding of, 344. T94 

in bringing out extrasystoles, 550 
inability to hold, 106 

in cardiovascular syphilis, 756 

in decompensation, 639, 647 

in examination of heart, 436 

in myocarditis, 666 
in acute poisoning, 34, 82 
in alcoholism, 34, 82, 1284 
in ascaris infection, 1137 
in atrophic rhinitis, 336 
in coma, 82, 249 
in diabetes mellitus, 34, 82, 249 
in esophageal diverticula, 903 
in gangosa, 1117 
in gastritis, 34 
in nasal s/philis, 336 
in poisoning (acute), 34, 82 

(cartolic acid), 34, 82, 1304 

(ether and chloroform), 82 

(formaldehyde;, 1305 

(hydrocyanic acid), 34, 82, 1305 

(laudanum), 82 

(mercury), 33 



Breath in poisoning (opiumy, 1306 

(phosphorus), 34, 1306 
in rhinitis (atrophic), 336 
in stomatitis (gangrenous), 36 

(mercurial), 35 
odor of, 34, 249 

shortness of, in endocarditis, 683 
syphilis of nose, 336 
uremia, 34, 82, 249 
in sounds (diminished), 302 

(distant). 367 

(muffled), 355 

(normal), 276, 301, 417 

in atelectasis, 399 

in emphysema, 353. 354 

in pleurisy with effusion, 367. 368, 371, 
375 

in pneumonia, 390 

in pneumonia (broncho), 396 

in pneumothorax, 379 

in pulmonary edema, 401 

in pulmonary insufficiency, 729J731 

in pulmonary and pleural hydatids, 425 

in variation in, 307, 729 
Breathing, 83. 285, 305, 306, 307. 309 
abdominal, 285 
absent or suppressed, 306 
accelerated, 105, 108 

in internal anthrax, 1123 

in tuberculosis, 405 
and sinus arrnythmias, 563 
air hunger, 83, 106 

from foreign bodies in bronchi, 351 

in asthma, 359 

in cardiovascular insufficiency, 647 

in diabetic coma, 106, 1166 

in myocarditis, 66 

in concealed hemorrhage, 109 
amphoric, 308. (See Rales, p. 312.) 

in pneumothorax, 308, 379 
arrest of, in syncope, 102 
and chest outline, 284 
and cholelithiasis, 978 
and examination of chest, 287, 301, 304 
and use of stomach tube, 850 
bronchial (normal), 306 

pathologic, 307, 392 
broncho-vesicular (normal), 307 
(pathologic), 307 

in broncho-pneumonia, 397 
Biot's respiration, 107 

in meningitis, 10S 

in pneumonia, 10S 
"catchy," in pleurisy, 363 
cavernous, 308 
Cheyne-Stokes, 108, 436 

in acute infections, 108 

in alternating pulse, 563, 636 

in apoplexy, 108 

in botulism, 1289 

in cerebrospinal fever, 108 

in coma, 108 

in decompensation, 108, 647 

in diabetic coma, 108, 1166 

in during sleep only, 108 

in interstitial nephritis, 248 

in malaria, 1048 

in meningitis, 108 

in opium poisoning, 108 



SYMPTOM INDEX 



1315 



Breathing. Cheyne-Stokes, in pericarditis, 787, 
801 

in pneumonia, 108 

in tumors of brain, 1244 

in typhoid fever, 108 

in uremia, 108, 248 
cog-wheel, 306 

in tuberculosis, 306, .417 
costal, 285 

in diaphragmatic pleurisy, 374 

in men and women, 288 
differentiated from dyspnea, 105, 306 
feeble, 306 

forced, in effusions, 369 
indicated on polygram, 515 
in abdominal examination, 803, 804, 810 
in abscess (retropharyngeal), 341 
m adenoids, 284, 340 
in alcoholism, 1284 
in anesthesia, 483 
in aneurysm, 105 
in angina, 647, 769 
in anthrax (internal), n 23 
in apoplexy, 107 
in asthma, 359. 360 
in aviator's syndrome, 1283 
in brain tumors, 107 
in carcinoma of stomach, 93 r 
in chlorosis, 150 
in chorea, 107 
in collapse, 107 
in coma, 82, 108 
in colic. 107 
in cretinism, 178 
in croup, 105 

in diabetic coma, 82, 83, 106, 1166 
in effusions, 105, 306, 307 
in emphysema, 354, 355 
in fever (typhoid), 107, 1004 
in fractures (rib), 107 
in gastric carcinoma, 931 
in hydrophobia, 107 
in hysteria, 107 
in internal anthrax, 11 23 
in malaria, 1048 
in meningitis, 107, 108 
in mitral stenosis, 435 
in neuralgia (intercostal), 107 
in pericarditis, 795, 798 
in pleurisy, 107, 306, 363, 367, 368, 374 

(diaphragmatic), 374 
in pneumonia, 107, 108, 304, 306, 307, 387, 
389. 390, 391, 392 

broncho, 396 
in poisoning (arsenical), 1303 

atropin, 1303 

chloral hydrate, 1304 

cocain, 1304 

gelsemium, 1305 

hydrocyanic, 1305 

trencn gas, 348 
in polyserositis, 795. 796 
in pulmonary tumors, 307. 421 
in syncope, 102 

in tuberculosis, 304, 306, 307, 406, 413, 417 
in tumors (pulmonary, , 307, 421 

(brain), 107 
in typhoid fever, 1004 
irregularity in, 107 



Breathing, in jerky, 107 

in " Kussmaul dyspneic type," 82 
in mirror test for in apparent death, 1301 
in mouth, 335 
in adenoids, 340 
and hoarseness, 343 
normal, 285, 305 
in puerile, 305 

in pneumonia, 305 
in shallow, causes of, 288, 647 
and atelectasis, 398 
in pleural effusion, 485 
in pneumonia, 389 
in typhoid fever, 1004 
slow, 108, 178, 1304 

stertorous, 106, 108. (See also Rales, p. 310,) 
in adenoids, 106 
in enlarged tonsils, 106 
in coma, 79. 82, 83, 106 
in poisoning (carbolic acid), 1304 
(hydrocyanic), 1305 
(opium), 1306 
(laudanum), 82 
(mushroom), 1305 
sunstroke, 1283 
stridulous, 105 
in aneurysm, 105 
in croup, 105, 343 
in glottic obstruction, 105 
tubular, 307, 367. (See also Rales, p. 312.) 
distant, in pneumonia, 300, 387, 390, 

39i. 392 
importance of, 308 
in bronchopneumonia, 397 
in pericarditis, 787. 798, 801 
in pulmonary tumors, 421 

congestion, 401 
normal, 307 
pathologic, 308 
variations in, 107 
vesicular, 305 
vocal cords in, 12 16 
wavy, 107 
Breathlessness in cardiac disease, 600, 664 
in cardiovascular syphilis, 756 
in uncinariasis, 1139 
Bronzing, 17 

in Addison's disease, 174 
in cirrhosis of liver, 17, 971 
in diabetes, 17, 19 
in Hodgkin's disease, 167 
Bruits. (See Murmurs.) 
Buboes, bullet, 1107 

bulbar paralysis, 1264 

gonorrheal, differential diagnosis of, 1034 
in plague, 1033 
syphilitis, 1107 
Bulbar paralyses, 1264 
Bulimia, 871 

in anemias, 146 
in diabetes, 871 
in typhoid fever, 871 



Cachexia, absence of, in "obscure tumors," 816 
and atrophy of the liver, 972 
and complicating purpuras, 168 
and degeneration of nerve cell, 1190 



1316 



SYMPTOM INDEX 



Cachexia, and emaciation, 54. 56 

in carcinoma of esophagus, 904 
and hydrothorax, 382 
blood pressure in, 481, 482 
gums in, 38 
in abscess of liver, 967 
in achylia, 881 
in Addison's disease, 175 
in Banti's disease, 155 
in biliary cirrhosis, 972 
in carcinoma of the esophagus, 904 

lung, 421 

stomach, 929, 933 
in cirrhosis (biliary), 972 
in ectasia (post-stenotic) , 901 
in Hodgkin's disease, 166 
in liver abscess, 969 
in malaria, 484, 1048 

blood pressure in, 484 
in morphinism, 483 
in pellagra, 1290 
in post-stenotic ectasia, 901 
in pulmonary tumors, 421 
in splenomegaly with hepatic cirrhosis, 155 
in tuberculosis, 415 
in tumors (.pulmonary; , 421 

petecniae in, 27 

pulse in, 490, 491 
Caput medusae, 27 

in cirrhosis of liver, 806, 970, 971 
Casts, fibrinous, in bronchitis, 347 

in urine, 241, 242 
in nephritis, 242, 243, 257, 259, 260, 262, 264 
in urine, 239 

basis of, 240 

blood, 242 

brown, 242 

epithelial, 240, 242, 260 

fatty, 239, 242, 259 

granular, 239, 241, 243, 244 
brown, 242 
in influenza, 1020 
in congestion of kidney, 253 

hyaline, 239, 240, 241, 243 
in amyloid kidney, 266 
in congestion of kidney, 253 
in influenza, 1020 

hypothesis of, 239 

in amyloid kidney, 266 

in atrophy (acute yellow), 974 

in Bright's disease, 242 

in chronic passive congestion, 253 

in erythremia, 163 ( 

in influenza, 1020 

in jaundice, 19 

in rheumatism (acute), 1153 

in serum disease, 993 

in sunstroke, 1283 

misleading forms, 243, 244 

of bronchial tubes, 330 

of thoracic cavity, 348 

persistent, 240 

prostatic, 244, 274 

pseudo-, 243 

pus, 242 

showers of, 241, 244 

significance of, 240, 243 

spurious, 244 

true, 239, 241 



Casts, in urine, typical, 244 

waxy, 241, 243, 260, 265, 266 

without albuminuria, 240 
Cheyne- Stokes breathing. (See Breathing.) 
Chills and chilliness, 67 
and cyanosis, 16 
and fever, 75 
feigned, 1296 
in abscess (cerebral), 1251 

liver, 966 
in acute infections, 78 
in anthrax, 1123 
in biliary colic, 978 
in blastomycosis, 11 27 
in bubonic plague, 1033 
in carcinoma (gastric) , 932 
in cerebral abscess, 1251 
in chickenpox, 1103 
in cholecystitis, 976 
in cholelithiasis, 978 
in colic (biliary), 978 
in dengue, 1035 
in Dietl's crises, 268 
in diphtheria, 1075 
in dysentery, 948 
in empj'ema, 374 
in encephalitis (lethargic\ 1087 
in endocarditis (malignant), 677 
in erysipelas, 11 18 
in filariasis, 1142 
in fever (flood), 1058 

Malta, 1054 

paratyphoid, 1002 

rat bite, 1061 

Rocky Mountain spotted, 1055 

typhoid, 1005 

typhus, 1052 

yellow, 1036 
in gastric carcinoma, 93 2 
in infections (acute), 78 
in Leishmaniasis, 10O0 
in lethargic encephalitis, 1087 
in leukemia (lymphatic), 159 
in liver abscess, 966 
in malaria, 1037. 1045 
in malignant endocarditis, 677 
in measles, 1066 
in meat poisoning, 1132 
in meningitis, 1079 

(suppurative), 1084 
in miliary tuberculosis, 10 11 
in movable kidney, 268 
in myelitis (acute), 1261 
in myostitis (suppurative), 1161 
in myxedema, 178 
in nephritis (acute), 256 
in peritonitis, 960 
in pneumonia, 388 

(broncho), 396 
in poisoning (meat), 113 2 
in pyelitis, 269 
in pyemia, 11 19 
in renal infarct, 270 
in rheumatism (acute), 1151 
in septicemia, 10 11 
in smallpox, 1095 
in suppurative myositis, 1161 
in tonsillitis, 342 
in typhoid fever, 1005 



SYMPTOM INDEX 



3*7 



Chills in typhus fever. 1052 

in varicella. (See Chickenpoxl . 1 103 
in variola (smallpox), 1095 
yellow fever, 1036 
recurring, in pyemia, 11 19 
Chlorides, urinary, 212 

clinical application of, 213 

excretion, 212, 213 

in meningitis, 108 1 

relation to edema and albuminuria, 213 

retention, 213 

tests for, 212 
Choked disc, 81, 1227, 1228 

in abscess (cerebral), 1251 

in aneurysm (intracranial), 1240 

in brain tumor, 81 

in coma, 81 

in pachymeningitis, 1238 
Chyluria, 196 

in filariasis, 1141 
Claudication, in arteriosclerosis, 763. 767 
intermittent, 53 
of heart, 768 
spinal, 53 
Clubbing of fingers, 41 

in bronchiectasis, 349 

in congenital heart lesions. 742 

in emphysema, 353 

in pulmonary stenosis, 736 
Cog-wheel breathing. (See under Breathing.) 
Colic, 85, 86, 87 

abdominal, 50, 85, 90, 764, 1305 

blood pressure in, 485 

in angioneurotic edema, 1271 

in appendicits, 955, 956, 957. 958 
precautions in, 957 

in ascaris infection, 1137 

in Asiatic cholera, 1032 

in dysentery, 948 

in poisoning (arsenical), 1288 
(lead), 87, 1287 
(lead acetate), 1305 
biliary, in cholecystitis, 978 
colon, 85, 87, 952 
cramp, 46 

due to gastric ulcer, 87 
epigastric, in pancreatic calculi. 965 

in pancreatic cysts, 964 

in pancreatitis, 964 
examinations in, 90 
gallstone, 70, 86, 956, 977, 978. 979 
lead, 87 

mucous (enteritis), 944 
renal, 86, 956 

(Dietl's crises), 86 
simple transitory, 85 
ureteral, 83, 86 
Collapse and (shock), 109 
and pain, 85 
blood pressure in, 480 
diastolic jugular venous, 496. 796 
in abscess (hepatic), 109 
in accidents, 109 
in angina pectoris, 109 
in aortic insufficiency, 716 
in appendicitis, 109, 956 
in Asiatic cholera, 1031, 1032 
in cholera infantum, 944 
in colic, 109 



Colapse in coma (diabetic), 1166 
in Dietl's crises, 268 
in fever (yellow), 1036 
in heat exhaustion, 1284 
in hemorrhage, 109 
in hernia (strangulated), 109 
in intestinal obstruction, 88, 89 
in malaria, 1048 
in Meniere's disease, 1235 
in myocarditis, 667 
in movable kidney, 268 
in pancreatitis, 109, 964 
in perforation (ulcer), 926 

(typhoid), 1003 
in peritonitis, 960 
in pneumothorax, 377 
in polymyositis, 1160 
in poisoning (carbolic acid), 1304 

(colchicum), 1304 

(croton oil), 1304 

(lobelia;, 1305 

(mushroom), 1305 

(oxalic acid), 1306 

(ptomain), 1288 
in rupture of heart, 802 
in typhoid perforation, 1003 
in ulcer perforation, 109, 926 
in yellow fever, 1036 
obscure cases of, 109 

of abdominal viscera and cardiac displace- 
ment, 438 
of chest in tuberculosis, 69 
of lung in pyopneumothorax, 377 

atelectasis, 398 

lobular pneumonia, 394 
pulmonary, in aneurysm, 775 

in pneumothorax, 324 
pulse in, 109, 49L 494 
respiration in, 107, 108 
stomach, in differentiating tumors, 819 

in examination of stomach, 831 
temperature in, 73 
theory of (shock), 109 
venous, 487, 496, 503 

in tricuspid insufficiency, 707 
vomiting in, 872 
Coma, 79. 83, 1202 

conjunctival reflex in, 1194 

diabetic 82, 83, 1166 

diagnosis in, 82 

examination in, 79, 82 

hysteric, 81 

in alcoholic meningitis, 1085 

in Asiatic cholera, 1032 

in atrophy (acute yellow), 974 

in auricular flutter, 558 

in botulism, 1289 

in brain tumors, 1244 

in caisson disease, 1239 

in cardiac decompensation, 515 

in cerebral hemorrhage, 80, 1247 

in cholera infantum, 944 

rheumatism, 1153 

thrombosis, 1250 
in diarrhea, 944 
in diphtheria, 1075 
in ectasia (post-stenotic) , 900 
in encephalitis (lethargic), 1088 
in epilepsy, 1272 



i 3 i8 



SYMPTOM INDEX 



Coma in fever (milk), 1057 

(rat bite), 1062 
in gastritis, 905 
in glioma, 1244 
in gout (retrocedent) , 11 73 
in heat exhaustion, 79 
in hemorrhage (cerebral), 1247 
in high blood pressure (hypertension), 479 
in jaundice, 19 

in lethargic encephalitis, 1088 
in malaria, T048 
in meningitis, 1080, 1082, 1262 

alcoholic, 1085 

pachy-, 1238 

tubercalous, 1083 
in milk fever, 1057 
in mitral regurgitation, 687 
in mountain sickness, 1282 
in multiple sclerosis, 1240 
in nephritis (acute;, 256 

(interstitial), 262 
in pachymeningitis, 1238 
in poisoning (acetanilid), 80 

arsenical, 1287. 1303 

botulism, 1289 

carbolic acid, 1304 

chloral hydrate, 1304 

cocain, 1304 

drugs, 79 

food. 1289 

hydrocyanic, 1305 

lead, 479. 1305 

lead acetate, 1305 

lobelia, 1305 

opium, 1306 

ptomain, 79. 1289 

strychnia, 80 
in poliomyelitis, 1092 
in post-stenotic ectasia, 900 
in rabies, 1125 
in rat bite fever, 1062 
in retrocedent gout, 1173 
in rheumatism (cerebral), 1153 
in sclerosis (multiple), 1240 
in sleeping sickness, 1145 
in sunstroke, 79, 1283 
in thrombosis (cerebral), 1250 
in tricuspid insufficiency, 706 
in trypanosomiasis (sleeping sickness), 1145 
in tuberculous meningitis, 1083 
in tumors of brain, 1244 
in uremia, 247, 248 
in yellow atrophy (acute), 974 
of acidosis, 82. (See also Coma, diabetic.) 
pulse in, 81 

recurrent, in hydrocephalus, 1242 
temperature in, 81 
tests for, 80 
uremic, 80, 92, 249 

in nephritis, 256, 265 
vigil, 75. 79 
Congestion, cerebral, 872, 1241 

in meningitis, 1081 

in sunstroke, 1283 
hepatic, in cardiovascular insufficiency, 648 

in examination of abdomen, 809, 810 

in hepatic hyperemia, 967 

in Laennec's cirrhosis, 969 

in pericarditis, 801 



Congestion, hepatic, in sunstroke, 1283 

in tricuspid stenosis, 727 
in acute myelitis, 1261 
in aneurysm, 776 
in erythromelalgia, 1270 
in filariasis, 1142 
in myelitis, acute, 1261 
in neuritis, 98, 1267 
in Raynaud's disease, 1270 
in sunstroke, 1283 
in syphilis of lung, 11 10 
in syringomyelia, 1260 
in trench gas poisoning, 348 
in typhoid fever, 1002, 1003 
of abdominal viscera, 872 
of brain, in meningitis, 108 1 
of conjunctiva, in bubonic plague, 1033 

in fourth (Duke's) disease, 1073 
of face, in cerebral hemorrhage, 1247 

in dengue, 1035 

in fever, yellow, 1036 

in poisoning, gelsemium, 1305 
hydrocyanic, 1305 
of intestinal mucosa, in enteritis, 943 

in Asiatic cholera, 103 1 
of kidney, 253 

acute, 254 

chronic passive, 253 

in alcoholism, 1285 

in decompensation, 648, 653 

in diabetes insipidus, 1169 

in diphtheria, 1074 

in mitral regurgitation, 687 

in paroxysmal tachycardia, 560 

in pregnancy, 254 

in scarlet fever, 107 1 

in sunstroke, 1283 

in tricuspid insufficiency, 703, 705 
stenosis, 727 
larynx, in laryngitis, 343 

in croup, 343 

in trench gas poisoning, 348 
of legs, 42 
of lungs, 399. 400, 401 

accompanying apoplexies, 400, 1247 

active, 400 

acute, 680 

hypostatic, 400 
in typhoid, 1003 

in diphtheria, 1074 

in fever, Malta, 1054 
typhoid, 1005 

in mitral stenosis, 699 (Fig. 311^ 

passive, 400, 648, 670 

in mitral regurgitation, 687 

in trench gas poisoning, 348 
of meninges, in meningeal infection, 107 

in smallpox, 1095 
of ovaries, in mumps, 1069 
of peritoneum, 960 
of stomach mucous membrane, 900 

in Asiatic cholera, 1031 

in gastric ulcer, 921 
of throat, in diphtheria, 1075 

in bronchitis, 345. 346 
passive. 400. 401, 810 

in cardiovascular insufficiency, 648 

in Laennec's cirrhosis, 970 

in myocarditis, 667 



SYMPTOM INDEX 



1319 



Congestion, passive, in peritonitis, 962 
pulmonary, 399. 400, 401 

accompanying apoplexies, 401 

in arteriosclerosis, 766 

in mitral regurgitation, 44s, 680 

in pericarditis, 802 

in sunstroke, 1283 
superficial, in erythromelalgia, 1270 
venous, in bronchitis, 345 

in kidney stasis, 253 

in trench gas poisoning, 348 

in tricuspid insufficiency, 703 (Fig. 314) 
Convulsions, 46, 49 
and fever, 75 
feigned, 81, 1295 
frothy lips in, 81 
in anthrax (internal), 11 23 
in ascaris infection, 11 37 
in brain tumors, 1243 
in cerebral hemorrhage, 1247 

rheumatism, 1153 
in congenital hydrocephalus, 1242 
in coma, 80 

in dementia (paretic), 1253 
in epilepsy, 80, 1272 

(Jacksonian), 1272 
ergotism, 1289 
fever (milk), 1057 

(scarlet), 1071 
in heart block, 565. 570 
in hemorrhage (cerebral), 1247 
in hemorrhage (concealed), 109 
in hydrocephalus (congenital), 1242 
in nydrophobia (rabies), 1124 
in infections in children, 78 
in jaundice, 19 

in laryngismus stridulous, 344 
in meningitis, 1079, 1082, 1249 

pachy-, 1238 

tuberculous, 1084 
in milk fever, 1057 
in myelitis (acute), 1262 
in multiple sclerosis, 1240 
in nephritis (acute), 256 

(interstitial), 262 
in pachymeningitis, 1238 
in paralysis (spastic), 1258 
in paretic dementia, 1253 
in poisoning (aconite), 1303 

arsenical, 1303 

carbolic, 1304 

cocain, 1304 

colchicum, 1304 

corrosive sublimate, 1304 

gelsemium, 1305 

hydrocyanic acid, 1305 

lead, 1287 

lead acetate, 1305 

oxalic acid, 1306 

potassium nitrate, 1306 
chlorate, 1307 

strychnin, 80, 1307 
in pneumonia, 388 

(broncho) 396, 397 
in poliomyelitis, 1092, 1093. 
in rabies, 1124 

in rheumatism (cerebral), n 53 
in scarlet fever, 107 1 
in sclerosis (multiple;, 1240 



Convulsions in smallpox, 1095 

in spastic paralysis, 1258 

in sunstroke, 1283 

in tetanus, 80 

in tuberculous meningitis, 1084 

in tumors of brain, 1243 

in uremia, 80, 247, 248, 249, 256, 1249, 1273 

in whooping cough, 1105 
Coryza, 335 

in bronchitis, 34s 

in hay fever, 336 

in influenza, 1019 

in measles, 1066, 1068 

in poliomyelitis, 1092 

in whooping cough (pertussis), 1104 
Cough, 326 

causes of, 326, 327 

diminuendo, in emphysema, 328 

feigned, 1294 

from foreign bodies in bronchi, 351 

"Gander," in aortic aneurysm, 775 

in abscess of liver (perforation), 967 

in angina pectoris, 770 

in aortic aneurysm, 328, 775. 777. 779 
insufficiency, 714 

in asthma, 359. 361 

in atelectasis, 399 

in bronchiectasis, 328, 349 

in bronchitis, 345, 346, 347 

in croup, 328, 343 

in effusion (pericardial), 328 

in emphysema, 328, 352 

in endocarditis, 714 

in gastritis, 906 

in hay fever, 336 

in Hodgkin's disease, 167 

in hydatids (pulmonary and pleural), 425 

in infarct (pulmonary), 418 

in influenza, 1019. 1021 

in laryngitis, 342, 343 

in mediastinal pressure, 328 

in mitral regurgitation, 687 

in perforation of liver abscess, 967 

in pericarditis, 800 

in pharyngitis, 339 

in pleurisy, 363 

in pneumonia, 328, 388, 390, 391 
(broncho), 395. 396, 397 

in pulmonary and pleural hydatids, 425 

in pulmonary infarct, 418 
tumors, 421 

in smallpox, 1097 

in trematoda infection, 1134 

in trench gas poisoning, 349 

in tuberculosis, 327, 328, 406, 410, 417 

in tumors of larynx, 328, 344 

in whooping cough, 328, 1103. 1104, 1105 

in "winter cough," 347 

inquiry concerning, 67 

postural modifications, 328 

various types and causes of, 326, 327. 328 
Cramps, 46 

colic, 46 

in intermittent claudication, 53' 

in jaundice, 19 

in migraine, 93 

muscular cramp, 1162 

occupational, 46 
Crepitation. (See Rales.) 



13 20 



SYMPTOM INDEX 



Is, Charcot-leyden. in asthma. 331. 359 

in bronchitis, 347 

in feces, 939 

in sputum. 331 
cholesterin, in gallstones. 97 7 

in sputum. 331 

tests for. 942 
fatty acid, in sputum. 331 
hematoidin, in sputum. 331 
in urine, 231. 232. 233, 234, 235. 273. 274 
thorn-apple. 233 
Cyanosis, 15. 16. 418 
and dyspnea, 105 

and edema in heart disease, 21. 22. 435 
and erytm-ocytosis. 162 
from foreign bodies in bronchi. 351 
in ambulants, 16. 435 
in angina, 647 
in aneurysm 776, 778 
in arteriosclerosis, 766 
in Asiatic cholera, 1032 
in asthma. 16, 359. 361 
in atresia of aorta, 741 
in auricular flutter, 556 
in bronchiectasis, 349 
in bronchiolitis, 3^7 
in bronchitis, 346 
in bronchopneumonia, 16. 397 
in cardiac insufficiency, 37. 51. 648. 649. 650 
in cerebral hemorrhage, 1247 
in cholera. Asiatic, 1032 
in coma. So 
in congenital heart disease. 16, 162. 163, 

352. 742 
in congestion of lung, 401 
in cretinism (sporadic : " 
in croup, 16. 343 

in defective ventricular septum. 742 
in diphtheria (laryngeal), 16 
in drug poisoning, 16 
in effusions (pleural). 16 
in endocarditis. 675 
in erythremia, 16, 111, 163, 164. 435 
in erythrocytosis. 16. 162, 163 
in erythromelalgia , 42 
in emphysema, 16. 352, 354 
in examination of heart, 435. 439. 556 
in fever (typhus). 1053 
in hemorrhage (cerebral; , 1247 
in Hodgkin's disease, 166 
in hysteria. 16 

in influenza, 1020, 1021. 1022 
in Landry's paralysis, 1263 
in lymphatism, 176 
in malaria. 1048 
in mediastinal tumors, 16 
in mitral regurgitation, 687 

stenosis, 435. 701 
in mountain sickness, 12S2 
in myocardial overstrain, 664 
in myocarditis, 666 
in neuritis, 16 

in obstruction of glottis, trachea, and bron- 
chi, 16 
in obtaining blood for examination. 113 
in pain (severe). 16 
in paralysis of diaphragm, 16 
in passive congestion of lung, 401 
in patent ductus botalli. 739 



Cyanosis in patent foramen ovale, 738, 739 
in pericarditis, 787, 800. 801 
in pleurisy. 16. 365. 371 
in pneumonia. 16, 375. 393 

(broncho), 397 
in pneumothorax, 378 

blood pressure in. 482 
in poisoning, arsenical, 1303 

acetanilid. 80 

drug, 16 

formaldehyde. 1305 

laudanum. 52 
in pulmonary insufficient, 730. 731 

fibrosis. 16 

stenosis. 439. 453- 732. 736 
in Raynaud's disease. 42. 1270 
in right heart stasis, 648 
in spasm of diaphragm, 16 
in sporadic cretinism, 178 
in suffocation, 16 
in sunstroke, 12 S3 
in trench gas poisoning, 348 
in tricuspid insufficiency, 703, 706. 707 
in tuberculosis. 300, 406 
in typhus fever. 1053 
::: uremia. 5 :> 
in venous stasis, 706 
of buccal cavity-, 34 
of ear. 33- 435 
of extremities, 163 
of fingernails, 16. 42, 390 
offo:: _: 
:: legs. -2 
of Up 5 

in decompensation, 435 
of tongue. 37 

paroxysmal, in patent foramen ovale. 739 
red, in erythremia, 16, 163, 164, 435 
vagus ov exaction in, 470 



Deafness. 33- 335 

in arteriosclerosis. 766 

in caisson's disease, 1239 

in fever (scarlet) , 1 o 7 1 

in hysteria, 1235, 1280 

in lesions of auditory nerve. 1234 

in meningitis, 108 1 
(infantile), 1086 
(serous), 1085 

in retropharyngeal abscess. 341 

in rhinitis. 335 

in scarlet fever, 107 1 

in syphilis, nil 

in uremia, 248 

many causes of, 1234 

mind-, 14. 1204 

•'nerve-.'" 1234. 1235 

sudden, 1234 

tests for. 1234 

word-, in tumors of brain. 1244 
Delirium, 1202 

acute febrile. 75 

Bell's mania, 75 

blood pressure in delirium tremens. 483 

delusions in. 1201 

forms of, 75. 1202 

illusions in, 1201 



SYMPTOM ENDEX 



1321 



Delirium in abscess (cerebral), 1251 
in acute yellow atrophy. 974 
in alcoholic meningitis. 1085 
in anemias. 146 
in Asiatic cholera, 1032 
in atrophy (acute yellow), 97^ 
in cerebral abscess, 1251 

rheumatism, 1253 
in children. 75 
in cholera infantum. 944 
in chorea. 1274 
in coma, 79. 80 
in diphtheria, 1075 
in encephalitis. 1088 
in epilepsy, 1202 
in fever (.milk), 1057 

rat bite, 1062 

scarlet. 1071 

(typhoid). 1003. 1005, 1006. 1202 
in fevers. 75 

in gout (retrocedent;. 11 73 
in hemorrhage (concealed). 109 
in nysteria and epilepsy, 1202 
in jaundice. 19 

in lethargic encephalitis, 1088 
in leukemia. 146 
in meningitis, 1080 

(alcoholic), 1085 
in milk fever, 1057 
in myxedema. 178 
in noma. (See Stomatitis.) 
in pneumonia, 389, 1286 
in poisoning (atropin;, 1303 

belladonna, 80 

cocain, 1304 

colchium, 1304 

lead, 479- 1287 

potassium chlorate, 1307 
nitrate. 1306 
in poliomyelitis, 1092 
in rabies. 11 24 
in rat-bite fever, 1062 
in Raynaud's disease, 1270 
in retrocedent gout, 11 73 
in rheumatism (cerebral;, 1153 
in scarlet fever, 1071 
in small pox, 1098 
in stomatitis (gangrenous). 36 
in sunstroke, 1283 
in tremens, 1182, 1202 

and alcoholic meningitis. 1085 

blood pressure in, 483 
in typhoid fever, 1003, 1005. 1006. 1202 
Delirium cordis, 551, 554, 685. 701 

arrhythmia of, 543 

in pericarditis, 801 

pulse in. 494, 551. 554 
Dementia, feigned, 1298 
in brain tumors, 1244 
in chorea (Huntington's 1 ). 1275 
paralytica. 1237. 1251 

types of. 1253 
paretic, 748, 1184, 129S 
Diarrhea (purging, enteritis), 9.13 
acute fermentative, 943. 944 
blood pressure in, 481 
cholera infantum, 944 
"Cochin China" in sprue, 1063 
feces in, 937. 938 ., 



Diarrhea, "hill," 1063 
in achylia. 880. 881 

afternoon recession. 881 
in Addison's disease, 174- 
in anemias. 146 
in anthrax (internal), 1123 
in appendicitis, 955. 958 
in bubonic plague. 1033 
in cardiac disease, 648 
in chorea, 1031, 1032 
in chronic enteritis, 944 
in cirrhosis of liver, 971 
in dropsy (epidemic), 1057 
in dysentery, 945. 948. 949 
in embolism of intestinal arteries. 953 
in enteritis (chronic). 944 
in epidemic dropsy. 1057 
in fever (glandular,), 105S 

(Malta). 1054 

(typhoid), 1000. 1004, 1005, 1007 
m fevers. 75. 79 
in gastritis, 905, 906 
in glandular fever. 1058 
in hyperchlorhydria, 868 
in indigestion (intestinal;, 944 
in infection (trematoda), 1133 
in influenza, 1020 
in intestinal indigestion, 944 

obstruction. 950 
in jaundice, 19 
in lead poisoning, 1287 
in malaria, 1048 
in Malta fever. 1054 
in meningitis (tuberculous; , 1083 
in nephritis (parenchymatous), 259 
in noma (See Stomatitis), 36 
in obstruction (intestinal), 950 
in pellagra. 1290 
in peritonitis (tuberculous), 963 
in poisoning (arsenical), 1288, 1303 

cantharides, 1303 

caustic alkalies, 1304 

corrosive sublimate, 1304 

lead, 1287 

lead acetate, 1305 

lobelia, 1305 

mushroom, 1305 

phosphorus, 1306 

potassium chlorate, 1307 
in poliomyelitis, 1092, 1093 
in pneumonia, 388, 389 

(broncho;, 397 
in purpura, 169 
in small pox, 1098 
in sprue, 1068 

in stomatitis (gangrenous), 36 
in thrombosis of intestinal arteries. 953 
in trematoda infection, 1133 
in tuberculous peritonitis, 963 

meningitis , 1083 
in typhoid fever, 1000, 1004, 1005. 1007 
membranous, 944, 945 
morning (Hill;, 1063 
organisms in, 943 
rice water, 1031. 1032 
simulated, 1295 
Dilatation. (See Distention.) 
Dilatation, cardiac. 182, 431, 432, 433. 591. 59; 
a cause of murmurs, 685 



1322 



SYMPTOM INDEX 



Dilatation, acute, 401, 638, 646, 654 

from fright, 98 
and chest outline, 285 
and hypertrophy, 592, 601 
auricular, 575, 577, 682 
determination of (percussion), 439 

roentgenograph^, 432, 571, 575. 576, 577 
excessive, effect on preexisting murmurs, 446 
extreme, 667 
general, 586, 782 
in anemia, 452 

in aortic insufficiency, 579, 580 
in aortic stenosis, 581 
in apoplexy, 401 

in congenital asthenia, 550, 595. 598, 601 
in "drop-heart," 573, 596, 597. 598, 599. 603 
in emphysema, 354 
in goitre, 182 
in infections, 446 
in influenza, 597 

in mitral insufficiency, 575, 576, 679 
in mitral stenosis, 577 
in paroxysmal tachycardia, 560 
in pneumonia, 325. 389. 445. 596 

interstitial, 424 
in rheumatism, 596 
in trench gas poisoning, 348 
in massive, 666 
in minor, 662, 666 
in morbid, 592 

in non-recognition of, chief causes, 431, 441, 
442, 573, 594- 603, 608, 638, 657, 664, 
666, 670 
in normal, heart diameters, 430 
in normal, outlines, 57L 572, 573 
in obligatory vs. morbid, 591, 592 
of aorta, 581, 584. 585 
of aortic ring, 452 
of left heart, 576, 578, 581. 679, 682, 

698, 700, 710, 713. 717. 525 
of right heart, 436, 438, 440, 576, 577, 
679. 682. 698, 700, 703, 705, 727, 
734 
outlines of heart in disease, 575. 576, 577 
post-operative, 182 
relative valvular insufficiency in, 685 
silent, 636 
simple, 462 

source of great error, 431 
sub-acute, 638 
universal, 636 
without murmurs, 433, 636 
Diplopia, 1 23 1 

in hysteria, 1280 
in lethargic encephalitis, 1088 
Distention and dilatation, abdominal: 439, 764, 
803, 807, 810, 812, 817, 820, 1004 

and congestion of lungs, 400 

excessive, 820 

fixation of liver and spleen in, 820 

general, 805 

in air swallowers, 817, 871, 872, 949 

in appendicitis, 958 

in cardiac disease, 439 

in embolism of intestinal arteries, 953 

in fever (typhoid), 1000, 1004 

in intestinal obstruction, 87. 95 1 

in intestinal paralysis, 88 

in pancreatic cysts, 964 



686, 



58i, 
730, 



Distention and dilatation in peritonitis, 88, 960 
in poisoning (corrosive sublimate), 1304 
in thrombosis of intestinal arteries, 953 
in typhoid fever, 1004 
local, 805 
arterial, 462, 581 

energy expended in, 471 
in aortic insufficiency, 452, 715, 719 
in cardiovascular syphilis, 755 
cardiac, 401, 433. 438, 462, 464, 503. 545. 
575. 579, 591, 592, 626, 662, 666, 667, 
. 701, 741. 742, 744 
protection from, 682 
colon, 312, 546, 812 
epigastric, 642. 667 
esophageal, 903, 931 
gastric, 838, 885, 891, 897, 898, 900 
in alcoholism, nor, 1285 
in air swallowers, 911 
in angina, 771 
in arteriosclerosis, 764 
in aviator's syndrome, 1283 
in carcinoma of stomach, 934 
in cardiac arrhythmias, 546 
in decompensation, 640, 642 
in examination of abdomen, 819 
heart, 446, 454 
lungs, 312 

stomach, 822, 824, 833, 835 
in gastric disorders, 871, 878, 884, 890, 

897, 898, 900 
in intestinal paralysis, 88 
in ulcer of stomach and duodenum, 911, 914 
intestinal, in angina pectoris, 771 
in aviator's syndrome, 1283 
in cardiac arrhythmias, 545 
in decompensation, 640 
in examination of abdomen, 817 
in examination of stomach, 835 
of connective tissue spaces in cardiac edema, 

649 
of gallbladder, 811 

in cholelithiasis, 976, 977, 979 
in tenia echinococcus infection, 1137 
of lungs, 306 

in serum disease, 993 
in asthma, 360 
in emphysema, 35 1. 354 
in splanchnic vessels, 463 
of synovial membrane, 44 
of tissues, in subcutaneous emphysema, 26 
of veins, 496, 499 

in abdominal examination, 806 

in cirrhosis of liver, 970 

in tricuspid insufficiency, 703, 707, 744. 745 

stenosis, 727 
of eye, in embolism of central artery, 1222 
of ventricles, in cerebral abscess, 1251 
pericardial, 482, 790, 798 
precordial, 667 
substernal, 667 
Dreams, due to cerebral anemia, 1241 
"Drop heart," 428, 431, 449, 572. 594, 598, 605 
Dropsy. (See Edema.) 
Drowsiness, day, in arteriosclerosis, 765 

in cardiac insufficiency, 103, 597, 640, 1202 
in cerebral anemia, 1241 

hemorrhage, 1246 
myocardial overstrain, 654 



SYMPTOM INDEX 



KV3 



Drawsiness in acromegaly. 185 
in anemias. 146 
in aviator's syndrome. 1283 
in cerebral abscess. 1251 

anemia. 1241 

hemorrhage. 1246 
in diabetes mellitus, 1166 
in diabetic coma. 1166 
in encephalitis (lethargic), 1087 
in hemorrhage (cerebral), 1246 
in lethargic encephalitis, 1087 
in meningitis, 1080 
in opium poisoning. 1306 
in pericarditis. 801 
in tricuspid insufficiency. 706 
in trypanosomiasis, 1145 
in uremia, 247 
preceding sunstroke, 1283 
Dryness, of buccal cavity, 35 

from mouth breathing, 35 

in mumps, 35 
of cornea, in tumors of brain. 1245 
of eye, in collapse, 32 

goiter. 32 
of hair, in Leishmaniasis. 1060 

in myxedema. 178 

in sporadic cretinism, 177 
of lips, in aconite poisoning, 1303 

in adynamic states, 34 

in coma, 34 

in febrile conditions, 34 

in nasal obstruction, 34 
of mouth, in botulism, 1289 

in goiter, 183 

in mumps, 1068 

in simple stomatitis. 35 
of mucous membrane, in lesions of trifacial 
nerve, 1232 

in acute bronchitis, 345, 346 
of throat, in atropin poisoning, 1303 

in atrophic pharyngitis. 339 
of tongue, in Asiatic cholera, 1032 

in coma, 79 

in fevers, 36 
of skin, in acute nephritis, 256 

in bubonic plague, 1033 

in carcinoma, 20 

in diabetes insipidus, 1169 

in diabetes mellitus, 20, 1166 

in fevers, 75 

in interstitial nephritis, 20 

in malnutrition, 20 

in morphin addicto, 62 

in myxedema, 20, 178, 179 

in pneumonia, 71 

in sporadic cretinism, 177 

in syringomyelia, 1260 

in typhoid. 71 
secretory, 35 
Dulness, cardiac (heart), 293. 432. 439, 440, 
441, 442, 443, 454, 461, 679. 686, 746 

in aortic insufficiency, 710. 718 
stenosis, 725 

in cardiovascular syphilis. 75 7 

in emphysema, 354 

in mitral stenosis, 693, 700 

in myocarditis, 670 

in pulmonary insufficiency, 730. 731 

in valvular lesions. 746 



Dulness in abdominal examination. 24. 808, 810. 

S3-' 
in abscess (pulmonary), 4*9. 4^o 
in aortic aneurysm. 585. 775. 777. 77*. "81 
in ascites, 24 

in compression of lung. 367. 399 
in effusion (pleural). 281 
in emphysema, 454 
in examination of abdomen. 808. 810. 832 

of chest, 280. 281. 293 

of kidney, 814 
in gastroptosis, 891 

in hour-glass contraction of stomach. 90: 
in lymphatism, 176 
in pericarditis, 789. 797. 798. 799. 800 
in pleurisy. 363, 365. 367. 37 1. 375 
in pneumothorax. 298, 379 
in pulmonary abscess, 419. 4^o 

and pleural hydatids, 425 

edema. 301 

tumors, 421 
in splenic tumor, 812 
in tuberculosis, 300, 417 
liver, 293, 810, 1004 

in acute yellow atrophy, 974 

in emphysema, 353 

in examination of abdomen, 810 

in lungs, 293, 294 

in peritonitis, 960 

in stomach, 832 

in typhoid, 1004, 1006 
manubrial, 176 

mental (hebetude, torpor, etc.). in anemias, 
146 

in cerebral abscess. 1251 

in cretinism, 177 

in lethargic encephalitis. 1087. 1088 

in meningitis, 1081 

in pellagra, 1290 

in Raynaud's, 1270 1 

in typhoid fever. 1004, 1006 
modified, 292, 296, 299 
percussion, 292, 293. 391, 419- 412, 585. 

693. 757. 775. 777. 78i, 799. 901 
pulmonary, 299 

in (broncho,), 397. 398 

in lung cavities, 300 

in pneumonia, 299. 3S7. 390, 391 
shifting, 24 

in effusions, 281, 363- 307 

in transudates, 363, 367 
thoracic areas of. 379 
Dysarthria, 1202 

in bulbar paralysis. 1264 
Dyslexia. 1203 

Dysphagia, in aneurysm (aortic), 5S5. 775 
in brain tumors, 1245 
in bulbar paralysis. 1264. 1265 
in carcinoma of esophagus. 904 
in cerebral hemorrhage, 1248 
in esophageal carcinoma. 904 

strictures, 902 
in esophagitis, 901, 903 
in hemorrhage (cerebral), 1248 
in laryngitis (tuberculous). 344 
in lockjaw (tetanus), 11 26 
in lesions of medulla oblongata. 12 13. 

vagus, 1236 
in multiple sclerosis, 1240 



i3 2 4 



SYMPTOM INDEX 



Dysphagia in paralysis (bulbar). 1264. 1265 
in poisoning (acid), 1302 

atropin, 1303 

cantharides, 1303 
in quinsy, 342 
in rabies, 11 24 
in tetanus (lockjaw). 11 26 
in tonsillitis. 342 
in trichiniasis, 1138 
in tuberculous laryngitis. 344 
in tumors of brain, 1245 
Dysphonia in aneurysm (aortic). 585. 5S6 

in tumors of larynx, 344 
Dyspnea, 105 

and cyanosis, 16, 105 

and polycythemia, 162 

apparent, 592 

breathing in, 105 

chest outline, changes in, 107 

" Cheyne-Stokes." {See Breathing.) 

circulatory, 105, 435. 436 

continuous, 248 

exertion, 106, 146, 436, 600, 670, 1296 

fatal, 107 

feigned, 1296 

from corset pressure, 640 

from foreign bodies in bronchi, etc.. 105, 351 

in abscess, subphrenic, 961 

retropharyngeal. 341 
in acute myelitis, 1262 
in anemias, 106, 146, 631 

Addison's pernicious. 152 
in aneurysm, 776, 778 
in angina pectoris, 106 
in anthrax (internal), 11 23 
in aortic insufficiency, 721 
in aortitis, 736 
in arteriosclerosis, 766 
in asthma, 50, 105, 106, 355, 359, 360 

cardiac, 106, 359 
in aviator's syndrome, 1283 
in beri-beri, 1291 
in botulism, 1289 
in bronchiectasis, 349 
in bronchiolitis, 347, 397 
in bronchitis, 346, 347 
in cardiac decompensation. 105, 490, 639, 

647, 648 
in cardiovascular syphilis, 756. 750. 760 

frequently recurring, 756 
in croup, 105, 343 

membranous, 1075 
in coma (diabetic), 248, 1166 
in diabetes, 106 
in diabetic coma, 1166 
in diphtheria, 1075 

laryngeal, 105 
in "drop" heart. 490. 597. 600. 606 
in edema of glottis, 343 
in emphysema, 106, 352, 354- 35 5 
in endocarditis, 675. 676. 683. 1012 
in effusions, 106, 365 
in exertion, 106 

in anemias, 106, 146, 631 

in aortitis, 106 

in bronchitis, 106 

in cardiac disease. 106 

in cardiovascular syphilis. 756 

in chlorosis, 146 



Dyspnea, in exertion, in decompensation, 106, 
639 

in 'drop" heart. 490. 597. 600, 606 

in emphysema, 106 

in effusions (pleural), 106 

in examination of heart. 436, 490 

in mitral regurgitation. 687 

in myocardial degeneration. 670 

in myxedema, 178 

in pericarditis, 787. 800 

in pulmonary edema, 106 
embolism, 106 

in snuff habituation, 61 

in syphilis, 1107 

in tricuspid regurgitation, 630, 631, "03, 
706 

in tuberculosis, 106, 416 

in uremia, 106 

simulated, 1296 
in fatty heart, 670 
in gastritis, 906 
in gout (retrocedent), 1173 
in heart disease, 51, 436, 446, 490, 625, 648, 
664, 666, 670 

"drop," 490, 597, 600, 606, 625 

fatty, 670 
in Hodgkin's disease, 51, 167, 756 
in infarct (pulmonary) in, 418, 419 
in infections, 446 
in influenza, 102 1 
in leukemia (myeloid), 157 
in Landry's paralysis, 1263 
in lymphatism, 176 
in mediastinal pressure, 106 

tumors, 756 
in mitral regurgitation. 68 7 

stenosis, 435, 701 
in mountain sickness, 1282 
in myelitis (acute), 1262 
in myocarditis, 666 
in nephritis, 263, 480 
in pericarditis, 787. 800 
in pleurisy with effusion, 365. 37 1 
in pneumonia, 105, 389, 393 

broncho, 396. 397 
in pneumothorax, 378, 482 

blood pressure in, 482 
in poisoning, acid, 1302 

carbolic, 1304 

corrosive sublimate, 1304 

gelsemium, 1305 

mushroom, 1305 

strychnin, 1307 
in pulmonary and pleural hydatids, 425 

congestion, 400, 401 

fibrosis, 106 

infarct, 418, 419 

insufficiency, 730 

stasis, 105 

stenosis, 736 
tumors, 421 
in quinsy, 105 
in rabies, 11 24 
in stenosis of glottis, 105 
in subphrenic abscess, 961 
in syphilis, 11 07 

in tricuspid insufficiency, 703. 706 
in tumors of bronchi, 105 
of larynx, 344 



SYMPTOM INDEX 



T325 



Dyspnea in tumors of mediastinum, 75" 
pulmonary, 421 
in tuberculosis, 105, 406. 410, 416 
in uremia, 105, 106, 248 
in venous stasis, 706 
indicated on polygram, 515 
objective, 105, 436, 490 

in cardiovascular insufficiency, 647 

in mitral regurgitation, 687 

in tuberculosis, 406 
obstructive, 105 

lung borders in, 296 

in laryngeal diphtheria, 105 

in pneumonia, 105 
orthopneic, 107, 435, 560, 756, 787. (See 

also Dyspnea of recumbency.) 
of recumbency (orthopnea), 50, 107, 436, 
560, 647 

in aneurysm, 107 

in aortic insufficiency, 741 

in ascites, so, 107 

in asthma, 50, 107 

in decompensation, 51, 107 

in effusions, 107 

in emphysema, 107 

in Hodgkin's disease, 51 

in mediastinal tumors, 50, 107 

in paroxysmal tachycardia, 560 

in pericarditis, 50, 801 

in pleurisy, 51 
paroxysmal (and spasmodic), 6, 106 

in aortic aneurysm, 107, 776 

in aortitis, 106 

in asthma, 106 

in cardiac insufficiency, 106, 640 

in croup, 106 

in laryngismus stridulous, 106 

in mitral regurgitation, 687 

in pericarditis, 787 

in pulmonary edema, 106 
stenosis, 736 

in retropharyngeal abscess, 341 

in tumor below glottis, 107 

in uremia, 248 
persistent, 106, 609 

in cardiac decompensation, 106 

in cardiovascular syphilis, 756 

in emphysema, 106 

in stenosis of air passages, 106 
production of, 446, 480 
recurrent, in cardiac insufficiency, 640 
stridor, 105 
subjective, 105, 446, 490 

in cardiovascular insufficiency, 105, 647 

in endocarditis, 675 

in hydrophobia, 1124 

in myocarditis, 666 

in psychasthenia, 105 

in strychnin poisoning, 1307 

in tuberculosis, 406 

in uremia, 105 
sudden, in pulmonary infarct, 418 
suffocative, in diphtheria, 1075 

in lymphatism, 176 
vagus over-action in, 470 
Dysuria, 191 

in colic (renal), 86 

in cystitis, 273 

in locomotor ataxia, 1255 



Dysuria in poisoning (cantharides), [303 

in prostatitis, 274 
in rc>nal colic, 86 

tuberculosis, 270 
persistent , 270 



Earache. 33 

in infections, 33 
Ecchymoses, 27, 1228 
in hemophilia, 170 
in pertussis, 327 
in plague (bubonic), 1033, 1034 
Ectasia, 824, 878, 887, 919 

in atony (gastric), 886, 887, 888 
in carcinoma (gastric), 935 
pain in gastric ulcer with, 912 
post -stenotic, 899 

syphilis of stomach resembling, 936 
Edema (dropsy, anasarca), 20, 21 
and chloride retention, 20, 213 
anginoneurotic, 21, 183, 1270, 1271 

familial, 1269 

of glottis, 21 
bilateral, 22 

blood pressure, laking in presence of, 474 
blue, 23 
cachectic, 23 

cardiac, 21, 22, 24, 435, 436, 460, 461, 636, 
648, 649, 704 

secondary, 23, 625, 630, 636, 645, 646, 67a 
cardinal signs of, 21 
cerebral, 1241, 1252 
circumscribed, 22 
diurnal, 21, 22 

in cardiac decompensation, 21, 646 
incompensation, 632 
. effect of posture on, 22 
elusive, 22 
feigned, 1296 
following tonsillitis, 264 
fugitive, in pulmonary congestion, 401 

glomerulonephritis, 258 
gangrenous, in anthrax, 1123 
general, 436, 560 
gravity, in sprue, 1064 

in heart disease, 21, 22, 625, 649, 701 
hemorrhagic, 102 1 
hydremic, 26, 22 
in abscess of liver, 22, 966 

perinephritis, 22 
in amyloid kidney, 266 
in anemias, 21, 23 
in aneurysm, 776, 778 
in ankylostomiasis, 1139, 1140 
in anthrax, 1123 
in arteriosclerosis, 766 
in beri-beri, 23, 1291 
in Bright's disease, 21, 22, 23, 213 
in bubonic plague, 1033, 1034 
in carcinoma (gastric), 932 
in cirrhosis of liver, 971 
in congestion (pulmonary), 400, 401 
in dementia (paretic), 1252 
in dermatomyositis, 11 59 
in elephantiasis, 25 
in empyema, 22 
in epidemic dropsy, 1057 



1326 



SYMPTOM INDEX 



Edema in erysipelas, 11 18 
in filariasis, 1141 
in glomerulonephritis, 258 
in goiter, 183 
in gout, 1 172 
in heart disease, 21, 435 
in hysteria, 1279 
in influenza, 1021 
in lethargic encephalitis, 1087 
in leukemia, 23 
in locomotor ataxia, 1256 
in lymphangitis, 22, 23 
in Madura foot, 1130 
in mitral regurgitation, 687, 703. 704 

stenosis, 701 
in myositis (suppurative), 1161 
in nephritis, 20, 22, 256, 257, 258, 259, 260, 

262, 263, 632 
in neuritis, 22, 23, 98, 1267, 1268 
in obtaining blood for examination, 113 
in paretic dementia, 1252 
in paroxysmal tachycardia, 560 
in pericarditis, 22 
in pulmonary congestion, 400, 401 
in rheumatism (acute), 1153 
in scurvy, 23, 171 
in serum disease, 993 
in sinus thombosis, 1240 
in smallpox, 1097 
in sprue, 1064 

in suppurative myositis, 1161 
in syphilis, 11 09 
in syringomyelia, 1260 
in tricuspid insufficiency, 703, 704, 706 

stenosis, 727 
in trichiniasis (trichinosis), 23, 1013, 113 8, 

1159 
in uncinariasis, 1109, 1139, 1140 
indurative, in syphilis, 1109 
inflammatory, 20, 400 
infectious, 400 
. leathery, 22, 815 
localized, 22 

in aortic aneurysm, 776, 778 

in empyema, 374 

in examination of heart, 436 

in hepatic abscess, 966 
lymph, 25, 26 
marble, 22 

in nephritis, 257 
Milroy's, 20 
nocturnal, 22 
non-inflammatory, 22 
obstructive, 20 
of ankles, alone, 13 

in chlorosis, 150 

in mitral regurgitation, 687 

in myocardial degeneration, 670 

in nephritis, 259 

in scurvy, 171 
of arms, alone, 23, 4.2 

in aortic aneurysm, 776. (See also Edema 
of extremities.) 

in effusion, 23 

in thrombosis, 23 

in tumors, 23 
of calves, alone, 22 

of chest wall, in examination of heart, 438 
of cord, in periodic paralyses, 1269 



Edema of cord, in poliomyelitis. 1092 

of extremities, 21, 23, 42. (See also Edema 
of arms and legs.) 

in Addison's pernicious anemia, 146, 152 

in arteriosclerosis, 689 

in Bright's disease, 22 

in cardiac decompensation, 21 

in chlorosis, 146 

in endocarditis, 683 

in gastric carcinoma, 852 

in leukemia, 146 

in nephritis, 257 

in syringomyelia, 1260 

in toxic heart, 645 
of eyelids, 15. 3 1 

in anemia, 31 

in Bright's disease, 31 

in chronic poisoning, 31 

in nephritis, 15, 22, 256, 263 

in pertussis, 31 

in polymyositis, 1159 

in trichiniasis, 1138, 1159 
of face, 32 

in angioneurotic edema, 1270, 1271 

in cardiac disease, 435 

in nephritis, 22, 256, 259 

in polymyositis, 1159 

in trichinosis, 23, 1013, H59 
of feet, in angioneurotic edema, 1270, 127 1 

in myocardial degeneration, 670 
of glottis, 343 

in acute nephritis, 257 

in angioneurotic edema, 21, 1270, 1271 

in interstitial nephritis, 263 

in laryngitis, 343 

in quinsy, 342 
of hands, in angioneurotic edema, 1270, 1271 
of head, 23 
of joints, 43 
of larynx, in acute rheumatism, 1153 

in serum disease, 993 

in smallpox, 1097 
of legs, 20, 22, 42. (See also Edema of 
extremities.) 

in arteriosclerosis, 766 

in cardiac decompensation, 645 (Fig. 292) 
dilatation, 636 (Fig. 286) 

in gastric carcinoma, 932 

in interstitial nephritis, 632 (Fig. 282) 

in tricuspid regurgitation, 704 (Fig. 315) 

due to varicose veins, 22 
of lungs, 385 

in hemorrhagic pneumonitis (influenza;, 
1021 

in pneumonia, 382 

in trench gas poisoning, 348 
of malignant anthrax, 1123 
of mucous membranes in bronchitis, 345, 

346 
of neck, 23 
of polymyositis, 1159 
pitting in, 649, H59 
progressive, in pericarditis, 801 
pulmonary, 301, 399, 400, 1263 

("infectious" or "inflammatory"), 400 

in anthrax, 1123 

in arteriosclerosis, 766 

in decompensation, 632 (Fig. 282), 648 

in Landry's paralysis, 1263 



SYMPTOM INDEX 



1327 



Edema, pulmonary, in mitral regurgitation, 687 
in nephritis, 268 
in rheumatism (acute;, 11 53 
dyspnea in, 106 
renal, 22, 24 

in decompensation, 648, 640 
retinal, in nephritis, 263 
sacral, 43 
simulated, 1296 
transient, 21 

in serum disease, 993 
unilateral, 22 
vagaries of, 21 
Effort syndrome. (See Soldiers' Hearts.) 
Effusion (exudate;, 24. (See also Edema and 
Ascites.) 
abdominal, 24, 805, 812 
and loss of resonance, 279 
aspiration of, 36s. 368, 801 
examination of chest in, 279, 280, 281, 296, 

310 
hemorrhagic, 307 

in pericarditis, 782, 797 
subcutaneous, 26 
in amyloid kidney, 266 
in arthritis deformans, 1156 
in lobular pneumonia, 394 
in renal edema, 22 
joint, 44 

in arthritis deformans, 1156 
in locomotor ataxia, 1256 
intermittent, 1271 
massive, 24, 365, 368 

in pericarditis, 798, 799, 800 
in pleurisy, 363, 368 
in roentgenography, 577 
pericardial, 84, 296, 432, 437, 438, 440, 441, 
782 (Fig. 355), 783 (Fig. 357), 786, 794. 
796, 797, 799. 78o, 801, 802, 1137, 11S2 
and esophageal obstruction, 902 
blood pressure in, 482 
breathing in, 307 

cardiac outline in, 782 (Fig. 355). 797 
complicating acute rheumatism, 11 52 
in angina pectoris, 769 
in decompensation, 649 
in nephritis, 259, 264 
in pulmonary stenosis, 736 
in roentgenography, 571, 577, 581, 783 
in tricuspid insufficiency, 705 (Fig. 316) 
pulse in, 494 
symptoms of, 789, 791 
vomiting in, 872 
itoneal, 22, 649, 962 
ersistent, 797 
eural, 84, 280, 281, 287, 296, 302 (Fig. 119), 

363, 366, 370 (Fig. 137), 1137 
blood pressure in, 481, 484 
breathing in, 307, 310 
change in chest outline, 107, 285 
chest in, 287, 298, 301, 367 
coma in, 82 
decubitus in, 50 
displacement of heart in, 322, 323, 368, 

431. 437, 438, 440. 802 
examination of chest in, 287, 298, 301, 367 
in arteriosclerosis, 766 
in bronchiectasis, 350 
in chylous pleurisy, 426 



Effusion, pleural, in decompensation, myocardial, 
649 

in hydrothorax, 383 

in influenza, 1022 

in nephritis, 264 

in pleurisy, 361, 362, 363, 364 

in pneumonia, 385, 387, 391 

in pneumothorax, 376, 378 

in pulmonary and pleural hydatids, 425 

in tricuspid insufficiency, 706 
purulent, 797 

in pericarditis, 782, 801 

in pleurisy, 362 
sanious, in pericarditis, 782, 797, 801 
serous, 358 

in empyema, 374 

in examination of abdomen, 812 

in leukemia (myeloid), 157 

in pericarditis, 782, 794, 797 

in pleurisy, 362, 365, 368, 370 
sign of, 44 
small, 24 

in proliferative peritonitis, 962 
Egophony, 309 

in pericarditis, 798 
in pleural effusions, 309 
in pleurisy, 371 
Ehrlich's typhoid diazo reaction, 245, 246 

in infection, 246 
Emaciation. 13, 54 
causes of, 55, 56 
facial, in hemiatrophy, 31 
feigned, 1294 

in abdominal examination, 806, 823 
in achylia, 881, 934 
in advanced age, 56 
in anorexia nervosa, 879 
in arsenical poisoning, 1288 
in arthritis deformans, 1156 
in asthenia (congenital), 56, 605, 607, 623, 871 
in atrophy (progressive muscular), 1264 
in carcinoma, 12 

of esophagus, 904 

of pancreas, 964 

of stomach, 12, 56, 934, 935 
in cysts (pancreatic), 964 
in diabetes insipidus, 1169 

mellitus, 56 
in dysentery, 948 
in fevers, 56 
in gastric carcinoma, 934, 935 

syphilis, 936 

ulcer, 934 
in gastritis, 906 
in goiter, 183 
in Hodgkin's disease, 166 
in hyperchlorhydria, 868 
in hysteria (traumatic), 1281 
in infantile meningitis, 1086 
m infection (trematoda), 1134 
in Leishmaniasis, 1060 
in leukemia, myeloid, 157 
in meningitis, infantile, 1086 

tuberculous, 1083 
in miliary tuberculosis, 406, 1011 
in pancreatic cysts, 964 
in pellagra, 1290 
in poisoning (arsenical), 1288 
in progressive muscular atrophy, 1161. 1264 



1328 



SYMPTOM INDEX 



Emaciation in sprue, 1064 

in starvation, 56 

in syphilis (gastric), 936 

in traumatic hysteria, 1281 

in trematoda infection, 11 34 

in trypanosomiasis, 1145 

in tuberculous meningitis, 1083 

in tuberculosis, 56, 406, 416, 1011 

in tumors of brain, 1243 

inquiry concerning, 67 

progressive, 56 
Emboli, bacillary, in leprosy, 1121 

cerebral, 1190, 1249, 1250 

formation, 673 

in endocarditis, 677 

in fever (typhoid), 1002 

in infarct (pulmonary), 419 

in infection, 980 

in intestinal arteries, 953 

in systemic arteries, 739 

of skin, 677 
Embryocardia, 449 
Emprosthotonos, 51. 1126 
Enlargement (swelling) , of bones- in acromegaly, 

185 

in myeloma, 161 

in pulmonary hypertrophic osteoarthro- 
pathy, 189 
of central canal of cord in syringomyelia, 1260 
of chest, 283 

in asthma, 107, 359 

in pleural effusion, 107 
of extremities, 42 

in angioneurotic edema, 1271 

in elephantiasis, 26 

in lymphedema, 26 
of foot, in acromegaly, 184, 185 

in Madura foot, 11 29, 1130 

in pulmonary hypertrophic osteoarthro- 
pathy, 189 
of gland (thyroid), in neurasthenia, n 84 
of glands, 43 

in adenitis (tuberculous), 167 

in anemia (aplastic pernicious), 154 

in anthrax, 11 23 

in diphtheria, 1075 

in erysipelas, 11 18 

in Hodgkin's disease, 43, 51, 160, 164, 
165, 166 

in leukemia, 43 

lymphatic, 158, 160 

in lymphangitis, 23 

in lymphatism, 175. 176 

in lymphosarcomatosis, 167 

in mumps, 1068 

in phlebitis, 23 

in quinsy, 342 

in rat bite fever, 1061 

in stomatitis (ulcerative), 36 

in syphilis, 34. 160, 167, 1107 

in trypanosomiasis, 114 5 

in tuberculin tests, 413 

in tuberculosis, 160, 167 

in whooping cough, 1104 
of hand, 40 

in acromegaly, 184, 185 

in myxedema, 41, 179 

in pulmonary hypertrophic osteoarthro- 
pathy, 189 



Enlargement of head, in acromegaly, 185, 186 

in cretinism, 177 

in hydrocephalus, 30 

in osteitis deformans, 31, 188 

in oxycephaly, 31 
of heart. (See Heart, dilatation, cardiac.) 
of joints, 45 

in arsenical poisoning, 1288 

in blastomycosis, 11 28 

in joint effusions, 1271 

in scurvy, 172 
of lips, 34 
of liver, 6 

and cardiac displacement, 438 

and loss of resonance, 279 

in amyloid kidney, 266 

in anemia (aplastic pernicious), 154 
(splenic), 154 

in Banti's disease, 155 

in Brazilian trypanosomiasis, 1146 

in congenital hemolytic jaundice, 156 

in erythremia, 163 

in Gaucher's disease, 155 

in glandular fever, 1058 

in Hodgkin's disease, 167 

in leishmaniasis, 1060 

in leukemia (myeloid), 157 
in lymphatic, 159 

in paroxysmal tachycardia, 560 

in relapsing fever, 1049 

in rickets, 11 75 

in splenomegaly of Gaucher type, 155 
with hepatic cirrhosis, 155 

in syphilis, 1111 

in trematoda infection, 1134 
of lungs, and cardiac displacement, 438 

in emphysema, 35 1, 352 
of lymph glands, in erysipelas, 11 18 

in Hodgkin's disease, 164, 165, 166 

in leukemia (lymphatic), 158, 159 

in Still's syndrome, 161 

in trypanosomiasis, 1145 
of lymph nodes, in Brazilian trypanosomia- 
sis, 1146 

in leukemia (lymphatic), 158 

in yaws, 11 14 
of muscles, in muscular dystrophy, 1265, 

1266 
of sella turcica, 185, 186 
of skull, in achondroplasia, 189 

in cretinism, 177 

in hydrocephalus, 1242 
of spleen, in amyloid kidney, 266 

in anemia (aplastic pernicious), 154 
pernicious, 156 
splenic, 154 

in Brazilian trypanosomiasis, 1146 

in erythremia, in, 163 

in glandular fever, 1058 

in Hodgkin's disease, 164, 166, 167 

in internal anthrax, 11 23 

in Landry's paralysis, 1263 

in leishmaniasis, 1060 

in leukemia (lymphatic), 158, 160 
myeloid, 157 

in lymphatism, 176 

in malaria, 1045, 1048 

in Malta fever, 1054 

in meningitis, 1080 



SYMPTOM INDEX 



1329 



Enlargement of spleen in relapsing fever, 1040 

in rickets. 1175 

in Rocky mountain spotted, [056 
in six -day fever, 1050 
in splenomegaly, 154. 155 
in Still's disease, 161, 1157 
in syphilis, 11 n 
in trench fever, 1065 
in trypanosomiasis, 1145 
in tuberculosis, 406 
of thymus, in lymphatism, 176 
of thyroid, in acromegaly and myxedema, 
186 
in exophthalmic goitre, 179, 180 
in lymphatism, 176 
in neurasthenia, 11 84 
of tongue, 37 

in acromegaly and myxedema. 37 
in cretinism. 177 
in myxedema, 178 
of tonsils, in scarlet fever, 1070 
of veins, in hepatic cirrhosis, 27, 28 

in intrathoracic tumors, 28 
permanent, in elephantiasis, 26 
progressive, in acromegaly, 184, 185, 186 
Eosinophilia, 139 

as a clinical sign, 139, 140 
associated with intestinal parasites. 139 
in ankylostomiasis, 11 39 
in asthma (spasmodic), 140 
in bronchitis, 347 
in echinococcus disease, 426 
in fever (scarlet), 140 
in Hodgkin's disease, 166 
in hydatid disease, 139, 426 
in leukemia (myeloid), 157 
in measles (absent), 140 
in syphilis, 140 

in trichiniasis, 139, 1138, 1160 
in whooping cough, 1104 
Epistaxis, 337 

and associated conditions, 337 
and paroxysmal cough, 327 
in Banti's disease, 155 
in bubonic plague, 1033 
in fever (Rocky Mountain spotted), 1055 
typhoid, 1003, 1004, 1005 
yellow, 1037 
in hemophilia, 170, 337 
in influenza, 102 1 
in leprosy, 1120 
in "renal," 223 
in sinus thrombosis, 1240 
in splenomegaly with hepatic cirrhosis, 155 
Eruption. (See Rash.) 
Erythema, in aortic insufficiency, 710 
in Brill's disease, 1053 
in cutaneous lesions (feigned), 1295 
in dengue, 1035 
in dermatomyositis, n 59 
in dropsy (epidemic), 1057 
in epidemic dropsy, 1057 
in Escherich's infection, 1073 
in feigned cutaneous lesions, 1 295 
in fever (miliary , 1057 
trench, 1065 
typhoid, 1006 
typhus, 1053 
in gout, 1 172 

84 



Erythema in infections, 1073 
Escherich's, 1073 
in influenza, 1020 

in lethargic encephalitis, 1088 
in meningitis, 108 1 
in neuritis, 98 
in pellagra, 1 2O0 
in tuberculin reaction, 414 
syphilitic, 341 
Erythemia and enlargement of liver, 810 
and blood content, 463 
secondary, in pulmonary stenosis, 736 
Erythrocytosis, 162, 163 
and cyanosis, 16 
and high altitudes, 162 
causes of, 162 

in acute yellow atrophy, 162 
in erythremia, 163. 164 
in myxedema, 162 
Euchlorhydria, 867 

Exhaustion (prostration, asthenia, weakness), 14, 
102. (See also Fatigue.) 
and cardiac weakness, 588 
and congestion of lung, 400 
and use of stomach tube, 849 
bone marrow, 855 

cardiac, in acute infections, 446, 590 
in arteriosclerosis, 766 
in aviator's syndrome, 1283 
in fevers, 76 
in goiter (exoph.), 180 
in leukemia, lymphatic, 160 
in mitral regurgitation, 685 
in oxalic acid poisoning, 1306 
in pulse in, 490 
in temporary, 464 
circulatory, in scurvy, 171 
death from, 67 
delirium in, 1202 
gums in, 38 
heat, 1284 
in acromegaly, 186 
in Addison's disease, 173. 174 
in anemias, 145, 186 
in anthrax, 1123 
in aortic insufficiency, 714 
in arthritis deformans, 1156 
in Brill's disease, 1053 
in bronchiectasis, 350 
in bubonic plague, 1033 
in carcinoma, gastric, 932 
in cardiac insufficiency, 102 
in compression myelitis, 1261 
in delirium tremens, 1286 
in dementia (paretic), 1252 
in diabetes mellitus, 1166 
in diarrhea, 864 
in diphtheria, 1075 
in dysentery, 948 
in encephalitis (lethargic), 1087 
in fever, 76 

typhoid, 1004, 1005, 1006 
typhus, 1052 
in gastric carcinoma, 932 
in hysteria (traumatic), 1281 
in infections, 588 
in influenza, 597, 1019 
in leishmaniasis, 1061 
in lethargic encephalitis, 1087 



133° 



SYMPTOM INDEX 



Exhaustion in leukemia (lymphatic), 1591 
in lupinosis, 1132 
in meningitis, 1081 
in myasthenia gravis, 1267 
in myelitis (acute), 1261 

compression, 1262 
in myocardial overstrain, 658 
in myocarditis, 666 
in neurasthenia, 1176 
in noma. (See Stomatitis.! 
in paroxymal tachycardia, 560 
in paralysis agitans, 1267 
in paretic dementia, 1252 
in pericarditis, 801 
in pneumonia (broncho), 396 
in poisoning (aconite), 1303 

arsenical, 1288 

gelsemium, 1305 

meat, 1132 

potassium chlorate, 1307 

strychnin, 1307 
in quinsy, 342 

in rheumatism (acute), 1152 
in rickets, 11 75 
in sclerosis (primary combined), 1256 

lateral, 1257 
in scurvy, 171 
in shock and collapse, 109 
in sprue, 1064 
in stomatitis (gangrenous), 36 

ulcerative, 36 
in tonsillitis (suppurative), 342 
in traumatic hysteria, 1281 
in trypanosomiasis, 1145 
in typhoid fever, 1005 
in typhus fever, 1052 
in whooping cough, 1104 
muscular, in anemias, 14s 

Addisonian pernicious, 151 

botulism, 1288, 1289 

congenital asthemia, 505 

multiple sclerosis, 1240 

paralytic vertigo, 1270 
myocardial, 76, 451, 608 
nervous, in neurasthenia, 1176 
of respiratory center, 108 
physical, 102 
psychosis, 76 
temperature in, 73 
Expression. (See Facies.) 



Facies (physiognomy), 12, 13, 15 
adenoid, 340 

asphyxial (in chlorine gas poisoning), 348 
Bright's disease, cachectic, 266 
Hippocratic, in appendicitis, 956 

Asiatic cholera, 1032 

peritonitis, 960 

shock and collapse, 100 
hysteric, 81, 102 

traumatic, 1281 
in acromegaly, 185, 186 
in adenoids, 340 
in amyloid kidney, 266 
in anemia (Addisonian;, 151 
m angina pectoris, 769 
in ankylostomiasis, 1139 



Facies in asthma (spasmodic), 359 
in bronchiectasis, 349 
in carcinoma, 12, 929 
in cardiac decompensation, extreme, 435 
in congenital syphilis, 31 
in cretinism, 177 
in erythremia, 163, 164, 435 
in facial hemiatrophy, 31 
in fever (scarlet). 1070 

typhus, 1051, 1053 

yellow, 1036 
in goiter, exophthalmic, 32 
in heart disease 433 
in hydrocephalus, 30 
in hysteria (traumatic), 1281 
in leontiasis ossea, 31 
in myocarditis, 666 
in myxedema, 178, 179 
in nephritis, 12, 256, 263 
in osteitis deformans, 31 
in oxycephaly, 31 
in Paget 's disease, 31 
in pellagra, 1290 
in pneumonia, 389 

broncho, 397 
in pneumothorax, 378 
in poisoning (chlorine gas), 348 

hydrocyanic acid, 1305 

strychnin, 1307 
in pseudo-muscular hypertrophy, 1266 
in rickets, 30 
in smallpox, 1097 
in spasmodic asthma, 359 
in syphilis, 12, 13, nil 
in tetanus, 11 26 
in tuberculosis, 416 
leontine, in leprosy, 1121 
risus sardonicus, 562, 11 26, 1307 
sub-icteric, in decompensation, 435 
Fatigue and fatigability. (See also Exhaustion.) 
and acute myelitis, 1261 
and muscular cramp, 1162 
and myalgia, 1162 
and nephritis, 255, 258 
and pneumonia, 385 
and tonsillitis, 1150 
and trench nephritis, 266 
cardiac in angina pectoris, 772 
in acute rheumatism (arthritis), 1155 
in arteriosclerosis, 765 
in asthenia, 102, 150 
in aviator's syndrome, 1283 
in chlorosis, 150 
in drop-heart, 895 (Fig. 389) 
in heart disease, 606, 608 
in leukemia, 159 
in neuralgia, 94 
in neurasthenia, IT79, 1181 
in neuritis, 98, 1267 
in primary lateral sclerosis, 1257 
in simulated mania, 1298 
mental, in congenital asthenics, 606 
muscle, in myasthenia gravis, 1267 
muscular, in feigned joint disease, 1295 
Fever, 67, 71, 72, 73 

absence of, 74 1 

agonal, 73 

and chill, 75 

and convulsions, 75 



SYMPTOM INDEX 



1331 



Fever and digestive organs, 75 
and nervous system, 75 
and pain, 84 
and rash, 7 5 
asthenic, 76 
delirium in, 75 
heart muscle in, 76 
hysterical, 73. 1277 
in abscess, cerebral, 1251 

of brain, 91 

of liver, 966 

pulmonary, 420 
in acute cholecystitis, 976 

cystitis, 273 

miliary tuberculosis, 1011 

myelitis, 1261 

perihepatitis, 973 

rheumatism, 1151 

tuberculous arthritis, 1154 

yellow atrophy, 974 
in adenitis (tuberculous), 1034 
in anemia, 74. 145 

Addison's pernicious, 152 
in aneurysm (abdominal), 90 
in anthrax, 1123 

internal, 11 23 
in apoplexy, 74 
in appendicitis, 90. 954. 955 
in arthritis (acute tuberculous;, 1154 

syphilitic, 1157 
in Asiatic cholera, 1032 
in atrophy, acute yellow, 973 
in Bell's mania, 75 
in biliary colic, 978 
in blastomycosis, 1128 
in Brazilian trypanosomiasis, 1146 
in Brill's disease, 1053 
in bronchiectasis, 349 
in bronchiolitis, 347 
in bronchitis, 345, 346 
in bubonic plague, 1033 
in carcinoma, gastric; 932 
in cerebral abscess, 1251 

embolism, 74. 81 

hemorrhage. 1247 

rheumatism, 1153 
in chickenpox, 77, 1102, 1103 
in chlorosis, 145 
in cholecystitis (acute;, 976 
in cholelithiasis, 978, 979 
in cholera, 71. 73 
in chorea, 1275 
in colic (colon), 90 

biliary, 978 

gallstones, 90 

renal, 90 
in constipation (spastic) , 90 
in cystitis, 273 
in delirium tremens, 1286 
in dengue, 1035 
in dermatomyositis, 1159 
in diarrhea, 944 
in Diel's crisis, 268 
in diphtheria, 1074 
in dysentery, 948 
in elephantiasis, 26 
in empyema, 374. 375 
in epidemic dropsy, 1057 
in epilepsy, 1272 



Fever in erysipelas, 1118 

in "exhaustion," 74. 75 
in fever, flood, 1058 

glandular, 1058 

Malta, 1053. 1054 

miliary, 1057 

milk, 1057 

Oroya, 1062 

paratyphoid, 100 1 

rat bite, 1061 

relapsing, 1049, 1051 

Rocky mountain spotted, 1055 

scarlet, 77, 1069. 1070, 1071 

seven-day, 1059 

six day, 1059 

trench, 1065 

typhoid, 71, 74. 78, 1001, 1003, 1004, 
1005. 1006, 1014 

typhus, 1051, 1052 

yellow, 1035, 1036 
in filariasis, 1142 
in flood fever, 1058 
in fourth (Duke's;, disease, 1073 
in gastric carcinoma, 932 
in gastric and duodenal ulcer. 919 

perforation of, 926 
in glanders, 11 26 
in glandular, fever, 1058 
in gout, 1 172 

chronic, 1174 
in heat exhaustion, 74 
in hemorrhage, cerebral, 1251 
in Hodgkin's disease, 166, 167 
in hydatids (pulmonary and pleural), 425 
in hysteria, 73. 81 
in indigestion, intestinal, 944 
in infections, 73, 75, 76 
in inflammation of liver, 973 
in influenza, 1015, 1018, 1019- 1020. 1021 

1022, 1023, 1024 
in internal anthrax, 1123 
in intestinal obstruction, 89 
in Landry's paralysis, 1262 
in Leishmaniasis, 1060 
in leprosy, 1120 
in lethargic encephalitis, 1087 
in leukemia (lymphatic), 158, 159. 160 
in lymphedema, 26 
in malaria, 1037, 1045, 1048 
in Malta fever, 1053, 1054 
in measles, 77, 1066 

German, 77 
in meat poisoning, 1132 
in meningitis, 1079, 1080, 1081 

pachy-, 1238 

suppurative, 1084 

tuberculous, 1083, 1084 
in miliary fever, 1057 
in miliary tuberculosis, ion 
in milk fever, 1057 
in movable kidney, 268 
in mumps, 1068 
in myelitis (acute), 1261 
in myositis (dermato-), n 59 

poly-, 1 159. 1 160 

suppurative, 1161 

syphilitic, ti6i 
in nephritis (acute), 256 
in Oroya fever, 1062 



1 33 2 



SYMPTOM INDEX 



Fever in pachymeningitis, 1238 
in pancreatitis, 964 
in paratyphoid, 1001 
in pericarditis, 786, 791. 801 
in perihepatitis 'acute), 973 
in peritonitis, 74, 960 

tuberculous, 963 
in pestis major, 1034 
in pestis minor, 1033, 1034 
in pleurisy, 363, 369, 374 
in pneumonia, 7 1, 73. 74. 77. 375. 388, 391, 392 

broncho-, 396 
in poisoning .cocain), 1304 

lead, 90 

meat, 1132 

ptomain, 74 
in poliomyelitis, 1092 
in polymyositis, 1159 
in polyneuritis, 1268 
in pulmonary abscess, 420 
in pulmonary and pleural hydatids, 425 
in pulmonary tumors, 421 
in purpura, 168 

hemorrhagica, 169 
in pyelitis, 268, 269 
in pyemia, 11 19 
in quinsy, 342 
in rabies, 1124 
in rat bite fever, 1061 
in relapsing fever, 1049, 1051 
in renal infarct, 270 
in rheumatism (acute;, 44, 1151 

cerebral, 1153 

feigned, 1300 
in rickets, 1175 

in Rocky mountain spotted fever, 105.=; 
in rubella, 1072 

in scarlet fever, 1069, 1070, 107 1 
in septicemia, 1119 
in serum disease, 993 
in seven-day fever, 1059 
in six-day fever, 1059 
in smallpox, 77, 78, 1095, 1097, 1009 

vaccination, 1102 
in spinal injury, 73 
in stomatitis, 35 

gangrenous, 36 

ulcerative, 36 
in syphilis, 1107, 1109 
in syphilitic arthritis, 11 57 

gummata of liver, 973 

myositis, 1161 
in sunstroke, 74, 1283 
in suppurative meningitis, 1084 
in tetanus (lockjaw;, 11 26 
in tetany, 47 
in tonsillitis, 342 
in tracheo-bronchitis, 345 
in trematoda infection, 11 34 
in trench fever, 1065 
in trichiniasis, 11 38 
in trypanosomiasis, 1145 

Brazilian, 1146 
in tuberculin tests, 412 
in tuberculosis, 73, 145 

acute miliary, 300, 406, 10 11 
chronic, 410 
pneumonic, 407 
tuberculous adenitis, 1034 



Fever in tuberculosis, arthritis, 11 54 
meningitis, 1083, 1084 
peritonitis, 963 
in tumors (brain), 74 

pulmonary, 421 
in typhoid, 24s, 1001, 1003, 1004, 1005, 

1006, 1014 
in typhus fever, 1051. 1052 
in ulcer (gastric and duodenal), 90, 919, 926 

perforation of, 926 
in varicella (chickenpox) , 77, 1102, 11 03 
in whooping cough, 1105 
in yaws, n 12 

in yellow fever, 1035, 1036, 1037 
inquiry concerning, 67 
phenomena of, 75 
pulse in, 75. 76 
respiration in, 76 
sign of tuberculosis, 145 
significance of, 74 
simple continued, 10 12 
simulated, 1296 
sthenic, 76 
temperature in, 74 
termination of, 78 
types of, 73 
Fibrillation, auricular, 494. 509, 5U. 520, 529, 
53i. 551, 552, 553. 554. 555. 64s, 646, 
716 
indicated in electrocardiogram, 529, 531, 
551, 553. 554. 555 
polygram, 509, 5H, 55i. 552, 554, 555 
pulse in, 552 
Fibrinuria, 196 

Flatulence, and enlargement of heart, 785 
in achylia, 880 
in arteriosclerosis, 765 
in gastric and duodenal ulcer, 911, 914 

disorders, 871 
in gastritis, 905 
in Hill diarrhea, 1063 
in intestinal obstruction (volvulus), 88 
in neurasthenia, 1181 
in pneumonia (broncho-), 397 
in sprue, 1063 

in ulcer (gastric and duodenal), 911, 914 
preceding asthma, 359 
Flushing of face, 17, 102 
in alcoholism, 80 
in chlorosis, 150 
in fever, 17 
in migraine, 17, 93 
in pneumonia, 389 
unilateral, 17 
Formication, 101 

in apoplexy, 10 1 
in diabetes, 10 1 

in diseases of brain and cord, 10 1 
in drug habit, 62, 10 1 
in uremia, 247 
Fremitus and examination of chest, 28-7, 
288 
deductions concerning, 289 
in asthma, 361 
in atelectasis, 399 
in bronchitis, 346 
in congestion of lungs, 401 
in emphysema, 353, 355 
in pleurisy, 366, 368, 371. 375 



SYMPTOM INDEX 



333 



Fremitus, deductions in pneumonia. .587, 390, 
392 

broncho, 3 l >7 
in pneumothorax. 378 
in pulmonary and pleural hydatids. 425 
laws of, 288. 289 



Giddiness. (See Vertigo.) 



H 



Hallucinations (delusions), 1201 
feigned, 1298 
in alcoholism, 1085, 1285 
in delirium tremens, 1285 
in fevers, 75 

in Korsakoff's psychosis, 1285 
in meningitis, 1085 
in myxedema, 178 
in poisoning (atropin), 1303 
of hearing, in epilepsy, 1272 
of smell, in cranial nerve lesions. 1220 
Headache, 90, 99 

after lumbar puncture, 1083 

and nausea, 91 

anemic, 91 

asthenic, 94 

bilious, 91 

drug, 92 

feigned, 1297 

in abscess (cerebral), 1251 

in acromegaly, 185 

in adiposis dolorosa, 188 

in anemia (cerebral), 565, 1241 

in anemias, 91, 146 

add, per, 152 
in aortic insufficiency, 720 
in acute yellow atrophy. 974 
in arteriosclerosis, 765 
in Asiatic cholera, 1032 
in aviator's syndrome, 1283 
in atrophy, acute yellow, 974 
in botulism, 1288 
in Bright's disease. 92 
in Brill's disease, 1053 
in brain abscess, 91 
in brain tumor, 91, 1086 
in cerebral anemia, 565, 1241 

abscess, 125 1 

congestion, 1241 

hemorrhage, 1246 

rheumatism, 1153 

thrombosis, 1250 
in chronic meningitis, 988, 1086 
in congenital astnenia, 897 
in constipation, 91 
in dengue, 1035 
in diabetes mellitus, 1 166 
in diabetic coma, 83, 1166 
in epilepsy, 1272 
in erythromelalgia, 1270 
in fever, typhoid, 1003, 1004. 1005 

Rocky mountain spotted, 1055 

trench, 1065 

typhus, 1052 

yellow, 1036 
in fevers, 75 



Headache in gastritis. 905 
in gout, 91, 1 173 
in heart block, 565 
in hyperchlorhydria, 868 
in hemorrhagic pachymeningitis, 1238 
in hydrocephalus, 1242 
in hysteria, 93 
in influenza, 1018 
in jaundice, 91 

in lethargic encephalitis, 1087 
in leprosy, 11 20 
in lesions of cerebellum, 12 13 
in Marie's disease, 185 
in meningitis, 146, 1079, 1080 

chronic, 1086 

serous, 1085 

syphilitic, 1084 
in malaria, 70, 92, 1048 
in meat poisoning, 1182 
in migraine, 92, 93 
in middle-aged women, 93 
in mountain sickness, 1282 
in myxedema, 178 
in neuralgia, 70, 94 
in neurasthenia, 11 79 
in nephritis, chronic, 92 

acute, 256 

parenchymatous, 259 
in pachymeningitis, hemorrhagic, 1238 
in pneumonia, 389 
in poisoning, meat, 1132 

drug, 92 
in poliomyelitis, 1093 
in rheumatism (cerebral), H53 
in rhinitis, 335 

in Rock/ mountain spotted fever, 1055 
in serous meningitis, 1085 
in sinus infectious, 91. 92 
in smallpox, 1095, 1099 
in snufl habituation, 61 
in syphilis, 70, 1107 

of brain, 1242, 1243 
in syphilitic meningitis, 1084 
in trench fever, 1065 
in traumatic hysteria, 1281 
in tumors of brain, 1242, 1243 
in typhoid, 1003, 1004, 1005 
in typhus, 1052 
in uremia. 247 
in Weil's disease, 975 
in yaws, 11 14 
in yellow fever, 1036 
nocturnal, 1107, 11 14 
periodicity in, 93 
preceding asthma, 359 
psychasthenic. 93 
recurrent, 5 
sick, 92 
sinus, 91, 92 
temporal, 92 
toothache in, 92 
toxemic, 91 
Heart block, 466, 514. 53L 543. 552. 558, 565 
Heartburn. (See Pyrosis.) 
Heart sounds, abnormal accentuation. 444 
changes in timbre, 445 
clacking, 446 
"diastolic echo," 445 
displacement of heart, 446 



1334 



SYMPTOM INDEX 



Heart sounds, distant, 44=; 

fetal, 44s 

hollow, 445 

impure, 44s 

in acute infections, 446 

lost, 445 

loud, 444, 447 

metallic. 446 

muffled, 446 

murmurish, 446 

obscured, 445 

reduplication, 447 

replaced by murmur, 445 

ringing, 445 

slamming, 445 

splashing, 454 

split second, 448 

"third sound," 445 

weak, 445 
Hematemesis, 874, 875 

and use of stomach tube, 849 

in achylia, 882 

in acute yellow atrophy, 974 

in atrophy (acute yellow), 974 

in Banti's disease, 155 

in cirrhosis of liver, 969, 970, 971 

in coma, 82 

in gastric and duodenal ulcer, 87. 912, 913, 
926 

in gastritis, 906 

in hepatic hyperemia, 967 
cirrhosis, 970, 971, 972 

in poisoning (oxalic acid), 1306 
(phosphorus), 1306 

inquiry concerning, 67 

in splenomegaly with hepatic cirrhosis. 155 

simulated, 1297 
Hematuria, 222 

endemic, 1133 

hysterical, 1277 

in Barlow's disease, 172 

in bladder tumors, 274 

in colic (renal), 86 
(abdominal), 90 

in dengue, 1035, 1037 

in fever (yellow), 1037 

in malaria, 1048 

in meningitis, 1079 

in "renal epistaxis," 223 

in renal infarct, 270 

in scurvy (infantile), 172 

in yellow fever, 1037 
Hemianesthesia, 1204 

in apoplexy, 1248 

in apoplexies (symptomatic), 1249 
Hemoglobinuria, 222, 223 

and associated conditions, 223 

in angioneurotic edema, 1271 

in malaria, 224 

in poisoning, 223 

in Raynaud's disease, 1270 
Hemoptysis, and use of stomach tube, 849 

as source of error, 874, 875, 1277 

in bronchiectasis, 350 

in bronchitis, syphilitic, 348 

in coma, 82 

in infarct (pulmonary;, 418, 419 

in pneumonia, 391 

inquiry concerning, 67 



Hemoptysis in trematoda infection, 1134 
in tuberculosis, 407, 410, 411 
simulated, 1297 
Hemorrhage, 109, 874 
and icterus, 19 

and Jacksonian epilepsy, 1272 
blood pressure in 480 
blood reduction in, in 

cerebral, 68, 401, 1190, 1202, 1245, 1246, 
1247, 1249 

inherited tendency in, 68 
concealed, 109 
delirium in, 109 
feigned, 1297 
from bladder, 223 
from tongue, 37 
in achylia, 882 
in acute yellow atrophy, 974 
in anemia (Addisonian pernicious) , 152 

aplastic pernicious, 154 
in aneurysmal rupture, 109 
in anthrax, internal, 1123 
in apoplexy, 401 
in Banti's disease, 155 
in Barlow's disease, 172 
in bubonic plague, 1033, 1034 
in caisson disease, 1239 
in carcinoma of esophagus, 905 

gastric, 929, 932, 933. 934. 935 
in coma, 82 

in cystic degeneration of kidney, 272 
in dengue, 1035 
in diphtheria, 1076 
in ectopic gestation, 109 
in erythremia , 164 
in esophageal varices, 901 
in eye in diabetes, 1166, 1224 
in fever, paratyphoid, 100 1 

relapsing, 1051 

typhoid, 109, 1002, 1003, 1004, 1007. 1014 

yellow, 1036, 1037 
in gastric and duodenal ulcer, 109. 870, "910, 
912, 914. 915, 920, 934 

carcinoma, 929. 932, 933. 934. 935 

erosions, 930 
in Gaucher's disease, 155 
in hematocele (pelvic), 109 
in hematomyelia, 1239 
in hemophilia, 45, 69, 169, 170 
in hemorrhoids, 942 
in hemothorax, 109 
in influenza, 1018, 1019, 1021, 1022, 1023, 

1024, 1025, 1026, 1027, 1028 
in jaundice, 19 
in leishmaniasis, 106 1 
in lethargic encephalitis, 1087 
in leukemia (myeloid), 157 

lymphatic, 160 
in malaria, 1048 
in meningeal infections, 1078 

intra- and extra-, 1238 
in paratyphoid fever. 1001 
in plague (bubonic), 1033, 1034 
in poisoning (phosphorus), 975. 1306 
in polymyositis, n 60 
in pulmonary tumors, 42 1 
in purpura, 45, 168, 169 
in relapsing fever, 1051 
in renal tumors, 271 



SYMPTOM INDEX 



1335 



Hemorrhage in scurvy, 45, 171, 172 

in smallpox, 1097 

in splenomegaly with hepatic cirrhosis, 
of Gaucher type, 155 

in syphilis, 1100, n 11 

in syphilitic bronchitis, 348 

into joints, 45, 171 

in tuberculosis, 109 
of bladder, 273 

in tumors, pulmonary, 421 

in typhoid fever, 109, 1002, 1003, 1004, 1007, 
1014 

in ulcer (gastric and duodenal;, 870, 910, 
912, 914, 915, 920, 934 

in whooping cough, 1104, 1105 

in yellow fever, 1036, 1037 

spinal cord in diphtheria, 1074 

in per anemia, 147 

intra- and extrameningeal, 1238 

meningeal, 30 

in spastic paralysis, 1258 

nerves affected in, 1230 

ocular, i.i apoplexy, 1247 
nephritis, 263 

pontine, 1306 

retinal, in albuminuria, 1220, 1222, 1224 

simulated, 1297 

sources of, in hematuria. 223 
Herpes, 1269 

in coryza, 34 

in lesions of spinal nerve, 12 19 

in locomotor ataxia, 1255, 1256 

in malaria, 34, 1045 

in meningitis, 1080, 1081 
(tuberculous), 1084 

in neuralgia, 94. 95 

in pneumococcus infections, 389 

in pneumonia, 34, 389 

in spinal nerve lesions, 12 19 

in syphilis, 34 

in syringomyelia, 1260 

in tuberculosis, 406 

in tuberculous meningitis, 1084 

of lips, 34 

of nose, 33 

zoster, 95. 1163 
Heterochylia, 882 

as a symptom, 870 

in congenital asthenia, 897 
Hiccough, 108 

causes of, 108 

exhaustion from, 108 

in myelitis (acute), 1262 
Hippus, in migraine, 93 
Hoarseness, 14, 343, 1215 

in tracheo-bronchitis, 345 

of laryngitis, 342, 343 

larynx (tuberculous), 344 

preceding edema of glottis, 343 
croup, 343 
Hunger-pain. (See Pain.) 
Hydremia, in chlorosis, 150 
Hyperacidity, 920 

in gastric ulcer, 911, 915 

of stomach, 860, 863 
Hyperchlorhydria, ammonia excretion in, 214 

asthenic, 868 

diagnostic significance of, 869 

in gastric ulcer, proper, 867 



Hyperchlorhydria, recovery in, 869 

secondary or complicating. 868 

simple, 867 

simulating other conditions, 869 

stomach-contents in, 868 

symptoms of, 869 
Hyperesthesia, 1204 

and hyperalgesia, 1204 

cutaneous, 955 

gastric, 879, 926 

in angina pectoris, 440, 771 

in cardiac insufficiency, 97 

in neuralgia, 97 

in neuritis, 98 

in uremia, 247 

intestinal, 950 

laryngeal, 1236 

residual, 642 
Hyperpyrexia. (See Fever.) 

Hypertension, arterial, 478. (See also Blood 
pressure.) 

"conservative effects" a myth, 486 

excessive, 479, 480, 481 

excitement as a cause, 476 

in Adams Stokes syndrome, 480 

in angina pectoris, 480 

in aortic regurgitation (high "systolic"), 479 

in apoplexy, 479 

in arteriosclerosis, variability of, 479 

in asthma, 481 

in cardiorenal cases, 486 

in colic, abdominal, 485 

in epilepsy, 480 

in erythremia megalosplenica, 160, 480 
. in general anesthesia (ether and nitrous ox- 
ide), 483 

in. heart lesions, 485 

in intracranial pressure, 479 

in lend poisoning, 478 

in life insurance, 477 

in nephritis, 256, 262, 265, 460, 478, 480, 492 
acute, 256, 478. 492 

chronic, frequency of, as etiologic factor, 
487 
interstitial variety, 262, 265, 460, 478, 

480 
parenchymatous form, 478 

in pregnancy, 485 

in scarlet fever with renal complications, 484 

in spastic splanchnic crises, 478, 480 

misleading forms, 479 

points of special importance, 485 

systolic vs. diastolic "highs," 473. 4"8, 487 
Hypertrophy, cardiac, auricular, 682 

cardiac, of single chamber, 725 
true, 669 

in acromegaly, 185 

laggard, 754 

left ventricular, 553 

of heart, 438, 462 

of ventricles, 460, 727 

primary right ventricular, 706 

pseudo-muscular, 1265 

"work," 592 
Hypochlorhydria, 870 

in gastritis, 906 

senile, 883 
Hypotension, arterial. (See ■ also Blood 
pressure.) 



*336 



SYMPTOM INDEX 



Hypotension, conditions inducing it, 480 

"conservative" drops in blood pressure, 486 

in alcoholism, acute, 483 

in arteriosclerosis, 479 

in asthenia, congenital, 482 

in certain acute infections, 481 

in chloroform anesthesia, 483 

in cholera, 481 

in diphtheria, 480 

in ethyl chloride anesthesia, 483 

in heart failure, terminal, 482 

in heart lesions, acute, 485 

in malarial cachexia, 484 

in paracentesis, dangers of, 484 

in pericardial effusion, 482 

in pneumonia, 481 

in splanchnic tonus impairment, 482 

in syphilis, early stages, 482 

in thoracentesis, caution regarding, 484 

in tuberculosis, 482 

in typhoid fever, 483 

points of importance, 485, 486 
Hypotension, 480 

following relief of abdominal pressure, 484 
removal of effusion, 484 

in acute infections, 481 

in tuberculosis, 482 



Illusions. (See Hallucinations.) 
Indicanuria, 88, 192 

in colic (abdominal), 90 

in carcinoma (gastric), 852 

in intestinal obstruction, 87, 88 

in peritonitis, 880 
Insomnia, 103, 1202 

and "drop" heart, 597 

following influenza, 597 

in anemias, 146 

in asthenia, 103 

in aviator's syndrome, 1283 

in cardiac insufficiency, 103 

in cerebral anemia, 1241 

in cerebral hemorrhage, 1246 

in delirium tremens, 1286 

in diabetes mellitus, 1166 

in goiter, 183 

in gout, 1 173 

in paretic dementia, 1252 

in pellagra, 1290 

in pericarditis, 801 

in rabies, 1124 

in rheumatism (cerebral), 11 5 3 

in syphilis, 11 07 

in traumatic hysteria, 1281 

in tumors of brain, 1243 

scope of inquiry, 103 

insufficiency, myocardial, 590, 591, 607, 615, 
616, 621, 625, 630, 632, 635, 639, 640, 
641, 647 
Iodophilia, 125 

in empyema, 374 
Itching, 10 1 

in acroparesthesia, 1167 

in alcoholism (chronic), 10 1 

in anthrax, 102 1 

in chickenpox (varicella), 1002 

in cocainism, 101 



Itching in cranial nerve lesions, 11 16 
in dermatophiliasis, 1046 
in diabetes, 101 

in diseases of brain and cord, 10 1 
in epidemic dropsy, 961 
in gout, 1070 
in hysteria, 10 1 
in infection (pin-worm), 1036 
in jaundice, 10 1 

in lesions of cranial nerves, 11 16 
in morphinism, 10 1 
in neurasthenia, 10 1 
in pin-worm infection, 1036 
in poisoning (lead), 10 1 
in smallpox vaccination, 100 1 
in syphilis, 1007 
in tropical sore, 965 
in uremia, 247 

in vaccination (smallpox), 1001 
in varicella, 1002 
preceding asthma, 359 



Jaundice, 17. 18, 19, 974. 975, 978 
acute febrile, 974. 975 
and abdominal pain, 89 
bradycardia in, 490 

color of skin and mucous membranes, 19 
congenital hemolytic, 155 
conjunctiva, 19 
Dardanelles, 18 

due to paratyphoid bacillus, 18 
emotional, 18 
hereditary, 18 

in abscess of liver, 18, 966, 967 
in amyloid liver, 974 
in anemia, 18, 155 
in aneurysm (abdominal), 18 
in atrophy, acute yellow, 18, 19, 974 
in biliary cirrhosis, 972 

colic, 978 
in bronze diabetes, 19 
in carcinoma of liver, 18 

of pancreas, 965 
in cardiovascular insufficiency, 648 
in catarrh of bile ducts, 18 
in cirrhosis of liver, 17, 18, 175. 97 1 

biliary, 972 

syphilitic, 973 
in cholecystitis (acute), 976 
in cholelithiasis, 978, 979 
in colic (biliary), 978 

gallstone, 87 
in concussion of brain, 18 
in congenital hemolytic jaundice, 156 
in dengue, 1035, 1037 
in endocarditis (ulcerative), 18 
in fever (relapsing), 1051 

yellow, 1035, 1036, 1037 
in gallbladder disease, 975, 979 
in gallstones, 18, 87 
in icterus neonatorum, 19 
in infantilism, 18 
in infection, 19 
in inflammation of liver, 965 
in influenza, 10 18 
in liver abscess, 966, 967 

amyloid, 974 



SYMPTOM INDEX 



1337 



Jaundice in liver cirrhosis, 175, 971 
enlargement, 18 
in malaria, 104S 
in newborn, 19 
in obstruction (biliary), 20 
in pancreatic disease, 965 
in peritonitis tuberculous), 963 
in poisoning (phosphorus), 975. 1306 
in pneumonia, 18 
in pregnancy, 19 
in pyemia and septicemia, 11 19 
in relapsing fever, 18, 1051 
in septicemia, 1 119 
in spleen, enlargement of, 18 
in splenomegaly with hepatic cirrhosis, 155 
in syphilitic cirrhosis, 973 
in trematoda infection, 1134 
in tricuspid insufficiency, 706 
in tuberculous peritonitis, 963 
in urobilin icterus, 194 
in Weil's disease, 18, 974. 975 
in yellow atrophy (acute), 974 
in yellow fever, 1035, 1036, 1037 
Minkowski's, 18 
obstructive, 18, 19 
of buccal cavity. 34 
pulse, slow in, 490 
simulated, 1298 
skin in, 19 
stools in, 19 
symptoms of, 19 
toxemic, 19 
types of, 18, 19 
urine in, 19 



Ketonuria, 1163, 1164 
Koplick's spots. {See Rash.) 



Lachrymation in ophthalmic neuralgia. 94 

in poisoning (formaldehyde), 1305 
Lethargy, 79 

in encephalitis (lethargic), 1086 
Leucocytosis, in, 124, 137. (See also Lympho- 
cytosis.) 

and albumosuria, 215 

and fibrin increase, 115 

determination of,' 131, 134 

differentiated from leukemia, 138, 156, 159 

digestion, 137 

following operations and anesthesia. 139 

in abscess of liver, 966, 967 

in acute rheumatism, 1153 

in anemia (pernicious), 137 

in appendicitis, 138, 955, 1012 

in Asiatic cholera, 1032 

in Bell's mania following child birth, 76 

in blastomycosis, 11 28 

in bubonic plague, 1033, 1034 

in carcinoma (gastric, 138, 932 

in cerebrospinal meningitis, 1080 

in cholera, 1032 

in choluria, 138 

in colic (abdominal), 90 

in convulsions, 139 



Leucocytosis in delirium, 139 
in diabetics, 137 
in endocarditis, 678, 10 12 
in empyema, 374. 375 
in erysipelas, 11 17 
in erythremia, 163 
in fever (Malta), 1054 

scarlet, 140, 1070 

trench, 1065 

typhoid, 1003. 1012 
in gastric carcinoma, 932 
in gout, 1 173 
in Hodgkin's disease, 166 
in infections, 215, 216, 981 
in influenza, 1020 
in leukemia, differentiation of, 138. 156. 157. 

159 
in malignant disease, 138 
in Malta fever, 1054 
in measles, 1067 
in meningitis, 1080. 1081 

tuberculous, 1084 
in newborn, 138 
in osteomyelitis, 1154 
in poisoning (gas;, 139 

ptomain, 138 
in pneumonia, 13S, 375. 383. 387. 389. 391 

392, 1012 
in pregnancy, 137 
in pyemia, n 19 
in rheumatism (acute), n 53 
in scarlet fever, 1070 
in septicemia, 1011, 11 19 
in Still's disease, 1157 
in trench fever, 1065 
in trichuriasis, 1138 
in tuberculosis, 674 
in tuberculous meningitis, 1084 
in typhoid fever, 138. 1003, 1012 
in uncinariasis, 1139 
in uremia, 138 
in whooping cough, 1104 
of disease, 138 
physiologic, 137 
pre-agonal, 137. T 59 
Leucopenia, 111, 139, 140 

diseases associated with, 139. 140 

following use of drugs, 139 

in anemia (Addisonian pernicious). 155 

(aplastic pernicious), 157 
in chlorosis, 139 
in dengue, 1035 
in enteritis, 139 
in fever (Malta), 139 

paratyphoid, 139 

typhoid, 138, 139, 1003, 1007. ion 
in Gaucher's disease, 158 
in influenza, 139, 1032 
in Leishmaniasis, 1060 
in leprosy, 139 
in malaria, 139. 1045, 1049 
in measles, 139, 1067 
in miliary tuberculosis. 1011 
in pneumonia. 138 

in splenomegaly of Gaucher type, 155 
in tuberculosis, 139 

miliary, 10 11 
in typhoid fever, 139, 1004, 1007, 1012 
Levulosuria, 227 



133* 



SYMPTOM INDEX 



Lymphocytosis, in, 137, 139 
following use of drugs, 139 
in Addison's disease, 174 
in anemia, 139 

in anemia (aplastic pernicious), 154 
in chlorosis, 151 
in diphtheria, 139 
in goiter, 183 
in Hodgkin's disease, 166 
in infancy, 139 

in leukemia ('lymphatic), 158, 159 
in malaria, 139 
in Malta fever. 139 
in malignant growths, 139 
in measles, 139 
in scarlet fever, 139 
in syphilis, 139 
in trypanosomiasis, 139 
in tuberculosis, 139- 143 
in typhoid fever, 139, 1007 
in whooping cough, 1 104 



M 



Malaise, 1005 

in acromegaly, 185 

in alcoholism, 1285 

in ascaris infection, 113 7 

in Asiatic cholera, 1032 

in bronchitis (tracheo-) , 345 

in chickenpox, 1103 

in dermatomyositis, 1159 

in diphtheria, 1074 

in erysipelas, 11 18 

in fever (milk), 1057 

Oroya, 1062 

scarlet, 1070 

typhoid, 1004, 1005 
in gastritis, 906 
in lethargic encephalitis, 1087 
in malaria, 1048 
in Marie's disease, 185 
in meat poisoning, 1132 
in milk fever, 1057 
in myelitis (acute), 1261 
in myositis (suppurative), 1161 
in Oroya fever, 1062 
in pellagra, 1290 
in pleurisy, 369 
in poisoning (meat), 1132 
in poliomyelitis, 1092 
in rubella, 1072 
in scarlet fever, 1070 
in smallpox, vaccination, 1102 
in syphilis, 1107, 1109 
in tuberculin tests, 413 
in typhoid fever, 1004. 1005 
in varicella (chickenpox), 11 03 
in yaws, 11 14 
preceding sunstroke, 1284 

typhoid, 1004, 1005 
Meteorism, 949 

and abdominal examination, 25 

displacement of heart in, 446 

in fever (typhoid), 1014 

in heart disease, 446 

in intestinal neuroses, 949 

obstruction, 88 
in pneumonia, 389 



452, 453. 602, 



-00 



Meteorism, lung borders in, 296 

orthopnea in, 50 
Mind blindness. (See Blindness.) 
Miosis (contraction), 1220 

in alcoholic meningitis, 1085 

in cervical myelitis, 1262 

in catalepsy, 48 

in coma. 80 

in hemorrhage (pontine), 80, 1306 

in locomotor ataxia, 1254 

in meningitis (alcoholic), 986 

in myelitis (cervical), 1262 

in poisoning (carbolic acid), 1304 

(chloral hydrate), 1304 

(lobelia), 1305 

(opium), 62, 8o, 1306 
in pontine hemorrhage, 80, 1306 
in sunstroke, 1221 
persistent, 1221 

produced by drugs, 80, 1221, 1306 
Mouth breathing. (See Breathing.) 
Murmurs (bruits), 444, 449, 450, 451, 452, 453, 
454. 455, 461 
abnormal, 589 
absence of, temporary, 685 
accidental, 452, 453 
Alvarenga-Duroziez, 710 
anemic. 146, 451, 452. 453, 603, H39 

in advanced pernicious anemia, 152 

in "drop" heart, 603 

in uncinariasis, 11 39 
apex, misinterpretation of ; 

604, 609 
area of audibility, 679, 692, 702, ' 
asthenic, 450, 457 
audible in back only, 685 
auscultation of, 304 

in fonticulus gutturis, 441 
autoaudible, 715, 724 
bizarre combinations of, 79i. 797 
blowing systolic, 679 
blubbering, 774 
bruit de diabele, 146, 150 
cardio-pulmonary, 452, 789 
crescendo, 789 
decresendo, 789. 1747 
deductions from, 459 
definition of, 449 
diastolic, 28, 146, 459, 
715, 727, 729, 731, 
777 
differential points, 461 
dilatation, excessive, effect upon, 446 
dilatations and, 452 
diminuendo, 459, 747, 789 
duration, pitch and quality of, 684 
endocarditic, 451, 452 
esophageal, 833 

Flint, in aortic insufficiency, 720, 744 
friction, 410, 786, 788, 791, 793, 794. 799 
general dissemination of, 741 
glandular, 183 
hemic, 146, 451, 452, 453, H39 

diastolic, 452 
hissing, 715 
imperfectly developed, great importance of, 

452. 453, 742 
inflation, in examination of stomach, 833 
in anemia, 450, 451, 452, 736 



694, 708, 709. 711. 
•40, 741. 742, 744. 



SYMPTOM INDEX 



1339 



Murmurs in angina, 769 

in aortic aneurysm, 777. 778, 779, 781 

in aortic insufficiency, 663, 708, 709, 710, 

711, 713. 715. 7i6, 717, 7i8, 747 
in aortic stenosis, 723, 724, 743 

pseudo-, 769 
in aortic stenosis and coarctation of arch, 741 
in arteriosclerosis, 763 
in cardiovascular syphilis, 750, 758, 759 
in chorea, 1274, 1275 
in chlorosis, 150 
in combined valvular lesions, 742, 743, 744, 

745. 746. 747 
in congenital obliteration of aorta, 28 
in defective ventricular septum, 664 
in "drop" heart, 597. 598, 599, 602, 603, 

604, 609 
in endocarditis, 675 

malignant, 677 
in goitre (exophthalmic), 180, 182, 183 
in infections, 76 
in intracranial aneurysm, 1249 
in mitral regurgitation, 669, 679, 681, 684, 
685, 686 

in perfect and atypical, 451, 452, 453, 
602, 742 
in mitral stenosis, 568, 577, 690, 692, 693. 
694. 695, 697 

with fibrillation, 696, 698 
in "muffled" heart sounds, 446 
in myocarditis, 667 
in neck, 729 

in pairs and triplets, in pericarditis, 788 
in patent ductus botalli, 740, 741 
in patent foramen ovale, 739 
in pericarditis, 788, 789. 79i- 792, 793, 794 

799, 801 
in postural variations, 794 
in pulmonary insufficiency, 729, 730, 731 
in pulmonary stenosis and atresia, 734, 736 
in reduplication of heart sounds, 448 
in relative insufficiency, 685 
in serous exudates, 788 
in tricuspid insufficiency. 702, 704, 707, 727. 

744 
stenosis, 727 
intensification of on raising arms, 716 
interpretation, common sources of error, 450, 
intensity of, 451 

451, 452 
in tuberculosis, 410 
loud vs. "soft," 451 
miniature, 546 

misleading (in "drop " heart), 602 
mitral in "drop" heart, 604 
multiple, 743 

"murmurish" heart sound, 446 
musical, 451, 724 
obstructive, 455 
organic (rationale), 455 
pleuro-pericardial, 454, 794 
post-systolic, 452, 453, 740 
presystolic, 450, 461, 568, 577. 690, 692, 

693. 694. 695, 697. 727 
production of, 455, et seq. 
quality of, 715 
rationale of, 455, et seq. 
registration of, 524 
rhythm of, 461 



Murmurs, "sec-saw" in aortic insufficiency, 709, 

720 
silenced, 747 

"split" second sound, 663 
spurting, in examination of abdomen, 822 
suggestions concerning, 743 
systolic, 150, 180, 451, 459, 597 (Fig. 264), 
598, 681, 685, 694. 702, 708, 723. 743. 
745. 747. 763. 776, 777. 779. 784 (Fig. 
358). 1285 
thrilling, vibratory, 698 
timbre of, 4S1 
time of, 685, 715 
"to and fro," 710 
tonus deficiency and, 452 
transmission of, 452, 686, 692, 716 

continuity of, 686 

maximal, 710 
valvular, general causative factors, 461 
variations in, 451 
vibratory, 744 
"whiffing," 453 
Mydriasis (dilatation), 1220 
in alcoholism, 80, 1284 
in catalepsy, 1301 
in coma, 80, 83 
in diabetic coma, 83 
in epilepsy, 80 

in Loewi's test for hyperthyroidism, 181 
in poisoning (aconite), 1303 

atropin, 1303 

belladonna, 80 

chloral hydrate, 80, 1304 

cocain, 62, 80, 1304 

colchicum, 1304 

gelsemium, 1305 

hydrocyanic acid, 1305 

opium, 1306 

phosphorus, 1306 

ptomain, 1288 

strychnin, 80 
in tuberculous meningitis, 1083 
in uremia, 80 
persistent, 1220, 1221 
produced by drugs, 80, 1221 

N 
Nausea, 872 

in Addison's disease, 174 

in anemia (cerebral), 12 41 

in anemias, 146 

in aneurysm, 776 

in angina, 581, 694 

in appendicitis, 86, 954 

in Asiatic cholera, 1032 

in brain tumor, 91 

in botulism, 1288 

in bubonic plague, 1032 

in carcinoma (gastric), 932 

in cardiac disease, 648 

in catarrhal jaundice, 975 

in cerebral anemia, 1241 

concussion, 1294 
in cholecystitis (acute), 975 
in cirrhosis of liver, 971 
in colic (renal) , 86 

abdominal, 90 

gallstone, 87 
in coma (diabetic;, 1166 



1340 



SYMPTOM INDEX 



Nausea in concussion, cerebral, 1294 
in cysts, pancreatic, 964 
in diabetic coma, 11 66 
in Dietl's crises, 268 
in fevers, 75 
in fever (typhus), 1052 

scarlet, 1070 

Rocky Mountain spotted, 1055 
in gastritis, 905, 906 
in headache, 91 

in hemorrhage (concealed), 109 
in hernias, 90, 873 
in hyperchlorhydria, 868 
in hypersecretion, 869, 927 
in intestinal obstruction, 87, 950 
in injections, 78 
in influenza, 1020 
in jaundice, catarrhal, 975 
in lethargic encephalitis, 1087 
in Meniere's disease, 1235 
in migraine, 93 
in mountain sickness, 1282 
in movable kidney, 268 
in nephritis, acute, 256 

parenchymatous, 259 
in obstruction, intestinal, 87, 950 
in pancreatic cysts, 964 
in poliomyelitis, 1092 
in poisoning, aconite, 1303 

arsenical, 1288. 1303 

atropin, 1303 

botulism, 1288 

cocain, 1303 

corrosive sublimate, 1304 

lobelia, 1305 

meat, 1132 

phosphorus, 1306 
in purpura, 169 

in Rocky Mountain spotted fever, 1055 
in scarlet fever; 1070 
m sprue, 1064 
in typhus, 1052 
in ulcer, duodenal, 70 

gastric, 87 
preceding sunstroke, 1284 

syncope, 102 
sudden pallcr in, 15 
Neuralgia, cervical rib as cause, 96 
cervico-brachial, 95 
cervico-occipital, 95 
digital, 97 
femoral, 98 
gastric, 85 
hypogastric, 950 
intercostal, 95 
lumbo-abdominal, 98 
maxillary, inferior and superior, 94 
neuritis, relations to, 98 
ophthalmic, 94 
pain, character of, 94. 97 
peripheral, intense, 1238 
plantar, 97 
sciatic, 95 
sinus headaches, 91 
tender points in, 94 
trifacial, 94, 1232, 1233 
Neuritis, pain in, 98. (See Pain.) 
Neurocirculatory myasthenia, 620 
Night sweats. (See Sweats and sweating.) 



Numbness and tingling, 10 1 
in acroparesthesia, 1270 
in aura epileptica, 1271 
in apoplexy, 1246 
in beri beri, 1291 
in cervical rib, 96 
in chlorosis, 150 
in circulation, defective, 640 
in Erb's spinal paralysis, 1258 
in heart disease, 640 
in hysteria, 1279, 1281 

traumatic, 128 1 
in migraine, 93 
in myelitis, acute, 1261 
in nephritis, 262 
in neuritis, 1267, 1268 

and neuralgia, 1267 
in poisoning (aconite), 1303 

oxalic acid, 1306 

ptomain, 1288 
in sciatica, 96 
in tabes dorsalis, 1255 
"wading sensation," 640 



Obesity, 54. 187, 188 

•in cardiac disease, 668, 669 
in diabetes, 1166 
Oligemia, in 
Oligochromemia, 11 1 
Oligocythemia, 11 1 
Oliguria, 191 

Orthopnea. (See under Dyspnea) . 
Oxaluria, 214 



Pain, 83, 99, 100 

abdominal, 83, 84, 85, 87, 89, 645, 763. 77 1, 
772, 804, 805, 936, 1003, 1020, 1132, 
1287, 1288, 1303, 1305, 1306 

and fever, 90 

and jaundice, 89 

and pleurisy, 363 
absence of, 85 

and compression of cord, 1209 
and fever, 84, 85 
and tenderness, 100 
anginal, 560, 647, 664, 667, 73L 1268 
descriptive terms, 83 

epigastric, 87, 90, 100, 580, 645, 647, 654, 
667, 706, 771, 787, 879, 897. 905. 912, 
931. 935, 936, 954. 956, 958, 964. 976, 
978, 1057 
feigned, 1299, 1300 
girdle sensation, 100 
hunger, 868, 897, 912, 914- 9i6, 928 

in appendicitis, 878 

in congenital asthenia, 897 

in ulcer, 834 
in abscess (duodenal) , 99 

of liver, 966 

mediastinal, 423 

subphrenic, 881 
in acromegaly, 185 
in achylia, 882 
in acroparesthesia, 1270 
in acute infections, 84 
in acute intestinal obstruction, 87 



SYMPTOM INDEX 



1341 



Pain in adiposis dolorosa, 188 

in aneurysm, 84, 85, 99, 100, 585, 760, 768, 
776, 778, 779, 78l 

abdominal, 87 
in angina pectoris, 85, 99, 100, 769, 770, 771, 

772 
in anorexia nervosa, 879 
in anthrax, 1123 

internal, 11 23 
in aortic insufficiency, 720 

stenosis, 726 
in apoplexy, 1246, 1248 
in appendicitis, 83, 84, 85, 86, 100, 954, 956, 

957, 958, 1012 
in arms, 42, 75, 585, 647, 756, 1099, 1102, 

1284 
in arteriosclerosis, 85, 100, 764 
in arthritis deformans, 1156 

gonorrheal, 1158 

syphilitic, 1157 
in ascaris infection, 1137 
in atonic dilatation, 897 
in atrophy, progressive muscular, 1264 
in Barlow's disease, 172 
in blastomycosis (systemic), 11 27 
in Brill's disease, 1053 
in bronchitis (tracheo-), 345 
in bursitis, 99 
in caisson disease, 1239 
in calculus (ureteral), 83, 84 

renal, 85 
in carcinoma of esophagus, 904 

gastric, 85, 915, 928, 931. 932, 935 

pancreas, 964. 965 
in cardiac decompensation, 84, 90, 641, 644, 
645 

insufficiency, 99, 100 
in cardiovascular syphilis, 755, 760 
in cervical rib, 96 
in chickenpox, 1003 
in cholecystitis, 976 

acute, 85 
cholelithiasis, 85, 977. 978 
in cholera (Asiatic), 1032 
in coccygodinia, 99 
in colic, abdominal, 90 

biliary, 977. 978 

colon, 85, 99 

gall-stone, 84, 99 

renal, 84, 85, 86, 99 
in constipation (spastic), 952 
in cranial nerve lesions, 12 19 
in cystitis, 273 
in dementia (paretic), 1253 
in dengue, 1034 
in dermatomyositis, 11 59 
in Dietl's crisis, 86, 268 
in "drop" heart, 95 
in dysentery, 945. 94^ 
in elephantiasis, 26 
in emboli, 953 

in Erb's spinal paralysis, 1258 
in ergotism, 1289 
in erythromelalgia, 1270 
in esophageal diverticula, 903 
in esophagitis, 901, 903 
in examination of kidney, 814 
in eyes, 1035, 1065 
in fecal accumulation, 952 



Pain in fever, Malta, 1054 

milk, 1057 

oroya, 1062 

scarlet, 1070 

trench, 1065 

typhoid, 1003 

yellow, 1036 
in filariasis, 1142 
in flat-foot, 99 
in floating-kidney, 85, 86, 268, 956, (See 

Dietl's crisis.) 
in foreign bodies in bronchi, 351 
in gallstone colic, 84, 85 

in gastric carcinoma, 928, 931, 932, 934, 935, 
936 

crises, 935 

erosions, 926 

spasm, 878 

syphilis, 937 

ulcer, 870, 910, 911. 912, 914, 915, 920, 
921, 935, 
perforation, 925, 926 
in gastritis, 905, 906 
in gastroptosis, 884 
in gummata (syphilitic), of liver, 973 
in gonorrheal arthritis, 1158 
in goundu, 1117 
in gout, 85, 1 172, 1 173 

chronic, 1174 

retrocedent, 1173 
m headaches, 91, 92 
in heel, 100 
in hematomyelia, 1239 
in hepatic disease, 99 
in hernias, 83, 90, 99, 100, 873 
in herpes zoster, 95. 1163. 1269 
in Hodgkin's disease, 167 
in hydatids, pulmonary and pleural, 425 
in hyperchlorhydria, 868 
in hypersecretion, 869, 870, 927, 928 
in hysteria (traumatic), 1281 
in indigestion (intestinal) , 943 
in infantile meningitis, 1086 
in inflammation of liver, 965 

of bone, 85 
in influenza, 10 19, 1020 
in intercostal neuralgia, 95. 1163, 1219 
in intermittent claudication, 53 
in intestinal adhesions, 83, 951 

obstruction, 87. 950 
in insufficiency, aortic, 720 

post-stenotic motor, 889 

pulmonary, 731 

tricuspid, 706 
in joints, 44, 45. 99. 172, 185, 993, 1035, 

1054, 1062, 1114, 1120, 1173 
in leprosy, 11 20, 1121 
in lethargic encephalitis, 1087 
in leukemia (myeloid), 157 
in locomotor ataxia, 85, 100, 480, 1255, 1256 
in lower extremities, 42, 75, 489, 647, 1080, 

1095, 1099, 1103. 1255. 1284 
in lymphedema, 26 
in Madura foot, 1130 
in membranous enteritis, 945 
in meningitis, 1080 

infantile, 1086 

pachy-, 1238 

serous, 1085 



1342 



SYMPTOM INDEX 



Pain in mitral stenosis, 701 

in movable kidney, 99, 268 
in mumps, 1068 

in muscle, in cardiac disease, 640 
in muscular cramp, 1162 
in myalgia, 99, 1162, 1163 
in myelitis (acute), 1158, 1261, 1262. (See 
Osteomyelitis.) 

chronic, 100 

compression, 1260, 1262 
in myeloma, 161 

in myocardial over-strain, 654, 664 
in myocarditis, 667 
in myositis (dermato-), 1159 

poly-, 1159, 1 160 

suppurative, 1161 
in nephritis, acute, 256 
in neuralgia, 84, 85, 94, 97, 98, 99, 1268 

intercostal, 95, 1163 
in neurasthenia, 1181 
in neuritis, 84, 98, 99. 1267 

due to alcohol, arsenic, or lead, 1268 

multiple, 1262 
in osteomyelitis, 44 
in ovarian disease, 100 
in pachymeningitis, 1238 
in pancreatitis, 100, 964 
in paralytic vertigo, 1270 
in paroxysmal tachycardia, 560 
in pellagra, 1290 
in pelvic disease, 99, 100 
in pericarditis, 85, 100, 710, 786, 787, 791, 

801 
in perihepatitis (acute), 973 
in peritonitis, 88, 960 

tuberculous, 963 
in pleurisy, 84, 85, 100, 363, 369 

diaphragmatic, 374 
in pneumonia, 83, 85, 86, 100. 388 
in poisoning, acid. 1302 

arsenical, 1287, 1303 

cantharides, 1303 

carbolic acid, 1304 

corrosive sublimate, 1304 

formaldehyde, 1305 

lead, 1287 

meat, 1132 

mushroom, 1305 

oxalic acid, 1306 

phosphorus, 1306 
in poliomyelitis, 1054, 1092, 1093 
in polymyositis, 1159 
in progressive muscular atrophy, 1 264 
in prostatitis, 274 
in pulmonary hydatids, 425 

infarct, 419 

insufficiency, 731 

tumors, 421 
in pyelitis, 268 
in quinsy, 342 

in Raynaud's disease, 489, 1270 
in renal disease, 99 

infarct, 270 

tuberculosis, 270 
in rheumatism (acute), 84, 1151 

muscular, 98, 99 
in rupture of heart, 802 
in sacro-iliac, 884, 1158 

relaxation, 96, 884, 11 58 



Pain in sciatica, 95. 96 

feigned, 1300 
in sclerosis, primary lateral, 1257 
in scurvy. 172 

in sensory nerve irritation, 1186 
in serous meningitis, 1085 
in serum disease, 993 
in sinus headaches, 91 

accessory infection, 339 
in smallpox, 1095, 1099 

vaccination, 1162 
in soldier's heart, 609 
in spastic splanchnic abdominal crises, 87, 

936 
in spinal caries, 85, 99, 100 
in sprue, 1064 
in stomatitis, 35, 921 
in syphilis, 937, 1107, 1111 
in syphilitic arthritis, 1157 

gumma of liver, 973 
in synovitis, 99 
in syringomyelia, 1260 
in tabes, 87 

in- tapeworm infection, 1135 
in tetanus (lockjaw), 1126 
in thrombosis (abdominal), 953 
in tonsillitis, 342 
in traumatic hysteria, 1177 
in trematoda infection, 1134 
in trench gas poisoning, 348 
in trichiniasis, 99. 1138, H59 
in tricuspid insufficiency, 706 
in tuberculosis, 410 

of intestines, 953 

of peritoneum, 963 
in typhoid, 1003 

in ulcer (gastric and duodenal), 70, 84, 85, 87, 
100, 870, 910, 911, 912, 914. 915. 919. 
920, 935 

perforation of, 925. 926 
in varicella (chickenpoxj , 11 03 
in varicocele, 100 
in variola, 1095, 1099 
in vertigo (paralytic), 1270 
in viscera (hollow vs. solid), 84, 85 
in Weil's disease (acute febrile jaundice), 974 
in yaws, 11 14 
preceding shock and collapse, 109 

sunstroke, 1284 
precordial, 764, 769, 787. 801 
pubic, 100 
pulse in, 489 
radiating, 84 

referred, 45, 83, 84, 87, 642, 643. 644, 731. 
764, 765, 93i, 958, 976 

in abdominal colic, 90 

in aneurysm, 585 

in angina, 641, 644, 771 

in pericarditis, 787 

in pleurisy, 363, 374 
sacro-iliac, 99 
"shoulder," 99. 374 
tests for, 1204 
Pallor, 15, 16 

cyanotic, in mountain sickness, 1282 

false, 16 

feigned, 1293 

in anemias, 15, 14s 

in aneurysm, aortic, 776 



SYMPTOM INDEX 



1343 



Pallor in aortic aneuryms, 776 
insufficiency. 16, 434, 720 
in ascaris infection, 1137 
in asthma, 359 
in Bright's disease, 15, 145 
in Bubonic plague, 1033 
in carcinoma (gastric), 12, 145, 933 
in cardiac decompensation, 15, 435 
in catalepsy, 1301 
in cerebral concussion, 1294 
in chlorosis, 14s, 150 
in coma, 80 

in concussion (cerebral), 1294 
in drug habitues, 17 
in endocarditis, 675 
in epilepsy (petit mal), 1272 
in gastric and duodenal ulcer hemorrhage, 915 

carcinoma, 12, 145, 933 
in heat exhaustion, 1284 
in hemorrhage (cerebral), 401 

ulcer, is, 915 
in leishmaniasis, 1060 
in leukemia (lymphatic), 159 
in malaria, 1048 
in Meniere's disease, 1235 
in migraine, 93 
in myocardial overstrain, 664 
in myocarditis, 666 
in nephritis (acute), 15, 256 
interstitial, 15, 262 
parenchymatous, 15, 17, 22 
in neuritis, 98 

in "pasty," in Bright's disease, 15 
in pellagra, 1290 
in perforation (ulcer), 15 
in pericarditis, 787, 801 
in poisoning (aconite), 1303 
carbolic acid, 1304 
chloral nydrate, 1304 
drug, 17, 62 
gelsemium, 1305 
in Raynaud's disease, 1270 
in shock and collapse, 15, 109 
in sudden, 15 
in syncope, 15, 102, 1301 
in syphilis, 17, 1107, 1109 
in traumatic hysteria, 1281 
in tubal pregnancy, 15 
in typhoid fever, 1003 j 
in uremia, 80 
Palpitation. (See also Arrhythmias and Pulse), 
491 
in anemias, 146 

in auricular fibrillation, 554, 555 
in extrasystolic irregularity, 543 
in paroxysmal tachycardia, 560 
simple tachycardia, 491 
Paramnesia, 1201 
Paraphasia, 14, 1203, 1204 
Paresthesia, 101, 1204 
of intestines, 950 
in hematomyelia, 1239 
in tetany, 47 
Peptonuria, 222 

Perspiration. (See Sweats and Sweating.) 
Petechiae. (See Rash.) 
Phosphaturia, 213, 214 
Photophobia, and lachrymation, 33 
in botulism, 1289 



Photophobia in fever (yellow), 1036 
in iritis, 1228 

in lethargic encephalitis, 1088 
in measles, ro66 
in rabies, 11 24 
in yellow fever, 1036 
preceding sunstroke, 1284 
uremia, 80 
Pigmentation, 17 

and edema, in heart disease, 22 
in Addison's disease, 17. 173, 174, 175 
in anemias, 5 
in arg/ria, 17. 175 
in arsenical poisoning, 17, 1288 
in arthritis deformans, 1157 
in Bright's disease, 15. 262 
in "bronze diabetes," 17 
in chloasma gravidarum, 17 
in chorea, 1275 
in cirrhosis, hepatic, 17, 175 
in exophthalmic goitre, 17, 175, 183 
in Hodgkin's disease, 167 
in leprosy, 1121, 1122 
in melano-sarcoma, 17 
in nephritis, 15, 262 
in Parry's disease, 17, 175, 183 
in pellagra, 1290 
in pelvic disorders, 17, 175 
in pregnancy, 17 
in pruritus, 17 
in silver poisoning, 175 
in splenomegaly of Gaucher type, 155 
in syphilis. 1018, 1019 
in tuberculosis (peritoneal), 17, 963 
in typhus fever, 1052 
in vagabond's disease, 17, 175, 11 48 
in verminous bronzing, 175 
in von Recklinghausen's disease, 1269 
in yellow fever, 1037 
obscure, 17 

of buccal cavity, 34. 37 
tongue, 37 
Poikilocytosis, 152 
in' anemias, 127 

Addisonian pernicious, 154 
aplastic pernicious, 154 
in chlorosis, 153 
in leukemia, 127 
Polychromatophilia, 126 

in anemia (Addisonian pernicious), 154 
aplastic pernicious, 154 
Polycythemia, ill, 166 
Polydypsia, 1169 

in diabetes insipidus, 1169 
mellitus, 1066 
Polyphagia, in diabetes, 1166, 1167 
Polyuria, 190, 191 

and specific gravity, 191 
in amyloid kidney, 266 
in brain tumors, 1243 
in cystic degeneration of kidney, 272 
in diabetes, 1166, 1168 
in epilepsy, 1272 
in tumors of brain, 1243 
preceding uremia, 249 
asthma, 359 
Pressure symptoms, abdominal, 484, 490, 581, 806 
intra-, 550 
corset, 640 



1344 



SYMPTOM INDEX 



Pressure, symptoms, epigastric, 642, 868 

in cardiovascular syphilis, 755 
in abscess (cerebral), 1251 

mediastinal, 423, 741, 780, 872 
in aneurysm, 14, 489, 585, 733, 736, 741, 

775, 779, 78o, 781 
in angina, 642 
in Bright 's disease, 21 
in carcinoma of esophagus, 904, 905 

of pancreas, 965 
in cardiac insufficiency, 102 
in cardiovascular syphilis (pressure pain) , 755 
in cerebral abscess, 1251 

arterial crises, 478 

congestion, 1241 
in congenital asthenia, 897 
in enlargement of bronchial glands, 422, 423 
in esophageal diverticula, 903 
in "globus hystericus," 102 
in headache (anemic), 91 
in Hodgkin's disease, 166 
in hydatid cysts of liver, 969 

pulmonary and pleural, 426 
in hydrothorax, 21 
in hyperchlorhydria, 868 
in hypogastric neuralgia, 950 
in intermeningeal hemorrhage, 1238 
in leukemia (lymphatic), 158 
in mediastinal abscess (or tumor), 423, 741, 

780, 872 
in meningitis, 1086 
in mitral stenosis, 577 
in myocardial overstrain, 664 
in myocarditis, 667 

persistent upward, 670 
in neuralgia (hypogastric), 950 
in pachymeningitis, 1238 
in pericarditis, 790, 798, 801 
in pleurisy, 362 
in pneumothorax, 378, 482 
in pulmonary and pleural hydatids, 426 

tumors, 421 
in soldier's heart, 609 
in tumors of the brain, 1243 

pulmonary, 421 
in von Recklinghausen's disease, 1269 
intra-abdominal, 550 

-arterial, 478 

-auricular, 685, 695, 696, 697, 743 

-cerebral, in oxycephaly, 31 

-cranial, 492, 479, 564, 1243 
in chronic meningitis, 1086 
in serous meningitis, 1085 

-meningeal, hemorrhage, 1238 

-pericardial, 786, 801 

-ventricular, 720 
of new growths, 489, 806 
precordial, 146, 666, 675, 676, 778, 779 
pressure pain (in cardiovascular syphilis), 

775 
upon heart, 743 
venous, 706 
Prostration. (See Exhaustion.) 
Pruritus, in jaundice, 19 
Pulsating tumor, 775 
Pulsation, anemic, 781 
aortic, 438 

apex beat and "drop" heart, 438 
and posture, 438 
apparent force of, 438 



Pulsation, apex beat and "drop" heart, area of, 
436, 438 

displacement of, 437, 766 
respiratory lateral, 438 
forcible, 679 
heaving vs. wavy, 436 
in pericardial effusion, 798, 799 
inspection of, 436 
invisible, 438 
mixed, 718 
of normal heart, 438 
position of, 436, 437 
reliability of, 461 
reversed, 436 

systolic, retraction beyond, 437 
impulse, visible, 706 
of heart, tracings of, 504 
of lungs, abnormal signs at, 418 
percussion of, 289 
retraction of, 294, 418 
arterial, visible, 741 
capillary, 495 
carotid, 496, 502 

vs. jugular, 496, 502 
epigastric, 354, 706 
expansile, 439 

and deliberate, 438 
of aneurysm, 585 
of liver, 746 

of vascular growths, 781 
from mediastinal growths, 781 
in diagnosis of aneurysm, 585 
in "drop" heart, 581 
in jugular fossa, 765 
in veins of neck, 727 
normal, 42 

of abdominal aorta, 818 
of aneurysm, 436, 585 
of cardiac rhythm, 576 
of liver, 703. 706, 746 
over interspaces, 437 
presystolic jugular, 727 
transmitted, 585, 809 
venous, 496 
ventricular, left, 438 
vermicular, 762 
Pulse, 488. (See also Arrhythmias,) 
absent below knee, 53 
acute infections, 446 
affected by posture, 484 
alternating, 542, 558, 561 

indicated in electrocardiogram, 561 

in polygram, 516, 561, 562 
induced by exercise, 562 
jugular, 570 
significance of, 561 
prognostic, 561, 562 
amplitude, 474 
bizarre terminology of, 495 
bounding, 494 

brachial, at varying pressures, 477 
capillary, 146, 434, 495, 496 
cardiac venous, 502, 664, 710, 715 
carotid, 457, 496, 502, 765 
compensated mitral type, 515 
compressible, 1075 
congenital asthenics, 490 
Corrigan, 710, 714. 7i8, 72c 
deficit, 487 
dicrotic, 495. 1004, 1005 



SYMPTOM INDEX 



1345 



Pulse, disappearance, 493 

extrasystolic irregularity of, 492, 403, 508 

force of, 488 

frequency, 490 

full and large, 494 

gaseous, 495 

heart-block, 565. 568 

hyperthyroidism, 490 

in dorsalis pedis, 489 

in drug habituation, 490 

in fevers, 76 

in nephritis, 256, 259 

in peritonitis, 77. 494 

in pneumonia, 389 

broncho-, 397 
in posterior tibial, 489 
in scarlet fever, 1070, 1071 
in the thirties, 769 
in tuberculosis, 406, 410, 490 
in yellow fever, 75 
influenced by age and sex, 490 
intermittent, 493. 515, 545. 569 
irregularity of, 493. 515. 552 
jugular, 513. 569, 707 

systolic, 707 
lability of, 490 
lack of synchronism in, 765 
methods of "taking," 488 
Mouneret's, 495 
mouse-tail, 495 
normal, 497 

presystolic venous, 552 
of extreme exhaustion, 562 
palpation, technic of, 488 
paradoxic, 494 
peritoneal, wiry, 77, 495 
points to be determined in, 488 
positive penetrating venous, 496 
pressure, 182, 472, 473, 474. 744 

high, 479, 715 

importance of, 472 

increase of, 767 

in lead poisoning, 478 

in mitral stenosis, 696 

low, 762 

with high systolic readings, 764 

method of obtaining, 718 
pseudo-Corrigan, 146 
pulmonary capillary, 698 
radial, 461, 488, 513 
rapid: diseases found in, 491 

in hyperthyroidism, 182 
rate and rhythm of, 488 

increased fever with, 490 

recovery test, 635 
records, instrumental, 514. 764 
recurrent, 489 

-respiration, temperature ratio, 76 
running, 491, 557 
size of, 488 
slow, 491 
slowing of, 635 
small, wiry, 494. 495 
strong or weak, 76 
subclavian, 765 
systolic jugular. 739 

extreme examples of, 707 

venous, 796 
taken by instruments, 490, 496 

85 



Pulse-temperature ratio, disturbed, 1006 

tracings. 499. 557 

variations in, unilateral, 489 

venous, records of, 499. 505. 513. 556 

water-hammer. 494. 495. 719. 747 
Pulsus alternans, 490, 516, 550, 558, 561 

bigeminus, 494, 545, 548, 554. 560 

celer, 494, 516, 664, 719, 725. 747 
hidden, 729 
visible, 710 

deficiens, 493 

durus, 495. 725. 747 

intermittens, 493 

irregularis perpetuus, 494, 551, 555, 557, 701, 
702 

magnus, 494 

paradoxus, 796 

parvus, 494 

pulse, variations in, 489, 493. 495 

tardus, 494 

trigeminus , 494, 548 

vacuus, 494 
Pyrosis (heartburn), 102, 871 

in gastric atony, 890 * 

in gastritis, 906 

in hyperchlorhydria, 868 



Rales, 310 

bronchial, 397 
bubbling, 312 
consonating, 310, 312 
crackling, 311 
"death-rattle," 310 
crepitant, 311 

in pleurisy with effusion, 368, 369, 375 

in pneumonia, 311, 390 

in pulmonary edema, 311 

in tuberculosis, 311 
clicking (mucus click), 312 
dry, 310, 346 
friction, 313 
gurgling, 312, 346 
in asthma, 361 
in bronchitis, 346, 347 
in certain influenzal pneumonias, 1022 
in pneumonia, 391. 392 

broncho-, 396, 397 
in pulmonary congestion, 401 
in tuberculosis, 417 
moist, 310, 346 

in pneumonia, 391. 392 
broncho-, 396, 397 

pulmonary congestion, 401 

tuberculosis, 311, 417 
sibilant, in asthma, 361 

and sonorous, 310, 346 
significance of, 310 
tracheal, 310 
varieties, 310 
Rash (exanthem, eruption, vesicles, etc.). petech- 
ias, 27 
and fever, 75 
artificial, 1295 
drug, 28, 1070 
in anthrax, 1123 
in acute rheumatism, 11 53 
in blastomycosis, 1128 
in buccal cavity, 35 



1346 



SYMPTOM INDEX 



Rash in chickenpox, varicella, 35, 77, 1099, 
1 100, 1 103 
in chorea, 1172, 1275 
in creeping eruption, 1148 
in cutaneous lesions (feigned), 1295 
in dermatomyositis, it 59 
in dermatophiliasis, 1148 
in endocarditis, 677, 678, ion, 1012 
in Escherich's infectious erythema, 1073 
in erysipelas, n 18 
in erythema (infectious), 1073 
in fourth (Duke's; disease, 1073 
in feigned, in cutaneous lesions, 1295 
in fever, scarlet, 35, 77. 1069, 1070, 1071 

miliary, 1057 

rat bite, 1062 

Rockv Mountain spotted, 1056 

typhoid, 6, 1003, 1005, 1006 

typhus, 1051 
in glanders. 1127 
in herpes zoster, 95, 1269 
in jaundice, 19 
in locomotor ataxia, 1256 
in leprosy, 1121 
in lethargic encephalitis, 1088 
in measles, 28, 35, 77, 1066, 1067, 1072, 1073 

german, 77, 1072, 1073 
in meningitis, 1080, 1081 
in miliary fever, 1057 
in neuritis, 98 
in neuralgia (trifacial), 94 
in pyemia, 11 19 
in polymyositis, 1160 
in pellagra, 1290 
in poisoning (atropin), 303 
in pediculus pubis, 1148 
in rat bite fever, 1062 
in Rocky Mountain spotted fever, 1055 
in rubella, 77, 1072, 1073 
in rheumatism (acute), 1153 
in Raynaud's disease, 1270 
in scarlatina, 28 

in scarlet fever, 35. 1070, 1071, 1072, 1073 
in syphilis, 971. 1072, 1099. 1107, 1108, 1109, 
1110 

of lungs, 1009 
in sepsis, 1672, 11 19 
in smallpox, 35 77, 1095. 1096, 1097, 1099 

vaccination, 11 12 
in septicemia, 11 19 
in scabies, 1147 
in stomatitis 35 
in syringomyelia, 1260 
Koplik's spots, 1066, 1077, 1073 
in typhus fever, 1051 
in vaccination (smallpox), 1102 
in varicella. (See Chickenpox.) 
in variola. (See Smallpox.) 
in yaws, 11 14 
detechial, 27 

ulcer and gangrene, 1269, 1270 
Red cyanosis. (See Cyanosis.) 
Referred pain. (See under Pain.) 
Resonance, 293 
amphoric. 309 
hyper-, 296, 297 

in asthma, 361 

in atelectasis, 300 

in congestion of lungs (pulmonary), 401 



Resonance, hyper-, in emphysema, 297, 353,*355 
in pleurisy, 366, 367, 371 
in pneumonia (lobar), 299, 387, 390, 391 

broncho. 300, 395, 396, 397, 398 
in pneumothorax, 379. 380 
in pulmonary edema, 301 
in Traube's space, 279 
in tuberculosis, 300, 416 
impaired, in chest examination, 293 
in examination of heart, 439 
in pleurisy, 364. 36.S. 366 

of lungs, examination, 278, 279, 293, 296^290 
vocal, 308 

increased, 309 
normal, 308 
pathologic, 308 
Respiration. (See Breathing.) 
Ridges on nails, 41 

Rigidity, abdominal, with pain, 85, 363, 804, 956 
in appendicitis, 85, 955. 956, 957 
in cholecystitis (acute), 976 
in colic (biliary), 978 
in intestinal obstruction, 88 
in peritonitis, 960, 962 

tuberculous, 963 
in phantom tumor, 816 
ip pleurisy, 363. 374 
in poisoning (lead acetate), 1305 
cervical, in meningitis, 50, 1079. 1083, 1247 
tuberculous, 1083 
in poliomyelitis, 1093 
in typhoid perforation, 1003, 1004 
wry neck, simulated, 1301 
in apoplexy, 1247, 1248 
in brain tumors, 1244 
lethargic encephalitis, 1088 
lockjaw (tetanus). 1126 
paralysis agitans, 1276 
tetanus (lockjaw), n 26 
tumors of brain, 1244 
muscular, in meningitis (alcoholic), 1085 
in Erb's spinal paralysis, 1258 
in hysteria, 1259 

in primary combined sclerosis, 1256 
in rheumatism (muscular), 98 
in sclerosis (multiple), 1240 
primary lateral, 1257 
of fingers, in acroparesthesia, 1270 
of joints, in arthritis deformans, 44 
feigned, 1295 
of legs, in the spastic paralysis of infants, 

1258 
of limbs, in ataxic paraplegia, 1256 
in catalepsy, 48, 1294 
in cerebral hemorrhage, 1247 
in acute myelitis, 1263 
in Little's disease, 1258 
in intermittent claudication, 53 
in primary combined sclerosis, 1256 
in uremia, 249 
of neck, in poliomyelitis, 1093 
in apoplexy, 1247, 1248 
in meningitis, 50 
in simulated wry neck, 1301 
of spine, 43 

gastric ulcer, 916 
in poliomyelitis, 1093 
temporal, in arteriosclerosis, 92 
Risus sardonicus. (See under Facies.) 



SYMPTOM IXDEX 



1347 



Salivation. 35 

from overuse of mercury, 35. 1300 

in bulbar paralysis, 1264 

in feigned scurvy. 1300 

in goiter, 189 

in hysteria. 35 

in poisoning (corrosive sublimate), 1304 

(trench gas 
in quinsy, 342 
in sprue, 1064 
Sallowness. in abscess of liver, 966 
in Bright's disease, 146 
in cardiac disease, 672 
in cretinism, 183 
in drug habitues. 17, 1287 
in 1: 967 

in malaria (chronic), 1048 
in nephritis (parenchymatous), 15 
in poisoning (chronic arsenical), 1288 
in sprue, 1064 
in syphilis. 146 
Sighing, in cardiovascular syphilis, 756 

in pericarditis, 801 
Sinus arrhythmia. See Arrhythmia.] 
Soldier's heart. 60 
Sore throat. 5 

in diphtheria. 1074, 1075 

in Fever glandular), 105S 
(scarleti. 1070. 1071 

in poliomyelitis. 1092 

in rubella, 1072 

in sporotrichosis, 

in tcnsul;:;; 3J.2 

preceding chorea, 
rheumatism, 5. 1150 
acute. 1 155 
Spasms. (See Convulsions.) 
Speech. (See Impairment of.) 
Sputum, 328 

bloodv, feigned, 1294 
in actinomycosis. 1131 
in asthma. 330. 361 
in blastomycosis, 11 27 
in bronchiectasis. 329. 349 
in bronchitis (chronic). ;•_- 

eosinophil: 

putrid 

tracheo-, 346 
in congestion of the lungs, 400, 401 
in decompensation. 648 
in disease of the mitral valve 329 
in ecbinococcus cysts of the lung, 426 
in emphysema. 352 
in hysteria. 3^9 
in influenza . 10 19 
in laryngitis (tuberculous), 344 
in mumps. 1068 
in perforating abscess. 329. 967 
in pneumonia, 383. 387, 388, 391, 392, 

septic. 393 
in pneumonic plague, 1034 
in pu'm-inary abscess. 419 

gangrene. 421 

infarct, 419 

insufficiency, 731 

tumors, 421 
in trematoda infection, 1134 



1129 



ii54 



Sputum in tuberculosis, 330, 410 

miliary. 406 

pneumonic. 407 
in tumor of lungs. 327 
Stomatitis, 35 
aphthous, 35 
follicular. 35 
in blastomycosis, 112 7 
in foot and mouth disease, 1057 
in measles. 1067 
in sprue. 1063 
in streptotricha, 1127 
mercurial, 35 
parasitic. 35 

preceding lymphatic leukemia, 159 
Strawberry tongue, 37. 973 
Stupor, 79- (see also Coma.) 
alcoholic. 1284 
conjunctiva! ref.ex in, n 94 
in alcoholic meningitis, 1085 
in botulism, 1289 
in cholera infantum. 9-4 
in diphtheria, 10-5 
in encephalitis, 1088 
in gout (retrocedent), n 73 
in malaria, ro4S 
in meningitis, 10S0, 1262 
in poisoning (a tropin), 1303 

chloral hydrate, 1304 

cocain. 1304 

corrosive sublimate, 1304 

lead. 479 

acetate, 1305 

opium, 1306 

trench gas 
in sunstroke, 1283 
in tumors of brain, 1244 
in typhoid fpver, 1003, 1004 
in uremia. 247 
Sweats and sweating. 20 

absence of, in myxedema and cretinism, 174 

179 
and eryt hr ocy I otas. 162 
hydremia following, in 
in abscess of liver, 966 
m asthenia. 20 
in aneurysm. -76 
in Asiatic cholera. 1032 
in biliar] aolic, 978 
in brain tumors. 1245 
in bromidrosis. 20 
in cholecystiti:. acute, 976 
in cholelithiasis, 978 
in chill (feigned). 1296 
in co : ic (biliary), 97 S 
in collapse. 20 
in empyema. 3?4 
in feigned chill, 1296 

rheumatism. 1300 
in fever (miliary). 1057 

typhoid, 1001, 1006 
in fe\ers, 79 
in goiter '.exorh.). 183 
in heat exhaustion. 1284 
in hysuna. traumatic, 12S3 
in jaundice, '9- 20 
in leishmaniasis. 1060 
in locomotor ataxia, T256 
in malaria, 20. 1037, 1045 



1348 



SYMPTOM INDEX 



Sweats in meningitis, suppurative, 1084 
in miliary fever, 1057 

tuberculosis, 10 11 
in myelitis, acute, 1261 
in myositis (suppurative;, 1161 
in neuroses, 20 
Swelling. (See Enlargement.) 
Syncope, 15, 102, 1301 

and sinus arrhythmia, 492 
and hypertension, 478 
fatal, T02 
following aspiration, 102, 485 

hemorrhage, 102 

surgery, 102 
in acute myelitis, 126,2 
in Addison's disease, 174 
in anemia (acute cerebral), 565- 1241 
in anemias, 146 

add. pernicious, 152 
in aortic insufficiency, 720 

stenosis, 726 
in auricular flutter, 558 
in aviator's syndrome, 1283 
in brain tumors, 1244 
in cardiac dilatation, 102, 596 

decompensation, 102, 606, 640 
in dementia (paretic), 1252 
in diphtheria, 102 
in drug poisoning, 102 
in effusion (pleural), 485 

pericardial, 102 
in endocarditis, 102 
in gastric ulcer. (See under Ulcer.) 
in heart block, 466, 565 

soldier's, 608, 609 
in hemorrhage (ulcer), 915 
in mountain sickness, 1282 
in myelitis, acute, 1262 
in myocardial overstrain, 664 
in neurasthenia, 11 83 
in paretic dementia, 1250 
in pericarditis, 801 
in pneumonia, 102 
in poisoning (corrosive sublimate;, 1304 

drug, 102 
in soldier's heart, 608, 609 
in tumors of brain, 1244 
in ulcer hemorrhage, 915 
local (Raynaud's disease), 1270 
loss of consciousness in, 1202 



Tachycardia, 491, 559- (See also Arrhythmia and 
Pulse.) 
and alternating pulse, 561 
sinus irregularities, 563 
in fevers, 490 
in goitre, 182, 183 
in scarlatina, 491 
in tuberculosis, 491 
indicated on polygram, 512, 559, 560 

on electrocardiogram, 539. 560 
paroxysmal, 449 
pulse in, 490, 491 
Teeth grinding, 40, 1233 

in adenoids, 341 
Tenderness, 84, 100 

examination for, 831 



Tenderness, feigned, 1299 

in adiposis dolorosis, 188 

in alcoholic meningitis, 1085 

in aneurysm, 100 

in angina pectoris, 100, 439, 770, 771 

in anorexia nervosa, 879 

in appendicitis, 85, 847, 954, 955, 956, 957, 

958, 1012 
in arthritis (syphilitic), 101, 1157 

gonorrheal, 1158 
in asthenia, 100 
in Barlow's disease, 172 
in carcinoma (brain), 1244 

gastric, 928, 932 
in cardiac disease, 439, 641, 647 
in cholecystitis (acute; , 976 
in cholelithiasis, 978 
in colic (biliary), 898, 899 

renal, 85 
in dengue, 1034 
in dermatomyositis, 1159 
in Dietl's crises, 86 
in dysentery, 948 

in gastric and duodenal ulcer, 870, 910, 9J2 
915, 916, 920 

carcinoma, 928, 932 

erosions, 926, 930 

hyperesthesia, 879 

syphilis , 936, 937 
in gastritis, 906 
in gastroptosis, 884 
in gonorrheal arthritis, 10 1, 1158 
in gout, 101, 1172 
in headaches, 90 

in hyperchlorhydria, 868, 869, 879 
in hyperemia (hepatic) , 968 
'in hypersecretion, 869 
in hysteria, 100, 10 1 
in inflammation of liver, 965 
in intestinal obstruction (volvulus), 88 
in leukemia, myeloid, 157 
in lumbago, 100 
in lymphangitis, 23 
in mastoiditis, 100 
in meningitis (alcoholic/, 1085 
in migraine, 100 
in mumps, 1068 
in myalgia, 1163 
in myositis (suppurative), 1161 
in neuralgia, 94, 95, 98, 100 
in neuritis, 84, 98, 1267 

multiple, 1262 
in Oroya fever, 1062 
in pancreatitis, 964 
in peritonitis, 88, 960, 963 
in periostitis, 100 
in phlebitis, 23 
in pleurisy, 363. 374 

misleading referred pain and tenderness, 
363 
in poisoning (arsenic), 1303 

corrosive sublimate, 1304 
in poliomyelitis, 991. 992, 1092, 1093 
in post-stenotic motor insufficiency, 898 
in prostatitis, 274 
in pyelitis, 268 
in renal infarct, 270 
in rheumatism, 99. 100, 10 1, 1151 
in rickets, n 75 



SYMPTOM INDEX 



M49 



Tenderness in Schick's diphtheria tost, ooo 
in sciatica (feigned), 1300 
in scurvy, 172 
in sinusitis, 100 
in sinus thrombosis, 1240 
in spinal caries, 100 
in synovitis, 101 
in syphilis, 100 
in syphilitic arthritis, 11 57 
in trichiniasis, 1138 
in trichinosis, 10 13 
in tuberculosis, 10 1 

of intestines, 953 
in tumors (mediastinal), 100 
in typhoid, 1000, 1003, 1005, 1012 
in ulcer, 87 
in vaccination, 1102 
in Weil's disease, 975 
in yaws, 11 14 
muscle, in rheumatism, 99 

Rocky Mountain spotted fever, 1055 

trichiniasis, 11 38 
of eye in eyestrain, 91 
of glands, in glandular fever, 1058 
of hands, 41 
of head, 100 
of joints, in gout, 1172 

in rheumatism, 1151 
of teeth, in mercurial stomatitis, 35 
thoracic, 288 
Tenesmus, in Asiatic cholera, 1032 
in cystitis, 273 
in dysentery, 945, 948, 949 
in intussusception, 87, 89, 95 1 
in poisoning (arsenic), 1303 
in prostatitis, 274 
Thirst, in Asiatic cholera, 1032 

in carcinoma of esophagus, 904 
in cholera (Asiatic), 1032 

infantum, 944 
in diabetes insipidus, 1169 

mellitus, 1166 
in dysentery, 948 
in gastritis, 905 
in intestinal obstruction, 89 
in nephritis (acute), 256 
in poisoning (acid), 1302 

(arsenic), 1303 

(lead acetate), 1305 

(meat), 1132 
preceding sunstroke, 1284 
Thrills, apical presystolic, 439 
as diagnostic aid, 745 
associated with cyanosis, 439 
diastolic and systolic, 439 
hydatid, 811, 1136 
in aortic stenosis, 724 
in mitral insufficiency, 681 
in mitral stenosis, 691, 696 
in pulmonary stenosis, 73 r, 734 
in tricuspid stenosis, 727 
of defective ventricular septum, 742 
presystolic, 691 

of mitral stenosis, 745 

to right of sternum, 727 
significance of, 439 
systolic, in aneurysm, 778 
Thyroid enlargement. (See under Enlargement.) 
Tingling, 101 



Tinnitus aurium, in anemia (Addisonian perni- 
cious), 152 
in aortic insufficiency, 720 
in caisson disease, 1239 
in cerebral congestion, 1241 
in irritation of sensory nerve, 1192 
in lesions of auditory nerve, 1234 
in Meniere's disease, 104, 1235 
in meningitis (serous), 1085 
in poisoning (aconite), 1303 
in retropharyngeal abscess, 341 
in sensory nerve irritation, 1192 
in uremia, 248 
many causes of, 1234 
Tremor (twitchings), etc., 14, 45, 46 
conditions associated with, 45 
facial, 45. 4° 

in Adams Stokes syndrome, 570 
• in paretic dementia, 1252, 1253 

in strychnin po.soning, 1307 
fibrillary, in amyotrophic lateral sclerosis 
1264 

bulbar paralysis, 37. 38, 1265 

disseminated sclerosis, 38 

motor lesions, 1192 

muscular atrophy, 1264, 1265 

paralysis agitans, 38 
in acute disease, 45 
in alcoholism, 37, 46, 1286 
in arrhythmias (cardiac), 570 
in cardiac arrhythmias, 570 
in cerebral hemorrhage, 1246 
in convulsions, 49 
in delirium tremens, 46, 1286 
in dementia (paretic), 1252, 1253 
in drug habitues, 46 
in dystrophy (muscular), 1266 
in epilepsy (petit mal), 1272 
in exophthalmic goitre, 46, 179, 181, 183, 434 
in fever, 46 

milk, 1057 

typhoid, 45 
in hyperthyroidism, 179, 183 
in hypothyroidism, 187 
in hysteria, 46, 1279 

traumatic, 1281 
in lethargic encephalitis, 1088 
in meat poisoning, 1132 
in motor lesions, 11 92 
in multiple sclerosis, 1240 
in muscular dystrophy, 1266 
in paralysis agitans, 14, 46, 1276 
in paretic dementia, 1252, 1253 
in poisoning (drug), 46 

lead, 46, 479, 1287 

meat, 1132 

potassium nitrate, 1306 

strychnin, 1307 

tobacco, 61 
in poliomyelitis, 1093 
in sclerosis, 46 

amyotrophic lateral, 14 
in traumatic hysteria, 1281 
in uremia, 247. 249 
intention, 14, 45, 46 

in multiple sclerosis, 46, 1240 
muscular, 45 

in milk fever, 1057 

in paresis, 37 



*35° 



SYMPTOM INDEX 



Tremor, muscular, in uremia, 249 
of extremities, 45. 46. 183, 570 
of eyelids, in exophthalmic goitre, 181, 183 
of feet, in paralysis agitans, 1276 
of hand, 40 

in cerebral hemorrhage, 1246 

in paralysis agitans, 1276 
of head, 46. 183 
of lips, 46, 183 
of tongue, 36, 37, 45. 4 6 

in delirium tremens, 37, 1286 

in fevers, 36, 38 

in goitre, 183 

in paresis, 37. 38 

in sclerosis, 38 
passive, 45 
Tympany, 292, 298 
bell, 309 

in pneumothorax, 309, 379 
effect of posture, 298 
in aneurysm, 299 
in examination of the heart, 439 
in lung cavities, 300 
in pericardial effusions, 299 
in pleurisy with effusion, 366, 367 
in pneumonia, 390 

broncho-, 396, 397 
in pneumothorax, 309, 379 
in tuberculosis, 300 
Tympanites, 805 

and displacement of heart, 431, 437 

in abdominal examination, 25, 803, 805, 810, 

812 
in arteriosclerosis, 764 
in ascaris infection, 1137 
in cholera infantum, 944 
in fever (typhoid), 1000, 1002, 1005. 1006 
in influenza, 1020 

in intestinal indigestion (acute), 944 
in peritonitis, 960 



Urobilinurea, 194 

in anemia (Addisonian pernicious ) . 154 
in congenital hemolytic jaundice, 156 



Vertigo, 103 

and constipation, 104 

and hypertension, 478 

and reeling gait, 53 

auditory, 104 

feigned, 1300 

following heat exhaustion, 104 

sunstroke, 104 
in Addisonian pernicious, 152 
in alcoholics, 105 
in anemias, 104, 146 
in aortic insufficiency, 720 
in arteriosclerosis, 92, 104, 765, 766 
in ascaris infection, 1137 
in asthenia, 104 
in auricular flutter, 559 
in auto-intoxication, 104 
in aviator's syndrome, 1283 
in botulism, 1288 



Vertigo, in brain abscess, 104 

tumor, 103, 104, 140, 1142 
in Bright's disease, 104 
in bubonic plague, 1033 
in cachexia, 104 
in caisson disease, 1239 
in cardiac decompensation, 104, 640 
in cerebral anemia, 565. 1241 

congestion, 1241 

hemorrhage, 1246 

syphilis, 104 

thrombosis, 104, 1250 
in congenital asthenia, 897 
in dementia (paretic). 1252 
in effusion (pleural), 485 
in encephalitis, 1088 
in epilepsy (petit mal), 103, 104, 1273 
in erythromelalgia, 1270 
in exhaustion, 104 
in eyestrain, 104 
in fevers, 104 
in gastric disorders, 105 
in gastritis, 906 
in gout, 104 
in headaches, 91, 93 
in heart block, 565 
in heat exhaustion, 104 
in hysteria (traumatic), 1281 
in lesions of auditory nerve, 1234 

brain and cord. 104 

cerebellum, 104, 12 13 

lower pons, 104, 1213 
in locomotor ataxia, 104 
in Meniere's disease, 104, 1234, 1235 
in meningitis, 104 

syphilitic, 1084 
in migraine, 93 
in mountain sickness, 1282 
in multiple sclerosis, 1240 
in myocardial overstrain, 608 
in neurasthenia, H79. 1283 
in paresis, 104 
in paretic dementia, 1252 
in pleural effusion, 485 
in poisoning, aconite, 1303 

atropin, 1303 

food, 1288 

hydrocyanic (prussic acid), 1305 

lead acetate, 1305 

meat, 1132 

opium, 1306 
in poliomyelitis, 1093 
in sclerosis (disseminated), 104 
in soldier's heart, 608, 609 
in sunstroke, 104, 128. 1284 
in syphilis (cerebral), 104 
in syphilitic meningitis, 1084 
in traumatic hysteria, 12 81 
in trench fever, 1065 

in tumors of brain, 103, 1243, 1244, 1245 
in uremia, 247 
in "labyrinthine," 1235 
in laryngeal. 104 
in naso-pharyngeal, 104 
in paralytic, 1270 
in persistent, 104 
in preceding syncope, 102 
in varieties of, 104 
Vomiting, 872 



SYMPTOM INDEX 



1351 



Vomiting, cyclic, 913 

examination of vomitus, 873 

fecal, in intestinal obstruction, 88, 99 

feigned, 1300 

in abscess, cerebral, 1251 

of liver, 966 

subphrenic, 961 
in Addison's disease, 174 
in anemias, 146 
in angina, 647. 77i 
in angioneurotic edema, 1271 
in anorexia nervosa, 879 
in anthrax (internal), 1123 
in aortic aneurysm, 776 
in appendicitis, 86, 954, 955 
in Asiatic cholera, 1032 
in atonic dilatation, 898, 899 
in atony (gastric) . 890 
in atrophy (acute yellow), 974 
in botulism, 1288 

in brain tumor, 91, 1086, 1242, 1244, 124s 
in Bright's disease, 872 
in bubonic plague, 1033 
in carcinoma (gastric), 932, 934, 93s 
in cardiac disease, 647 
in catarrhal jaundice, 975 
in cerebellum, lesions of, 12 13 
in cerebral abscess, 1294 

concussion, 1294 

rheumatism, 1153 
in cholecystitis (acute), 976 
in cholera infantum, 944 
in cirrhosis of liver, 971 
in colic (abdominal), 90 

biliary, 978 

gallstone, 87 

renal, 86 
in coma (diabetic), 1166 
in concussion (cerebral), 1294 
in congenital stenosis of stomach, 937 
in crises (gastric), 935 
in dengue, 1035, 1037 
in diabetic coma, 1166 
in diarrhea, 944 
in Dietl's crises, 268 
in ectasia (post-stenotic), 900 
in epidemic dropsy, 1057 
in esophageal diverticula, 903 
in feigned hematemesis, 1297 
in fever, milk, 1057 

scarlet, 1070, 1071 

typhoid. 1007 

typhus, 1052 

yellow, 1035, 1036, 1037 
in fever*, 75 

in gastric and duodenal ulcer, 70, 910, 912, 
913. 915 

atony, 890 

carcinoma, 932, 934. 935 

crises, 935 
in gastritis, 905, 906 
in gout (retrocedent) , 1173 
in headache (sinus), 91 
in hematemesis (feigned), 1297 
in hernias, 90, 873 
in hepatitis. 70 
in hyperchlorhydria, 868 
in hypersecretion, 869, 927 



Vomiting in infections, 78 
in influenza. 102 1 

in intestinal obstruction, 87, 88, 950 
in intussusception. 87, 951 
in jaundice (catarrhal), 975 
in lead poisoning, 1287 
in Leishmaniasis, 1060 
in lesio.is of auditory nerve, 1234 

of cerebellum, 1213 
in locomotor ataxia, 913 
in malaria, 1048 
in Meniere's disease, 1235 
in meningitis, 1079 

chronic, 1086 

syphilitic, 1084 

tuberculous, 1083 
in migraine, 93, 872 
in milk fever, 1057 
in movable kidney, 268 
in mountain sickness, 1282 
in myelitis (acute), 1262 
in nephritis (acute), 256 

parenchymatous, 259 
in pancreatic cysts, 964 
in pancreatitis, 964 
in peritonitis, 960 
in plague (bubonic), 1033 
in pneumonia, 389 

broncho-. 39<\ 397 
in poisoning (acid;, 1302 

aconite, 1303 

arsenic, 1303 

atropin, 1303 

cantharides, 1303 

carbolic acid; 1304 

cocain, 1304 

corrosive sublimate, 1304 

food, 1288 

lead. 1287 

lead acetate, 1305 

lobelia, 1305 

mushroom, 1305 

oxalic, 1306 

phosphorus, 1306 

potassium chlorate, 1307 

trench gas, 348 
in poliomyelitis, 1092 
in post-stenotic ectasia, 900 
in purpura, 169 
in renal infarct, 270 
in rheumatism (cerebral). 1153 
in scarlet fever, 1070, 107 1 
in sea-sickness, 872 
in smallpox, 1095, 1099 
in sprue, 1064 
in trench gas poisoning, 348 
in tumor of brain, 1086, 1242, 1244, 1245 
in typhoid fever, 1007 
in typhus fever, 1052 
in ulcer (gastric and duodenal), 70, 87 
in whooping cough, 1104, 1105 
in yellow fever, 1035, 1036, 1037 
toxemic, 872 



W 



Weakness. (See Exhaustion.) 
Word blindness. (See Blindness.) 



GENERAL INDEX 



Abderhalden test, 935 
Abdomen, an obscure region, 803 
boundaries of, 807 
distention of, excessive, 820 

gaseous, 817 

general or localized, 80s 

sudden, in typhoid fever, 1004 
doughy, 963 
flaccid pendulous, 805 
inspection of, 80s 
landmarks of, bony, 807 

external, 80s 
measurement of, 285 
nutrition of, 805 
palpation of, 803 
prominent, 12 17 

in rickets, 1175 
pubic, surface-segment of, 806 
regional divisions of, 807 
scaphoid, 952 
" solid growths in, 973 
surface appearances of, 806 
topography of, 807 
veins of, superficial, 806 
Abdominal adhesions, universal, 820 
aorta, bifurcation of, 807 
colic, blood pressure rise in, 485 

examination in, of blood, 90 
of urine, 90 

hernia in, 90 

illnesses preceding, 90 

onset of, 90 
crises, spastic splanchnic, 936 
distress, 764 
examination, points determined in, 80s 

posture for, 80s 

technic of, 803 
flaccidity, 805 
lesions, decubitus in, So 

urgent, simulated, 643 
operations, dilatation of stomach after, 

897 
organs, disease of, 803 
outline, 80s 
pain, 363 
pockets, 820 

pressure, sudden relief of, 484 
quadrants, 807 

superior, inspection of, 436 
reflex, 1196 
rigidity, 363 

in appendicitis, 956 

involuntary, 804 
swelling, localized, 805 
tenderness, 100, 363 
tumors, cylindrical fecal. 816 

differentiation of, 818 

helpful data concerning, 815 



Abdominal tumors, mobility in, 81s 
obscure, 816 
"phantom," 816 
splenic, 812 
walls, relaxation of, 803, 80s, 831, 953 
Abscesses, abdominal, obscure, 910 
appendiceal, 961 
cerebral, 1250 
cold, 818, 902 
embolic, 420 
esophageal, 903 
formation of, in endocarditis, 678 

in myositis, 1161 
glandular, after vaccination, 1102 
mediastinal, 423 
of liver, 949, 961, 966 
complications of, 966 
diagnosis of, differential, 967 
diseases associated with, 966 
multiple, 967 
pain in, 966 
perforation in, 966 
"pointing" of, 966 
prognosis, in, 967 
pulmonary form of, 967 
roentgenography in, 966, 967 
septic, phenomena in, 967 
sweating in, 967 
symptoms of, 966 
. of lung, 326, 420 
pancreatic, 964 
peridental 587 
prostatic, 274 
pulmonary, 419 

breath sounds in, 306 
differentiation of, 326 
pyemic, 966 
renal, 271 

secondary, 815 
retropharyngeal, 341 
rupture of, into heart, 666 
septal, 33s 

subdiaphragmatic, 286, 961 
subphrenic, 286, 961 
tropical, 966 
tuberculous, 125 
Absent-mindedness in petit mal, 1272 
Acarus scabiei, 1147 
Accentuation, variants of, 730 
Accessory sinuses, 337, 338, 339 
Accident, clinical, rare, 351 
indemnity, 1292 

insurance and malingerers, 1291, 1297 
Acclimation fever, 1037 
Accommodation, response to, 1220 
Acetanilid poisoning, 80 
Acetic acid test, 862 
Acetone in the blood, 83 

in the urine, 228, 229 
Acetonemia, 249 



1353 



1354 



GENERAL INDEX 



Acetonuria, 1166 

Achard and Bensaud, bacillus of, 1001 
Achilles-jerk, 1194 
Aching, general, 100 
Achondroplasia, 33. 41. 189 
Achoria, 871 

Achromia marked in chlorosis, 150 
Achroodextrin, 863 
Achylia, age incidence of, 883 
frequency of, 883 
gastrica, 160, 879 

accompanying menstruation, 880 
diagnosis of, 881, 883 
differentiated from carcinoma, 934 

from gastritis, 906 
early stages of, 870 
functional, stomach contents in, 862 
lipase test in, 863 
secondary, 883 
senile, 883 
simple, 880 

active and passive, 880 
plumpness in, 881 
stomach findings in. 881 
of malignant disease of stomach, 884 
pancreatica, 881 
persistent, 882 
stools in, 882 
Acid-albumin, 218, 857 
Acid reflex, 881 
Acidity, gastric, test for, 860 
Acidosis, 3, 1 164 

as ominous symptom, 228, 229 
diabetic, 82 

in cases of, hypertension, 480 
ketone, 1163 
non-diabetic, 229 
treatment of, 1167 
Acids, intolerance of, 1068 

mineral, poisoning by, 1302 
Acne, scars from, 29 
Aconite poisoning, 1303 
Acromegaly (aromegalia), 184 
age and sex in, 184 
autopsy findings in, 184 
diagnosis, "street-car," 185 
differentiation of, 186 
etiology of, 184 
hands in, 40, 184 
historical note on, 184 
prognosis in, 185 
symptoms of, 185 
variations in, unusual, 185 
with myxedema, 178 
Acroparesthesia, 1270 
Actinomycosis, 1078, 1130 
atypical, 1129 
cerebral, 1131 
cutaneous, 1131 
of digestive tract, 1131 
pulmonary, 425, 1131 
Action current, measurable, 518 

vs. repose, 45 
Activity, excessive, and cardiac dilatation, 654 
premature resumption of, 589 
after articular rheumatism, 596 
after influenza, 597 
after pneumonia, 596 
forced, 658 



Acute yellow atrophy, 974 

diagnosis of, differential, 974. 1037 

morbid anatomy of, 974 

stools in, 974 

symptoms of, 974 

urine in, 974 
Adams-Stokes syndrome, 466, 480, 565, 570, 766 
Adaptation vs. "perfect compensation," 652 
Addisonian pernicious anemia, 151 
Addison's disease, 173 

blood in, 174 

diagnosis of, 175 

differentiation of, 175 

etiology of, 173 

leucocyte count in, 174 

morbid anatomy and pathology of, 173 

pigmentation of skin in, 17, 173. 174 

prognosis in, 175 

simulated, 175, U47, 1148 

symptoms of, 174 
Adductor-jerk, 1196 
Adductor reflex, crossed, 1195 
Adenie, 164 
Adenitis, malignant, 1032 

tuberculous, 167, 940, 1034 
Adeno-carcinoma, cylindrical-celled, 931 
Adenoids in whooping cough, 1105 

post-nasal, 340 

climate a cause of, 340 
diagnosis of, direct, 341 
sequelae of, 340 
symptoms of, 340 
Adhesions after appendicitis, 951 

duodenal, 845 

gastric, 923 

local immobilization by, 787 

pericardial, 792. 793 

peritoneal, effect of, 24 

pleural, 323. 366, 372, 375 
Litten's sign in, 286, 375 
lung borders in, 296 
'Adhesiveness sign," 816 
Adiposis dolorosa, 188 
Adolescence, diseases common in, 58 
Adrenal test, 178 
Adrenalin, action of, 1164 

in chromaffin tissue, 174 

test in cretinism, 178 
Adrenals, affections of, diagnosis of, 175 

function of, impaired, 173 
Adults, young, valvular lesions in, 672 
Aeration areas, reduction of, 378 
Aerophagi, 817, 872 
Affinities, selective, for toxins, 981 
Affliction, rhythmic, 793 
African tick fever, 1049 
Age, actual vs. apparent, 59 

blood pressure in relation to, 476 

estimation, 58 

height and weight relation to, 54 

periods, diseases limited to, 59 
Agglutination, principles underlying, 980 

reactions, 991 

in Malta fever, 1053. 1054 

tests in, paratyphoid, 1001 
of Widal, 1008, 1009 
Agglutinins, 982, 983 
Aging, rapid, 58, 59 
Agoraphobia, 11 79 



GENERAL INDEX 



1355 



Agraphia, 14, 1203, 1210 
Ague cake, 812, 1045 

dumb, sequelae of, 1048 
Ainhum, 11 17 
Air between lung and chest wall, 302 

cells in emphysema. 352 

content of organ percussed, 293 

hunger, 83, 106, 351, 647 

swallowing of, 817, 871, 911, 949 

vesicle, rupture of, 351 
Alas, working, in dyspnea, 33 
Albumin, derived, 215 

fermentation, 941 

in acute nephritis, 257 

in gastric contents, 863 

in normal saline solution, 933 

in sputum, 330 

ring, 219 

tests for, acid, 217 
brine, 217 
heat. 217, 218 

varieties of, 215 
Albuminometer (Esbach's), 220 
Albuminuria, 215 

accidental, 215 

affected by posture, 217 

and chloride retention, 213 

cold weather cases of, 217 

cyclic, 216 

febrile, 254 

from manipulation, 267, 814 

from septic foci, 217 

in malaria, 104s 

in yellow fever, 1036, 1037 

intermittent, 217, 247 

minima, 217, 240 

orthostatic, 217 

"physiologic," 250 

significance of, 216 

toxic, 254 

transient, 21s, 216 
gouty, 1 1 73 
Albumoses in the urine, 215, 220 

secondary, 216 

tests for, 216 
Albumosuria with leucocytosis, 215 
Alcaptonuria, 192, 194 
Alcohol, indulgence in, diseases due to, 62 

inquiries concerning use of, 61 
Alcoholic excess, 61, 241, 971 

meningitis, 1085 
Alcoholics, types of, 1285 
Alcoholism, acute, 1284 

chronic, 1284, 1285 
hypotension in, 483 

color of skin in, 80 

delirium in, 1285 

eyes in, 80 

hereditary, 68 

lesions of, digestive tract, 1285 
in lungs, 1285 
in nervous system, 1285 
renal, 1285 

paresis simulated in, 1285 

tremor of, 46 

visceral alterations in, 1285 
Ales, use of, and gout, 1170, 1171, H74 
Alexia, 1203 
Alexin, 983, 984 



Alexin, fixation, 984, 985 
Alexin, titration, 986 
Alizarin solution, 864, 865, 866 
Alkali-albuminate 220 
Alkalies-caustic, poisoning by, 1304 

fixed vs. volatile, in urine, 196 

ingestion of, and relief of pain. 932 

irritation from, 903 
Alkaline tide, 197 
Allen's test for glucose, 22s 
Allergic test of Noguchi, 748 
Allergy, 992 

principles underlying, 980 
Allochiria, 1204 
Almonds, bitter, odor of, 1305 
Alopecia, syphilitic, 13 
Alternating pulse, 542, 558, 561 

indicated in the electrocardiogram, 542, 
S61 

indicated in the polygram, 516, 561 
Alternative relationship between diseases, 68 
Altitude, high, and cardiac overstrain, 1057 

diarrhea of, 1063 

effects of, 162, 1282 
"Alt-tuberculin" of Koch, 412, 413 
Alvarenga-Duroziez murmur, 710 
Amaurosis, 1225 

uremic, 263 
Amaurotic family idiocy, 1259 
Ambard's laws, 203. 204, 205 

urea process, 203 
Amblyopia. 1225 
Amboceptors, 984 

(Ehrlich). 983 

hemolytic, 987 
"Ambulance chasers," 1292 
Ambulants, cyanosis in, 16 
Ameba dysenteriae, 94s 
Amebae, differentiation of, 947 

in Manila water supply, 946 

recognition of, 945 
Amebic abscess, 966 

dysentery cause of, 945 
Amidulin, 863 
Amimia. 14, 1203 
Ammonia in the urine, 207, 214, 234 

liberation of, 200 
Ammonio-magnesium phosphate, 232 
Ammonium urate, 234 
Amnesia, 1201 

auditory, 14 

memory in, 1298 

motor, 1203 

visual, 14 
Amyloid kidney, 266 

blood pressure in, 478 

liver, 974 

sex incidence in, 974 
Amylopsin, 851 

tests for, 864 
Amyotrophic lateral sclerosis, 1264 
Anachlorhydria as a symptom, 870 
Anacidity of stomach, 860 
Analgesia, 1209 
Anaphylaxis, 992 
Anarthria, 14, 1202, 1204 
Anasarca, 20 
Anastomoses, circulation by, 741 

series of, 734 



1356 



GENERAL INDEX 



"Anchovy sauce" sputum, 329 
Anemia, III, 144 
Addisonian, 151 
aplastic pernicious, 154 
arterial, 557. 558 
blood-findings in, 160 
blood picture of Addisonian anemia, present 

in Oroya Fever, 1062 
bothriocephalus, 127, 153, 160 
brain center, 479 
causes of, general, 147 
cerebral, 1241 

acute, 565 
chlorotic, 148, 162 

in achylia, 883 
diseases associated with, 164 
due to hidden infection, 148 

to piles, 942 
etiologic factors, 147 
examination of stools in, 161 
eye in, 147 
feigned, 1293 

general considerations in, 145 
in Arctic explorers, 147 
in duodenal ulcer, 919, 920 
in fatty heart, 670 
lymphatica, 164 
murmurs in, 452 
myelocytic, 161 
nutrition in, 147 
of the cord, 1254 
of the ear, 33 
of uncinariasis, 1139 
outward signs of, 145 
pernicious, Addisonian, 151-, 162 

in Oroya fever, 1062 
prognosis in, 162 
progressive, from hemorrhage, 915 

in cancer, 933 
rheumatic, 11 52 
secondary, blood in, 144 

conditions associated with, 147 

distinguished from pernicious, 160 

intractable, 920 

prognosis in, 162 
sex affected, 147 
simple, 144 
splenic, 154 

symptomatology of, 147 
types of, 15, 144 
Anemias, the, differential diagnosis of, 160 
Anesthesia, 1204 

bilateral, 1209, 1213 

blood pressure in surgical, 483 

chloroform, hypotension in, 483 

diagnostic, 816 

dissociated, 1260 

dolorosa, 1209 

ether, hypertension in, 483 

ethyl chlorid, 483 

feigned, 1299 

hysterical, 1280 

laryngeal, 1236 

•local, in examination of esophagus, 826 

macular, 1121 

nitrous oxid, 483 

of intestines, 950 

of leprosy, 1121 

oxygen, 483 



Anesthesia, patchy, 1208, 1212 

rupture of aneurysm during surgical, 647 
Anesthesin, use of, for pain, 921 
Aneurysm, abdominal, 87, 818 
and "heart pang," 760 
cardiac, 768 
in coma cases, 81 
in luetic aortitis, 752 
in relation to syphilis, 773 
in the young, 773 
inspection in, 776 
intracranial, symptoms of, 1249 
miliary, 1246 

of aorta, 773 (see also "Of Aortic Arch") • 
ascending, 582, 585, 775 

roentgenography of, 585 
descending, 584, 585, 779 
differentiated from dilatation, 584 
from mediastinal tumor, 585 
pressure symptoms in, 482, 790 
thoracic, 773 

clinical divisions of,. 7 74 
diagnosis of, 773. 779 
due to traumatism, 773 
etiology of, 773 
general consideration of, 780 
pulse in, 494, 777 
simulating spasmodic asthma, 358 
sound in, ringing, metallic, 777 
symptoms of, 585, 775. 777, 778, 782 
thrills and murmurs in, 777 
transverse, 584, 759. 779 
X-ray examination in, 584, 585, 780 
of aortic arch, 107, 358, 437, 489. 583. 748, 778 

entire, 585 
of left iliac artery, 84 
of the heart, 802 
palpation in, 777 
physical signs of, 776 
pseudo-abdominal, 818 
pulsation of, expansible, 423, 585 
rupture of, 647, 1246 
external, 774 
into esophagus, 776 
on sitting up, 776 
saccular, and malignant growth, 585 
simulated, 421 
sites for, 775 
statistics of, 774 
symptoms of, 775 
termination in, 775 
Aneurysmal asthma, 358 
diathesis, 12 

sac, obliterative pressure of, 733 
rupture of, 775 
Angina (crural), 42 
Angina pectoris, 769 

and fibrillation, 553 

and interstitial nephritis, 773 

associated with asthma, 359 

blood pressure in, 480, 77 1 

classic, 787 

dilatation of heart in, 772 

exciting causes of, 770 

feigned, 1293 

hyperesthesia in, 771 

hypertension in, 480 

in thoracic aneurysm, 778 

major, 440, 759. 76o, 769 



GENERAL INDEX 



1357 



Angina, in aortic insufficiency, 721 
in luetic aortitis, 753 
painful areas in, 641 
recurrent, 642, 645 
seizures of, 769 
typical, 769 

maximal expression of. 763 

miniature replicas of, 647, 755, 772 

minor. 647, 759. 772 

mistaken for neuralgia, 95 

pain in, 647, 731, 769, 771 
abdominal, 771 

potent factors in, 770 

prognosis in, 773 

rationale of, 772 

relief of, 770 

seizures of, at night, 772 

simulated by malingerers, 1293 

sinking sensations in, 101 

tenderness in, 770, 771 

under physical rest, 641 

with epigastric pain, 771, 936 
Angina, suffocative, 1074 

Vincent's, 1077 
Angiochoiitis, septic, 979 
Angio-neurotic edema, 21, 1270 
"Angle of Louis" as a landmark, 277 
Angular gyrus, lesions, 1225 
Anidrosis, 20 
Anilin poisoning, 64 
Animal parasites, 113 2 
Animals, species relationships in, 990 
Anisocytosis, 152 
Ankle clonus, 1195 
Ankles, edema of, 13 
Ankylosis in arthritis, 1157 
Ankylostomiasis, 1139 
Anopheles as carrier of malaria, 1038 

as host of filaria, 1141 

characteristics of, 1038 
Anorexia and emaciation, 871 

in gastric ulcer, 919 

nervosa, 879 
Antagonists, physiologic, 469 
Anthracosis, 424 

roentgenogram in, 320 
Anthrax, 11 22 

bacillus, 1 1 22, 1 1 23 

diagnosis of. 11 23 

due to occupation, 65, 1123 

edema, malignant, 11 23 

falling fever in, 1123 

forms of, intestinal, 1123 

hemorrhage in, 1123 

infection of, 1122 

interna'. 1123 

lesions of, 11 23 

symptoms of, constitutional, 11 23 
Antianaphylaxis, 993 
Antibodies, specific, 982 
Antienzymes, protective, 907 
Antiformin method, 332 
Antigens, action of, 982 
Antiperistalsis, 841 

in gastric ulcer, 923 
Antiserum, 991 
Antitoxin, diphtheria, 1075, 107 7 

production of, 981, 990 
Antivaccinationists, 1099 



Antrum of Highmore, abscess in, 337 

headache, 92 
pyloricum, 885 
Anuria, etiologic factors, 191 
Anus, hemorrhage from, feigned, 1297 

relaxation of, 89 
Anxiety, morbid, 1179 
Aorta, abdominal, aneurysm of, 818 

aneurysm of, 435, 437, 494. 582, 584, 585 

blood pressure in, 482 
Aorta, aneurysm of (see Aneurysm). 
area of, 433. 449 
arteriosclerotic, 768 
as storage power plant, 767 
ascending, aneurysm of, 582, 584, 585. 775 
atresia of, 739, 74 1 
bifurcation of, 807 
congenital obliteration or occlusion of, 28. 

806 
crossing of esophagus, 901 
descending, aneurysm of, 584, 585. 779 
dilatation of, 578, 720, 773 

diffuse, 759 

increased dulness in, 718 
disease of, and mitral disease, 717. 747 

syphilitic, 60, 752, 760 
enlarged, 585 
fibers around, 524 
illumination of, oblique, 583 

sagittal, 582 
lumen of, blocking of, 741 

reduction of, 721 
normal, roentgenoscopy of, 582; 
overaction of, 627 
position of, 431 

pressure in, systolic and diastolic, 471 
sclerosis of, 720, 769 
stenosis of, 741 
thoracic, aneurysm of, 773 
transverse, aneurysm of, 584, 759, 779 
wear and tear of, 460 
Aortic arch, aneurysm of, 107, 359. 437. 489. 
753, 773 (see Aneurysm). 

ascending, aneurysm of, enormous, 810 

dilatation of, 584, 753. 765. 773 
diffuse, luetic, 758 

resonance over, 439 

sclerosis of, 768 

shadow of, 583. 584 
endocarditis with insufficiency, chronic, 676 , 

715 
incompetence, 626, 708 

luetic, 753 
insufficiency, 626, 708 

after overstrain, 716 

arterial changes in, 581 

as commonly encountered, 708 

cardiac rhythm in, 576 

clinical elements of, 714 

compensated, configuration of aorta in, 581, 
711 
of heart in, 578, 711 

decompensation in, 720 

diagnosis of, at sight, 719 

dyspnea in, 721 

electrocardiogram in, 533 

heart sounds in, 719 

important sign in, 716 

incidence of, 449 



1358 



GENERAL INDEX 



Aortic insufficiency, luetic, 753 

murmur of, 708, 715, 716 
audibility of, 717 
duration of, 716 
transmission of, 716 

pain in, 720 

rationale of, 711 

roentgenography of, 578, 581 

signs of, associated, 710 
characteristic, 708 

silent, 716 

sources of danger in, 721 

sudden death in, 721 

symptoms of, cardinal, 715 

with dilatation, 713 
isthmus, blocking of, 741 
leakage, 626, 708 
lesions, effects of, 714, 746 
ostium, reduction of, 726 
pain, 7ss 

pulsation, 437, 581 
regurgitation, 626, 708 

and "drop" heart, 630 

blood pressure in, 479 

combined with mitral, 581 

compensation in, 463, 753 

distinguished from aneurysm, 781 

free, pulse pressure in, 753 

frequency of, 461 

in endocarditis, 676, 715 . 

jerking vessels in, 434 

manifest after thirty, 759 

pallor in, 16 

percussion area in, 712 

pulsation in, 437, 581 

roentgenography of, 581 

secondary, 760 
reserve, 767 
second sound, 725 

accentuation of, 460, 763 
stenosis, 721 

a progressive lesion, 726 

and regurgitation, 746, 747 

apex-beat in, 725 

arrhythmia in, 726 

at autopsy, 722 

audibility of, 725 

cardiac outline in, 581, 725 

compensated, 724 

differentiation of, 725 

dilatation in, 725 

enlarged left ventricle in, 725 

etiology of, 721 

frequency of, 461 

hypertrophy in, moderate, 725 

in a Turkish bath rubber, 726 

in males, 721, 722 

lines of murmur transmission in, 725 

luetic, 722 

maximal at base, 744 

murmur in, 723 
systolic, 743 

percussion area in, 724 

physical signs of, 722 

pulse in, slow, 725 

radiogram of, 579. 581 

rationale of, 725 

second sound in, obscure, 445, 725 

sphygmographic tracing of, 723 



Aortic stenosis, symptoms of, 722 
systole in, prolonged, 726 
thrill in, 724 
unrecognized cases, 726 
with regurgitation, 722 
valves, fusion of, 722 
sclerotic change in, 625 
Aortitis, broken compensation in, 753 
chronic productive syphilitic, 752 
diagnosis of, early, 753 
dyspnea of, 756 
luetic, 750 

blood pressure in, 753 
dyspnea in, 756 
figures concerning, 7 So 
pain in, 756 
sudden death in, 750 
masked manifestations of, 755 
of Francis Welch 752 
treatment in, response to, 753 
Ape hand, 12 17 
Apepsia gastrica, 879 
Apex beat and "drop" heart, 438 
and posture, 438 
apparent force of, 438 
area of, 436, 438 
displacement of, 437, 766 
respiratory lateral. 438 
forcible, 679 
heaving vs. wavy, 436 
in pericardial effusion, 798, 799 
inspection of, 436 
invisible, 438 
mixed, 718 
of normal heart, 438 
position of, 436, 437 
reliability of, 461 
reversed, 436 

systolic, retraction beyond, 437 
impulse, visible, 706 
of heart, tracings of, 504 
of lungs, abnormal signs at, 418 
percussion of, 289 
retraction of, 294, 418 
Aphasia, 1203, 1210, 1212 
motor, 1203 

sensory, 1203, 1204, 1245 
true, 14 
Aphemia, 14, 1203, 1204 
Aphonia, 344, 12 15, 1236 
feigned, 1293 

in tuberculous laryngitis, 344 
Aphthous stomatitis, 1057 
Apices, pulmonary, resonance of, 293 
Apnea, 436 

Apoplectic insult, 1247 

Apoplexy, coma in, 79 

congestion of. 401 

differentiated from uremic coma, 249 
following hypertension, 479 
hereditary tendency to, 68 
in nephritis, 266 
precocious, 748 
.pulmonary, 418 
symptomatic, 1250 
symptoms of, premonitory, 1246 
Appendicitis, 953 

acute catarrhal, 954 

diagnosis of, differential, 956 



GENERAL INDEX 



J 3S9 



Appendicitis, acute catarrhal, diffuse, symptoms 
of, 954 

prevalence of, 053 
adhesions after, 951, 959 
afebrile, 954 

age and sex incidence in, 954 
and floating kidney, 267 
bismuth meal in, 959 
bowel drainage in, 957 
chronic, 957 

diagnosis of, 86 
differential, 958 

diseases associated with, 958 

dyspeptic symptoms in, 958 

misnomers for, 957 

old inflammatory masses in, 957 
diagnosis of, confusion of, 956 
endo-appendiceal form, 954 
etiology of, 954 
examination in, rectal, 955 

exploratory operation in, 959 

vaginal, 955 
fatal sequence of, 953 
gangrenous, 954 
gastric symptoms in, 958 
in children, diarrhea in, 955 

primary operation in, 957 
leucocytosis in, 138, 955 
misleading sensations in, 956 
mortality of, 954, 959 
obstruction from, 806 
onset of, 85 
operation in, 956, 957 

during interval, 957 

exploratory, 959 
pain in, colicky, 957 

early. 83, 955 

localized, 958 

violent, 955 
palpation in, 955 
percussion in, 955 
perforation in, 955 
physical signs of, 955 
picture of. complete, 957 
position in, 50 
primary, with rupture, 957 
prognosis in. 957 
relapses in. 957 
roentgenology in, 847, 958 
simulating typhoid, 1012 
suppurative, 957 
surgical consultation in, 957 

interference in, 959 
symptoms in, suggestive, 958 
tenderness in, localized, 955, 956, 958 
tympany in, rigid, 960 
urinary examination in, 956 
with abscess of liver, 966 
Appendix, vermiform, abnormality of, 959 
detection of, 959 
filled, significance of, 847 
pathologic changes in, 958 
removal of. 959 
roentgen study of, 847 
Appetite, 871 
Apraxia, 14, 1203, 1204 
Aran-Duchenne paralysis, 1287 
Arborization block, 534 
defect, 534 



Arborizations, n 85 

Arch, aortic, coarctation of, 741 

Arctic expeditions, scurvy in, 171 

explorers, anemia in, 147 
Arcus senilis, 32, 763 
Areolar tissue, subsynovial, 587 
Argyll-Robertson pupil, 1221, 1252, 1254, 1256 
Argyria, 17 

discoloration of, 175 
Arm, affections of, 42 

extension of, against resistance, 1216 
flexion of, impaired, 12 16 
raising of, coincident with shoulder, 12 16 
sensory nerves of, 1207 
supination of, 12 16 
Armies, typhoid in, 10 13 
Army aviators, 1282 
Arrhythmias, analysis of, 543 
alternation, 542, 561 
auricular, 555 
bradycardia, 563 
cardiac, 543 

extracardial (sinus), 543, 563 
extrasystolic, 508. 527, 543 
heart-block, 512, 531, 565 
in endocarditis, 675 
in pericarditis, 788 
in pneumonia, 393 
intracardial, 543 
nodal rhythm, 569 
of auricular fibrillation. 529, 551 
of auricular flutter, 512, 555 
of cardiovascular insufficiency, 650 
of childhood and youth, 563 
paroxysmal tachycardia, 539, 559 
perpetua, 543. 55 1 
pressures in, high and low, 487 
sinus irregularities, 563 
toxic, 589 
vagus, 563, 1 1 83 
ventricular extrasystolic, 548 
Arsenic, poisoning by, 64, 1287, 1303 

poisoning by, treatment of, drug, 1303 
Arterial conservation of energy, 462 
hypertension, 92, 141 
chronic, 487 

nitrous oxid in, 483 
intercurrent infections in, 768 j 
sharp increase in, 764 
pressure, high and low, 715 
in kidney disease, 261 
poorly regulated, 768 
sustained, 462 
variations in, 472 
pulsation, visible, 28, 741 
reserve, 767 

system, anatomic structure of, 471 
tension, high, in renal asthma, 358 
overlooked, 1246 
in pressure cases, 581 
increase in, 444 
lability or stability of, 484 
variations in, normal, 761 
Arteries as auxiliary hearts, 462, 767 
carotid, heart sounds in, 444 
coronary, sclerosis of, 669 
electric variation of, 524 
goose craw, 488, 763 
intestinal, septic emboli in. 953 



i 3 6o 



GENERAL INDEX 



Arteries, optic, 1302 
palpation of, 763 
pipestem, 751 
pulmonary, emboli in, 418 
retinal, changes in, 763 
temporal, prominence of, 762 
transposition of, 742 
Arteriosclerosis, 761 

a cause of thrombosis, 11 90 
aging in, 762 
arteries palpable in, 762 
auscultation in, 763 
blood pressure in, 479 
cerebral seizures in, 766 
combination of diseases in, 763 
degenerative, 748, 75 1 
diagnosis of, accurate, 766 

factors in, 766 
etiology of, 761 
forms of, 761 
general, blood pressure in, 479 

changes in, 762 

in aortic insufficiency, 721 
headache of, 92 
in emphysema, 353 
in lead poisoning, 1287 
in men under thirty, 59 
in nephritis, 261 
luetic, 761 
mesenteric, 763 
physical signs in, 762 
precocious type of, 762 
pulse of, 488 
rationale of, 766 
senile, 761 

simulating epilepsy, 1272 
symptoms of, cerebral, 765 

early, 765 

gastro-intestinal, 765 

general, 765 
thoracic ailments in, 766 
vasomotor mechanism in, 767 
vertigo in, 104 
widespread, 726 
with gout, 1 173 
Arteritis, acute, complicating pneumonia, 393 
Arthritic purpura, 169 
Arthritides, secondary, 1154 
Arthritis, chronic, 587. H57 

in women. 11 74 
crico-arytenoid, 11 53 
deformans, 41, 44, H55, 1156 

acute, 1 155 

chronic, 1156 

differentiation of, 186, 1155 

general progressive, 11 56 

in women, 11 56 

pain in, 1156 

types of, 1 1 56 
gonorrheal, H55. H57 

diagnosis of, 1158 

in children, 11 58 

localization of, 1158 

onset of, 1 158 

polyarticular, 1158 
gouty, 1156, 1174 
in relation to tonsillitis, 588 
infantile, with anemia, 161 
multiple, 161 



Arthritis, Neisserian, 1158 

non-suppurative, 587 

pain of, 675 

pneumococcus, 1154 

recurrent infectious, 1157 
foci of infection in, 1157 
nutrition in, 1157 

recurring subacute, 1157 

rheumatic, 1151 

secondary pyemic, 44 

septic, 44 

in scarlet fever, 107 1 

streptococcic, 44 

syphilitic, 1157 

toxemic, 1157 

tuberculous, acute, 1154 
Arthrosia podagra, 1169 
Ascaris lumbricoides, 1137 
Ascites, 23, 805 

associated with fatty heart, 785 

chyliform, 25 

chylous, 25 

differentiation of, 24 

encysted, 25 

examination for, 439 

exudative, 963 

fatty, 25 

forcing liver upward, 810 

lactescent, 25 

massive, Grocco's triangle in 367 

of atrophic cirrhosis, 971 

pressure, 446 

rapid onset of, 972 

simulated, 1296 
Ascitic fluid, character of, 25 
Asiatic cholera, 1031 

blood in, 1032 

collapse in, 1032 

control of, difficult, 1031 

diagnosis of, 1032 
tentative, 1032 

differentiation of, positive, 1032 

etiology of, 103 1 

incubation period of, 1031 

morbid anatomy of, 103 1 

prognosis in, 1032 

purging in, 1032 

stages of, 1032 
Aspergillomycosis, 425 
Aspergilloses, 1127 
Aspergillus bouffardi, 1130 

fumigatus, 425, 1127 
Asphyxia, local, 1270 

of medullary center, 703 

of vasomotor center, 706 

phenomenon of, 480 

resuscitation after, 130 1 
Aspirating needle, choice of, 375 
Aspiration into heart, accidental, 800 

of mediastinal abscess, 423 

of empyema, 375 

pneumonia, 394 
Assault, false charges of, 1297 
Assimilation, 465 
Association fibers, 1191 

spinal accessory, 1236 
Astasia-abasia, 53 
Asthenia a cause of vertigo, 104 

chronic, congenital, 5, 69, 403, 404 



GENERAL INDEX 



1361 



Asthenia cnronic, visceroptosis of, 953 
congenital, 148, 284 
anemia of. 452 

dimensions of heart in, 428, 431. 572,594,608 
universal, in neurasthenia, 1182 
in relation to myocarditis, 666 
nutritional instability in, 404 
symptoms of, 1181 

universal congenital, .56, 68, 148, 217, 267. 
573. H79 
Asthenics, young, "drop" heart in, 608 
Asthma, aneurysmal, 358, 756 
bronchial, 106, 347, 481 
cardiac, 106. 756, 772 
cardio-renal, 358, 359. 360 
lungs of, voluminous, 766 
pollen, 357 
simulation of, 1293 
spasmodic, 355. 772 

age a factor in, 356, 361 

anaphylaxis in. 355 

attack in, pathology of, 356 
time of, 359 

aurae of, 359 

auscultation in, 360 

bronchial spasm in, 356, 360 

causative factors of, 355. 356, 360 

chronic, 361 

conditions associated in, 355 

cough in, 359 

cure of, 361 

differentiated from other types, 358, 359 

emphysema in, acute, 355 

etiology of, 355 

exciting factors, 356 

food sensitization in, 356 

heart dilated in, 359, 360 

hereditary, 356 

in childhood, 361 

mucosa swollen in, 360 

palpation and percussion in, 360 

physical signs of, 360 

prognosis in, 361 

pulse in, 359 

rationale of, 360 

sex incidence in, 356 

specific sensitization to, 356, 357. 992 

spurious, 358 

symptoms of, 359. 360 

true, paroxysms of, 355. 359. 360 

watching of heart in, 359 
thymic, 176 
uremic, 248 
Astigmatism, 1229 
Asystole, 565, 570 
Atavism, 69, 1265 

in hemophilia, 170 
Ataxia, cerebellar, 49, 1207, 1212, 1257 
Friedreich's, 1256, 1257 
gait in, typical, 52 
hereditary, 1256, 1257 ■ 
locomotor, 1254 
Marie's, 1257 
motor, 1207 
paretic, 1207 
static, 1207 
test of, 1207 
Ataxic paraplegia, 1256 
Atelectasis, definition of, 398 

86 



Atelectasis, diagnosis of, 399 

radiogram of, 579 

resonance in, 300 

secondary, 398 
Ateliosis, 187 
Atheroscleroses, 748 
Atherosclerosis, basic factors in, 751 
Athletes, breakdown of, 621 

chest expansion in, 285 

congenital asthenia in, 592 

"drop" heart in, 449 

heart of, 592, 654, 892 

length of life of, 57 

physical impairment in, 654 
Athletics, fitful pursuit of, 654 
"Athyrea." 176 

Atmosphere, close, sensitiveness to, 756 
Atony, gross, of stomach, 888 

effect of rest in, 890 

etiology of, 889 
feeding in, 890 
symptoms of, 889 

of stomach, simple, 838, 885 
secondary, 928 

peristalsis in, 886 
Atresia, 649 

ductus arteriosus in, 734 

of esophagus, congenital, 835 
Atrioventricular conduction bundle, 552 
Atrophy, acute yellow, 974 

differentiated from yellow fever, 1037 

alveolar, 351 

cardiac, obscured, 669 

from spinal lesion, 11 92 

muscular, scapulo-humeral, 1266 

of disuse, 45 

of extremities, feigned, 1293 

of liver, diagnosis of, 972 

of tongue, 37 

optic, primary, 1226 

post-papillitic, 1226 

progressive muscular, 1263 

with paralysis, 81 
Atropin, administration of, 917 

and sinus irregularity, 563 

effect of, on vagus, 470 

poisoning by, 1303 
Attitude in sickroom, 10 

of mind, 4 

significance of, 49 
Audibility of murmurs, areas of, 447, 709 
Auditory vertigo, 104 
Aura, epileptic, 1204, 1271 
Auricle, dilatation of, 551 

fibrillating dilated paralytic, 743 

flow of blood'into, 682 

left, blood capacity of, 698 
contractile power of, 695 
dilatation of, 693, 745 
enlargement of, 693 
overdistended, 546 

pressure in, 696 

right vs. left, 468 

tracings, 499 
Auricular and ventricular systoles, simultaneous, 
569 

bulge, 681 

complex, 521 

contractions, 458 



1362 



GENERAL INDEX 



Auricular, complex, in digitalis heart block, 565 
324 per minute, 556 
premature, 549 
dilatation, 460 
extrasystoles, 548 

clinical significance of, 549 
fibrillation, 494. 520, 55 1. 552, 553, 554, 555, 
64s, 646, 716 
in public clinics, 554 
with mitral stenosis, 554 
flutter, 490, 491, 539. 555. 556 
alternating pulse in, 561 
cause and frequency of, 556 
diagnosis of. 556 
duration of, 559 
in author's clinic. 556 
indicated in electrocardiogram, 556, 558 
indicated in polygram, 512 
symptoms of, 558 
venous pulse in, 556, 558 
overdistention, 742 
systole, 459 
ticking, 568 
vigor, 684 
Auriculo- ventricular bundle, 466 
Auscultation, 301 

areas, arbitrary, 305, 433 

cardiac, 449 
attitude for, 305 
by students, 693 

effects of cough and crying on, 304 
of exertion and posture on, 693 
errors in, 304 

extreme deliberation in, 304 
immediate and mediate, 302 
in emphysema. 353 
in mitral stenosis, 693 
in tuberculosis, 304 
interlobar, 305 
of displaced viscera, 379 
of heart beat, 304, 490 
of hollow of neck, 447 
of posterior apex, 418 
over compressed lung, 367 
phenomena of, 301 
precautions concerning, 692 
pressure during, 692 
unilateral vs. bilateral, 301 
value of. 443 
variations in, 301 
Auscultatory percussion of chest, 291, 294 
of liver, 810 
of stomach, 832 
Auto-hypnotism, 48, 1280 
Automatism in petit mal, 1272 
Autopsy room as a "mine-field," 743 
Aviator's syndrome, 1282 
Aviators, cardiovascular embarrassment in, 162 

polycythemia in, 162 
Axillary region, percussion of, 293 
Axis cylinder, 1185 
Axons. 1 185, 1 186, 1 193 
Awakening, early, 1241 
"Azure granules," 125 
Azygos uvulse, palsy of, 12 15 

B 

Babes, tlue, 649, 736. 739 

stillborn, pneumonia in, 424 



Babes, suffocative dyspnea in, 176 

syphilitic, 12, 424, 750 
Babinski's reflex, 1196, 1257 
Bachelor vs. benedict, 63 
Bacilli in gall-stones, 977 
Bacillus, acid-fast, in sputum, 333 

aerogenes capsulatus, 877 
in pneumothorax, 377 

anthracis, 11 23 

Bacterium tularense, 1056 

Boas-Oppler, 877, 878, 929 
in gastric carcinoma, 933 

Bordet-Gengou, 1103, 1104 

botulinus, 981, 1288 

comma, of Koch, 103 1 

diphtheria? of Loeffler, 1074 

epilepticus, 1271 

fusiform, 1077 

gas-forming, 791 

Klebs-Loefner, 1074 

lactomorbi, 1057 

lepra?, 11 19 

mallei, 11 26 

of Achard and Bensaud, 1001 

of bubonic plague, 1032 

of cholera, 937. 1031 

of Duval and Bassett, 943 

of influenza, 11 04 
Pfeiffer, 10 16 

of Koch, 401 

of tetanus, 11 25 

para typhosus A., 1001 

paratyphosus B., 1001 

pestis of Yersin, 1032 

pyocyaneus, 980 

rickettsia prowazeki, 105 1 

scarlatina?, 1069 

smegma, 332, 333 

timothy, 332, 333 

tubercle, 332, 401, 407 

typhosus, 1000, 1001 
Back, immobility of, 43 
Backache in women, chronic, 96 

of smallpox, 1095 
Backwardness of child, 1258 
Bacteria, a cause of vomiting, 872 

destruction of, 984 

emulsifying of, 996, 997 

fermentation by, 857 

grinding of, 995 

identification of, 992 

in relation to phagocytes, 995 

in the urine, 236 
resemblance of nocardia to, 425 
staining of, 116 
varieties of, in sputum, 331 
Bacterial hemolysis, 981 

toxins, 980 
Bacteriolysis, 982, 983, 984 
Bacteriurea, 236 
Bagdad sore, 1061 
Balantidium coli, 946. 1133 
Baldness due to syphilis, 1109 
Balloonists, affections of, 1282 
Ballottement renal (Guyon), 814 
Bamberger's disease, 189 
"Band sensation," 101 
Banti's disease, 155, 813, 969 
Barber's itch, 1127 



GENERAL INDEX 



1363 



Barium sulphate meal, 927 
Barkeepers and drinking habit, 64 
Barlow's disease, 171 

brawny induration in, 42 
Barrel-chest, 283, 352 
Bartonia bacilliformis, 1062 
Basedow's disease, 180 
Basophile granules, 116 
Basophiles, "polymorphs," 123 
Basophilia, perinuclear, 125 

punctate, in trench fever, 1065 
Bassler on gastric ulcer, 913 
Bastedo's sign, 958 
Beckmann's rosettes, 272 
Bedbug, 1 148 
Bedside study, 1 
Beef tapeworm, 1134 
Beer drinkers, gastric dilatation in, 888, 1285 

heart, hypertrophic, 671 

treating to, 671 

vats, human, 671 
Belching, 871 
Bell sound, 379 

tympany, 309 
Bell's mania, 75 

Belladonna, administration of, in gastric ulcer, 
841 

poisoning, 1303 
Bellot s test, 991 
Belly, big, in thin man, 25 

fat, 804 

hanging, 805, 831 

opening of. 816 

poached-egg. 25, 971 

scaphoid, 1083 
Belts, electric, scars from, 29 
Bence-Jones proteid, 161, 216 
Benedict's method of estimating sugar, 121 
Benzidin blood test, 87s, 876 
Beri-beri, 1291 

dietary influences in, 1291 

distinguished from dropsy, 105 7 

forms of, dropsical, 1291 
dry and wet. 1291 
mild and pernicious, 1291 

polyneuritis in, 1267 

symptoms of, 1291 
Bernard, Claude, on glycosuria, 1164 
Bial's test for pentose, 228 
Bibulous, the, euphemisms of, 61 
Biceps-jerk, 1194 

Biceps, syphilitic myositis of, 1161 
Bier her z, 671 
Biermer's sign, 299 
Big-bellied heavyweights, 57. 669 

the. high position of heart in, 670 
Bile, absence of, 938 

acids, 224 
tests for, 852 

action of, 852 

bacillus typhosus in, 1001 

current, blocked, 18 

ducts, diseases of, 978 

pigment in urine, 186, 224 
tests for, 224. 853 

secretion, intermittent, 973 

vomiting of, 873. 874 
Bilharzia hematobia, 1133 
Biliary calculi, examination of stools for, 978 



Biliary calculi, passage of, 64s 
colic, 978 

diagnostic points in, 978 
jaundice in, 978 
pain in, left-sided, 978 
tenderness in, 978 
passages, diseases of, 966 
Bilious attack, 869, 1093 

headache, 91 
Bilirubin in duodenal contents, 854 

test, 854, 855 
Biot's periodic apnea, 436 

respiration, 107, 801 
Bismuth and buttermilk, 959 
capsules, 577 

meal, 382, 823, 886, 890, 902, 917 
expulsion of, 918, 922, 923 
in cecum, 847 
retention of, 836 
oxychlorid, 834 
paste injections, 326 
shadow, 836 

in gastric ulcer, 917 
subcarbonate, 834 
suspension, 578 
Bites in the face, 1124 

of animals, 11 24 
"Black Assize," 1051 

death, 1033 
Blackmail, cases of, 1299 
Blackwater fever, 1048 
Bladder, contracted, 273 
epithelium, 237, 238 
hemorrhage from, 223 
irritability of, 955 
tuberculosis of, 235, 273 
tumors of, 274 
Blastomycosis, dermal, 1128 

systemic, 1127 
Blebs in erysipelas, 11 18 

in Raynaud's disease, 1270 
Bleeders, 112 

family of Mampe, 170 
warnings concerning, 170 
Blepharospasm, 1231, 1233 
Blindness, feigned, 1293, 1294 
in idiots, 1259 
total, 1225 
transient, 94. 1225 
unilateral, 1293 
uremic, 248 
Blocking of aorta, 741 
Blood, accelerated flow of, 696 
alkalinity of, 142 
back pressure of, 460 
body circuit of, 463 
casts, 240, 242 
cell count, 128 
cells in feces, 939 

"phantom," 223, 234 
red, count of, 129, 130 
normal. 126 
nucleated, 126 
rod-like bodies in, 1062 
volume index of, 137 
staining of, 115. 116 
Turck's irritation forms, 124 
white, accurate counting of, 131, 135 
in leukemia, 156 



1364 



GENERAL INDEX 



Blood cells, white, source of, 123 
cellular elements of, 116 
changes in, no 
circulation of, 456 
clinical tests of, no 
coagulation test of, 106 1 

time of, 141, 170, 1007 
collection of, for serum, 994 
color comparison in, 119 
concentration in typhoid, 1007 
corpuscles, count of, 135 
count, differential, 132 

dilution in, 129, 134, 135 

rulings in, 132 

test of accuracy in, 130 

white, low, 674 
-counters, types of, 132 
counting, rapid, 136 

rationale of, 135 
crises, 152 
cultures in endocarditis, 678 

in obscure infections, ion 

in pyemia and septicemia, 11 19 

in typhoid fever, 1009 
current, regurgitant, 705 
damming the flow of, 459 
dust, 114 
examination of, 90, no 

clinical tests, no 

in malaria, 1045 

method of, 113 

terms used in, no 
findings in chlorosis, 150 
filaria in, 1140 
flow of, regulation of, 472 
for examination, how obtained, 112 
fresh, examination of, 114 
hemoglobin in, 116 
high index of, 856 
human, phagocytic power of, 996 

precipitin test for, 990 
in rheumatism, 1152 
in sputum, 329 
in urine, 186, 222, 234 

accidental, 223 

"first jet," 223 

increased volume of, 480 
index in Hodgkin's disease, 166 
initial current velocity of, 472 
laking of, 140, 984 
-making organs, changes in, no 

diseases of, no 
malarial Plasmodium in, 1037 
menstrual, 223 
occult, 853 

in gastric carcinoma, 933 

in stomach contents, 912 

in stools, 912, 920 

persistent, 914 
oozing of, 932 
opsonin in, 99s 
oxygen shortage in, 1282 
phagocytic power of, 996 

negative and positive, 996, 999 
picture in splenomegaly, 155 
plasma, 141 
plates, counting of, 140 

direct and indirect, 140 
normal count, 140 



Blood plates, staining of, 140 
pressure, 471 
abnormal, 630 

high, 478 

low, 480 
aortic, sharp drop in, 713 
basic factors in, 471 
brachial, 472 
capillary, 471 
course of, 484 
determination, 471, 472 

by auscultation, 474, 475 

by Faught's formula, 478 

by fingers, 490 

by Koratkow s method, 474, 475 

by older technic, 473 

faulty figures in, 476 

five phases of, 475 
diastolic, 472, 473, 474, 484, 485 

low, 486 
drop, 484 

a sign of hemorrhage, 484 

sudden, 85, 481 
high, in stasis, 480 

in the middle-aged, 479 
important points in, 485 
acute infectious diseases, summary of, 

484 
in anesthesia, 483 
in angina pectoris, 1293 
in arteriosclerosis, 766 
in the aorta, 471 
in the arrhythmias, 487 
in erythremia, 164 
in men and women, 478 
in mesaortitis, 752 
in nephritis, 262, 265 
in pregnancy, 485 
in the small arteries, 472 
in typhoid, 1003, 1004 
in uremia, 249 
in the veins, 472 
influenced by age, 476 

by attitude and sex, 474 

by excitement, 476 

by exercise, 476 
initial, 472 
interpretation of, 471 

low, in acute infections, 481 

in cholera, 481 

in myocarditis, 667 

in pneumonia, 481 

in various diseases, 481 

persistent, 481 
maximum, 473 
mean, 474 
minimum, 474 

followed by recovery, 481 
muffled tones in, 475 
normal, at various ages, 476 

diastolic, 485 
peripheral, 472 
readings, 478 

systolic, normal, 475 
rise of, to, 300, 479 

in abdominal colic, 485 

in scarlet fever, 484 
220 +, significance of, 486 
statistics, concerning, 477 



GENERAL INDEX 



1365 



Blood pressure, systolic, 472, 473, 477, 484, 485, 
487 
low, 486 

in interstitial nephritis, 262, 632 
in scarlet fever, 107 1 
table of, 476 
variations, in arm and leg, 479 

normal, 761 
vs. life insurance, 477 
regurgitation of, into aorta, 715 
serum, artificial, 465 
smear, 113 

specimen, collection of, 1008 
stream, conservation and transformation of, 
47i 
speed of, 463 

substances taken into, 189 
tubercle bacilli in, 405 
sugar in, 121, 1163 

supply, adaptation and distribution of, 471 
coronary, 630 
intrinsic, 641 
tests, no 

benzidin, 876 
chemic, 875 
microscopic, 875 
urea, analysis of, 207 

excretion of, 208 
uric acid in, 1171 
ventilation of, 456 
vs. pus in urine, 223 
vessels, diseases of, 462, 586 
examination of, 427 
great, area of, 792 
jerking, 434, 435 
viscosity of, 480, 736 
volume, 136, 140, 141, 152 

total, determination of, 140 
white, 156 
Blue babies, 649, 736, 739 

line on gums, 1287 
Blushing and paling, rhythmic, 434 

morbid, 17, 102 
Boarding school, going to, 63 
Boas-Oppler bacillus, 877, 878, 900, 939 
vs. leptothrix, 878 
test for HC1, free, 861 
Bodies, chlamydozoan, 1094 

coccoid, in variola virus, 1094 
colloid, 272 
globoid, 1089 
Howell's, 128 
inclusion, 125 
Leishman-Donovan, 1060 
Negri, 1 1 24, 1 1 25 
protozoan, in scarlet fever, 1069 
Prowazek's, 993 
purin, 1 17 1 
ring, 128 
thermolabile, 983 
Bodily structure, delicacy of, 404 
Body growth, center for, 184 
tilting forward of, 5 1 
weight vs. heart mass, 670 
Bogginess, abdominal, 963 
Boggs coagulometer, 141, 142 
Boils, Aleppo, 1061 
gad-fly, 1 148 
Oriental, 1061 



Bone marrow cells, 123 
red, 153 

tumors, 818 
Bones, clumsy and enlarged, 184 
Borborygmi in intestinal obstruction, 806 
Boss, precordial, 438 
Bosses in rickets, 1175 
Botalli's duct, 28, 733, 739 
Bottom, sore, mi 
Botulism, 1288 

cause, 1288 

mortality, 1289 

symptoms, 1288 
Bougie, esophageal, passage of, 902 

use of, in hydrophobia, 904 
Boundaries defined by percussion, 290 
Bourget's retention fneal, 858 
Bowels, hemorrhage from, 1003 

inflation of, 89 

injections into, diagnostic, 89 

motions of, without medicine, 938 

obstruction of, 87, 960 
by worms, 1137 

strangulation of, 956 
Bow-legs in rickets, n 75 
"Bow-windowed risks," 285 
Brachial plexus paralysis, 1 2 18 
Bradycardia. 479, 491, 563 

abrupt transition to, 492 

contraction of heart in, 546 

in pappataci fever, 1059 

simple, significance of, 563 

suspicious, 568 
Brain abscess, headache of, 91 

cysts, 1242 

diseases of, 1237 

fag, 94. 1 179, 1 183 

fever, 1079 

infarcts of, 672 

in venous stasis, 706 

lesions, vertigo in, 104 

lobes of, lesions of, 12 n 

railroad, 1280 

syphilis of, 1243 

tuberculosis of, 1242, 1243 

tumor, 1227, 1228, 1242 
a cause of vertigo, 103 
diagnosis of, 1085 
headache of. 91 
symptom-complex of, 1086, 1252 

wet, 1241, 1285 
Brazilian trypanosomiasis, 1145 
Bread-crumbling tremor, 46 
Break bone fever, 1034 
Breast, funnel, 283, 284 

left, pain in lower zone of, 97 

pigeon, 283, 284, 1 175 
Breath, foul, from nasal catarrh, 336 

fruity, 240, 1 166 

"garlicky, 1306 

holding of, 344 

in diabetes, 82 

inability to hold, 106, 436, 639, 647. 756 

odor of, 34, 82 

sounds, muffled, 355 
normal, 417 
of distant quality, 368 
rhythmic variation in, 729 
Breathing, abdominal, 285 



1366 



GENERAL INDEX 



Breathing, absent or suppressed, 306 

accelerated, 105 

amphoric, 308 

bronchial, normal, 306 

pathologic. 307 

broncho-vesicular, 307. 

catchy, 363 

cavernous, 308 

Cheyne-Stokes, 248, 436, 636 

cog-wheel, 306, 417 

costal, in women, 285 

women and men, 288 

deep, 334 

Kussmaul dyspneic, 82 

mirror test of, 1301, 1302 

mouth, 340 

normal, 285 

pathologic, 305, 307, 308 

puerile. 305 

shallow, causes of, 287 

slow, 108 

stertorous, 1304 
in coma, 79 

stridulous, 105 

tubular, 367. 798 
distant, 387 
normal, 307 

veiled, 308 

vesicular, 305 
Breathlessness, causes of, 756 
Bremer's blood test, 1167 
Brewery drivers, fatty heart in, 671 
Brick-dust deposit, 232 
Bright s disease as cause of pericarditis, 782 

chloride retention in, 213 

chrome, arteriosclerosis in, 762 

color in, 145 

disclosure of, to patient, 10 

edema in, 21, 22 

eye in, 1222 

family predisposition to, 68 

headache of, 92 

inflammation of serous membranes in, 264 

insanity of, 247 

pasty pallor in, 15 

skin in, 15, 145 

stages of, later, 799 

urea in, 201 

vomiting of, 872 
Brill's disease, 1013, 1053 

microorganism of, 1052 
Broadbent's sign, 437, 795 
Broca's center, 1203 
Brodie-Russell coagulometer, 141, 142 
Bromin poisoning. 64 
Bronchi, diseases of, 345 

foreign bodies in. 321, 350 
diagnosis of, 351 
diseases following, 351 
symptoms of, immediate, 351 

lumen of, reduced, 346 

primary, percussion of, 293 
Bronchial asthma, hypertension in, 48 r 
true. 106, (see also Asthma). 

breathing, 306 

glands, diseases of, 422 

associated ailments, 422 
symptoms of, 422 
X-rays in, 422 



Bronchial asthma, mucous membrane, carcinoma 

of, 321 
spasm, acute, 356, 993 
tree, meshwork of, 315 

roentgenization of, 321 
wall, inflammation of, 349 
whisper, 309 
Bronchiectases, multiple, 321, 349, 350 
Bronchiectasis, 349, 409 

cavity signs in, masked, 350 
compression dulness in, 350 
cough in, 349 
cylindrical, 349 
diseases associated with, 349 
forms of, 349 
infiltration zone in, 350 
physical signs of, 349 
prognosis in, 350 
rationale of, 350 
roentgenogram in, 321 
sputum in, 329, 349 
unilateral universal, 349 
Bronchiolitis, acute, 397, 
catarrhal, 398 
exudative, 356 
obliterative, 347 
Bronchitis, acute, 34s 

cough and fever in, 346 

prognosis in, 346 

prolonged attacks of, 346 

rales in, 346 

rationale of, 346 

substernal distress in, 346 
bacteria in, 345 
capillary, 345, 394. 395. 396 
causes of, exciting and predisposing, 

345 
chronic, as a secondary disease, 347 

characteristics of, 321, 347 

differentiation of, 347 

incidence of, diminished, 347 

roentgenogram in, 321 
eosinophilic, 347 
etiology of, 345 
fibrinous, 347 
in emphysema, 352 
influenzal, 336 

localized and suggestive, 410 
morbid anatomy in, 345 
prostration in, 346 
putrid, physical signs of, 347 
sex incidence in, 345 
suffocative, intense febrile, 348 
syphilitic, 347 
Bronchophony, distant, 309 
in pneumonia, 390 
whispered, 309 
Broncho-pneumonia, 394 
acute congestive, 396 

disseminated, 396 

miliary, 394 
as a mixed infection, 394 
chest outline in, 107 
chief types of, 397 
chronic, 423 

localized, 407 
common form of, 395. 396 

diagnosis of, 398 
complications of, 398 



GENERAL INDEX 



1367 



Broncho-pneumonia, complicating measles, 1067 
the exanthemata, 395 

congestive, acute, 395 

consolidation in, 396 

convulsions in, 396 

course of, 397 

cyanosis in, 397, 1022 

disseminated, 345, 395 

dyspnea in, 396 

etiology of, 394 

gastrointestinal disturbances in, 397 

in whooping cough, 1105 

influenzal. 102 1 

inspection in, 397 

lobar consolidation simulated in, 300, 102 1, 
1022 

malignant. 396 

palpation in, 397 

pathologic process in, 395 

percussion in. 397 

physical signs in, 397, 398 

primary, 395 
congestive, 39s 

prostration in, 396 

pseudo-lobar form, 394 

pulse in, 396 

rationale of, 398 

respiration in, 30s 

roentgenograms in, 324 

secondary, 39s 

signs of r pulmonary, 395 

silent areas in, 399 

temperature in. low, 396 

types of, subdivisions, 395 

urine in, 397 
Bronchoscopy, apparatus for, 313 
Bronchotetany, 356 
Bronchus and esophagus, union of, 835 

caliber, 302 

discharge of pus through, 967 

obstruction of. 310 
"Bronze John," 103s 
Bronzing in Addison's disease, 174 

in cirrhosis of liver, 971 

in Hodgkin's disease, 167 
Brown-Sequard symptom-complex, 1239, 1262 
Brownian movement, 114 
Bruce on Malta fever, 1054 
Brudzinski's phenomena, 1081, 1197 
Bruits, anemic, or "accidental." 451, 603 

aortic regurgitant, 676 

confused, multiple, 475 

d'airain, 309 

de diable, 146 

in chlorosis, 150 

de pot fS16. 298 

diastolic, 448, 449, 629 
aortic, 146 
common, 744 
-presystolic, 690 
pure, 690 

effect of posture on, 693 

esophageal, 902 

in aneurysm, 779 

intracranial, 1249 

in asthenia. 589 

in exophthalmos, 182 

misleading, 602 

mitral, 645, 747 



Bruits, mitral, systolic, transmission of, 686 

obscured by pressure, 693 

of aortic regurgitation, 710 

of defective ventricular septum, 741 

of pulmonary stenosis, 736 

of stenosis, genesis of, 747 

presystolic, 696 

pseudo-mitral stenosis, 744 

shifty and variable, 694 

systolic, 577. 629, 747 

in thoracic aneurysm, 777 
venous, 707 

voil6, 308 
Buboes, bullet, 1107 

gonorrheal, 1033 

of plague, E034 

syphilitic, 1107 
Bubonic plague, 1032 
Buccal cavity in syphilis, 1109 
pigmentation of, 34 

hyperesthesia, 1064 

membrane, erosions of, nil 
Build, powerful, misleading, 654 
Bulbar paralysis, asthenic, 1267 
Bulbus duodeni, 837 

deformity of, 767, 842, 84s 
Bulging, epigastric and precordial, 438, 790 
Bulimia in diabetes, 871 
Bullet bubo, 1107 

Bundle of His, 465, 466, 467, 468, 534 
Bunting's organism, 164 
Burdach's tract, 11 89 

Burker-Neubauer counting chambers, 133. 134 
Burns from corrosive acid, 902 
Bursitis, 98 

deltoid, 1268 
Butchers, Weil s disease among, 975 
Buttermilk cure, 1296 
Butvric acid test, 862 



Cabot's ring bodies, 128 
Cachexia, general, 972 

malarial, 1048 

of carcinoma, 933 
Cadaveric emanation, 34 
Caisson disease, 1239 
Calcareous plugs in sputum, 330 
Calcification of pericardium, 797 
Calcium carbonate in urine, 233, 234 

deficit, 47 

oxalate crystals, 214, 231, 234 

phosphate crystals, 231 

sulphate in urine, 231 

biliary, in feces. 942 

pancreatic, 942, 965 

renal, passage of, 268, 956 

simulated, 1296 

urinary, 86, 254, 274 

examination of, chemic, 275 

vesical, 1133 
Callosities from occupation, 66 
Calmette's test, 413 
Calves, apparent enlargement of, 1265 

cramping of, 772 

edema of, 22 
Cambridge electrocardiograph apparatus, 517 
Cammidge test, 965 



i 3 68 



GENERAL INDEX 



Cancer, age and sex incidence, 68 (see Carcinoma) , 

Boas-Oppler bacillus in, 878 

cells, 878 

gastric, pain of, 928 

green, 161 

of peritoneum, diagnosis of, 963 

of stomach, 838, 839 
color of skin in, 15 
suspected, test for, 858 
symptoms of, 906 
tumor in, 929 

pericarditis with, 797 

predisposition to, 68 

scirrhus, 931 

simulation of, 1294 

test in, Abderhalden, 935 
Cannon, W. B., and bismuth meal, 834 
" Canter" rhythm, 698 
Cantharides, poisoning by, 1303 
Capillaries and veins, consideration of, 462 
Capillary bronchitis, 395, 398 

deltas, blood pressure in, 472 

flow, control of, 462 

oozing, 731 

pulse, 495, 496, 715 
test for, 719 
Capsular cirrhosis, 973 
Capsule, internal, lesions of, 1208, 1245 
Capsules used in gastric tests, 917, 918 
"Captain of the Men of Death, "388, 761 
Caput medusa?, 27, 806, 970, 971 

quadratum, 30 
Car-sickness, 11 84 
Carbohydrate increase, 1166 

tolerance, 179, 1164 
Carbohydrates, acid affinities of, 857 
Carbolic acid, poisoning by, 1304 
Carbon bisulphid poisoning, 64 
Carcinoma, actively ulcerating, 874 

early, simulating achylia, 883 

from primary ulcer, 909 

gastric, 928, 930 
diagnosis of, 915 
early, 928 
. facial expression in, 12 
scirrhus, 841 
stomach contents in, 862 

nasal, 336 

of brain, 1242, 1244 

of bronchial mucous membrane, 321 

of esophagus, 904 

of gall-bladder, primary, 977 

and gall-stones, concurrence of, 977 

of liver, secondary, 968 

of lung, 421 

of pancreas, 964 

stools in, 964 

of pylorus, 836, 851. 93* 
feces in, 877 

on old ulcer base, 913. 9.15. 928 

secondary, with nodular irregularities, 811 

ulcerating, 933 

ventriculi, 838 
Cardia, malignant growths of, 931 

position of, 822 

tumors of, 933 
Cardiac and abdominal diseases, coexistent, 647 

area, 280 

increase in, 666, 717 



Cardiac area of dulness, deep, 439 
marked, 440 
relative, 439, 441, 686 
right, increased, 686 
superficial, 313, 439, 686 

percussion of, 293 

superficial, 278, 440 
determination of, 440 

arrhythmias, 543 
asthma, 106, 359 

paroxysmal, 772 
cycle, 460, 461, 502, 503 

registry of events of, 501 
dilatation in whooping cough, 1105 

neglected, 431 
disease, due to occupation, 664 

forecasts in, 653 
distress, alarming, 560 
edema as cause of vicious circle, 648 

rationale of, 649 
endurance, 470 
flatness in the stout, 670 
hypertrophy without dilatation, 592 
impulse, visible, 365 
inadequacy (see also Cardiac Insufficiency), 

621, 786, 893 
incompensation, minor, 604 

recognition of, 639 

terminal, 191 
" insufficiency, 471 

age as factor in, 650 

chronic general, 581 

effective therapy in, 650 

extreme general. 769 

fatigue a symptom of, 102 

in congenital asthenics, 651 

in tachycardia, 560 

metabolism in, 464 

minor, 621, 631, 651 

recognition of, 591 

relapses in, 671 

roentgenography of, 581 

severity of symptoms in, 650 

with wide dilatation. 581 
lesions, 571 

causative agents of, 652 

portals of infection for, 652 

roentgen diagnosis of, 571 
outline, 745 

aortic stenosis type, 579 

changes in, 693 

determination of, 650 

in aortic insufficiency, 710 

in fatty heart, 670 

in high blood pressure cases, 628 

shrinking of, 654 
overstrain, 653, 755 

and obesity, 669 

and past disease, 665 

causes of, common, 655 

chronic, 641 

in adolescence, 664 

in middle age, 65 s 

signs of, 664 
pain, distribution of, 641 
pathology, fallacy in, 592 
patients, comfort of, 633 
plexus, 1236 
profile, change in, 600 



GENERAL INDEX 



1369 



Cardiac research, 497 

instruments for, 496 
reserve, 464, 718 

diminution of, 635, 687 
progressive, 630 

impaired. 464, 592, 687, 759, 763 

limitation of, 431 

possibilities of, 470 

taxed for years, 699 
respiratory pressure, 729 
response, 470 

contraction of field of, 631, 772 

to digitalis, 639 
rest after infections, 589 
rhythm, disturbance of, 675 
silhouette, 574 

extension, 638 
stimulation by introduction of needle, 802 
sufficiency, tests of, 635 
therapy, 652 
tonicity, failure of, 592 
Cardiohepatic angle, 301, 790, 792 
Cardiopath, life expectancy of, 653 
Cardioptosis, 892 

and abdominal visceroptosis, 605 
and gastroptosis, concurrence of, 892 
Cardiosclerosis, 668, 669 
Cardiovascular alternatives, 68 
automatism, adaptive, 471 
breakdown, 763 
cases in hospitals, 554 
degeneration, 630 
disease, life expectancy in, 653 

murmurs in, 450, 451 
embarrassment in aviators, 162 
field of response, narrowing of, 756 
insufficiency, 589, 591, 765 

edema in, 648 

liver enlargement in, 648 

portal congestion in, 648 

recognition of, 637 

sense of constriction in, 755 

stasis in, 648 

symptoms of, 647 
subjective, 772 
lesions, effects of, 625 
■mechanism, 631 
paradox, 629 
problems, 590 
reserve, impaired, 591 

lack of, 486 

narrowing of, 640 
sufficiency, 591 
syphilis, 748, 765 

diagnosis of, 759 

initiation of treatment of, 759 

weakness, 590 

Carmin test, 946 

Carotid conduction, 717 

pulsation, 496 

pulse beat, 457 

reliability of. 461 
tracings 500, 501, 502, 504 
Carriers of diphtheria 1074 

of disease, goats' milk as, 1053 

kedani mite as, 1058 

moth midge as, 1059 
of entamebae, 947, 948 
of hydrophobia, 1124 



Carriers of infantile paralysis, 1089, 1093 
of malaria, 1038 
of sleeping sickness, 1146 
of smallpox, 1095 
typhoid, 1000 
Case books as unworked mines, 11 
history, cloudy or misty, 62 

of tyro vs. expert, 1 1 
-taking, concealment in, 67 
diseases, antecedent 937 
essentials of, 11 
euphemisms of, 67 
habits of patient, 937 
history of present ailment, 71 
obstacles to, n 
plain language in, 70 
questioning the patient, 71 
specific inquiry in, 67 
Casein undigested, 856 
Castration and obesity, 189 
Casts, associations of, 243 
basis of, 240 
fatty, 239 
epithelial, 240, 242 
fibrinous, in bronchitis, 347 
granular, 239, 242 

brown, 242 
hyaline, 239, 240 

in amyloid kidney, 266 
in the urine, 239 

in nephritis, 264, 265 
persistence of, 240 
misleading forms of, 243 
prostatic, 244, 274 
pseudo, 243 
pus, 242 

searching for, 243 
showers of, 244 
significance of, 243 
true, 239, 241 
typical forms of, 244 
under illumination, dim, 239 

high, 240 
waxy, 241 

without albuminuria, 240 
Cat bite, virulence of, 1124 
Catalepsy, 48 

hysterical, 1280 
simulating death, r3or 
simulation of, 1294 
Cataract, 32 

Catarrh, drunkard's, 906 
nasal, dry, 336 
of rubella, 1072 
simple, 35 
Catarrhal fever, 1015 

epidemic, 10 15 
Catarrhal jaundice, 975 

due to infection, 975 
epidemic type, 975 
Catharsis before examination, 803 
Cathartics, resistance to, 815 
Catheterization in stupor, 817 
Cattle, disease of, 1122 

infected, flesh and milk of, 1057 
Cauda equina, lesions of, 1239 
Cava, superior, obstruction of, 806 
Cavity exudates, 21 
formation, 408 



*37° 



GENERAL INDEX 



Cavity exudates, pulmonary, 407 
sucking sound in, 312 
huge, in pneumothorax, 302 
open, sign of, 298 
percussion note, 390 
pulmonary, pus in, 319 
roentgenography of, 319 
sign of, 308, 319 
types of, 417 
right thoracic, 382 
Cayenne-pepper sediment, 211 
Cecum, bismuth delay in, 847 
Cecum mobile. 806 

palpation of, 808 
Cell metabolism, products of, 980 
Cells, blood-pigment-bearing, 331 
caudate, 238 
columnar ciliated, 331 
compound granule, 238 
found in sputum, 331 
lecithin-granule, 244 
mono- or polynuclear, 331 
pelvic, 238 

renal mononuclear, 237 
polymorphonuclear, 143 
sphenoidal, 339 
Centers, cerebral, 1209 

cortical, 1209 
Centigrade scale, 1308 

Centrifugation, methods of, Gabbett's, 144, 332, 
333 
Loeffier's, 332 
Ziehl-Neelsen's, 332 
Centrifuge, electric, 221 
Centrum semiovale, lesions of, 12 11 
Cercomonas hominis, 1133 
Cerebellar hereditary ataxia, 1257 

tract, direct, 1188 
Cerebellum, abscess of, 1251 

congenital hypoplasia of, 1257 
lesions of, 1191, 1213 
rupture into, 1246 
tumor of, 1245 
Cerebral abscess, 1250 
causes of, 1251 
latent cases of, 1251 
meningeal form of, 1251 
symptoms of, 1251 
anemia, 1241 

acute, in heart block, 565 
apoplexy, ambulant case, 626 

in case of "drop" heart, 626 
centers, lesions of, topical diagnosis of, 1209 
concussion, feigned, 1294 
congestion, passive, 1241 
cortex, frontal, 1244 
Cerebrai diseases, convulsions in, 49 
fever in, 75 
edema, 1241 

embolism, heart disease in, antecedent, 1250 
hemorrhage, 1245 
attack of, 1247 
causes of. exciting, 1246 
coma n, 1247 

diagnosis uf ' differential, 1249 
diseases a<soc ated with, 1245 
hereditary predisposition to, 1245 
hypertens-on in 1245 
in cases of "diop" heart, 625 



Cerebral diseases, motor power in, 1247 
paralysis in, 1248 
reflexes in, 1248 
stages of, second, 1247 
symptoms of, 1247 
localizing 1248 
ocular, 1247 
premonitory, 1246 
residual, 1248 
ventricu ar, 1247 
seizures, curious, 766 
softening, 1249 
syphilis, curability of 1253 
tumors, spinal puncture n, 1082 
Cerebro-spinal meningitis, epidemic, 1077, 1079 
abortive. 1081 

Brudzmski's phenomena in, 1081 
complications of, 1081 
diagnosis of, 108 1 
fever curve in. 1080 
intermittent, 10S1 
Kernig's si^n m, xo8i 
legions of, residual, 1081 
Lumbar puncture in, 1082 
malignant, 1081 
prognosis in, 1081 
spinal fluid in 1082 
symptoms of. 1079 
treatment of, by serum, 108 1 
syphilis, 74S, 760 
system, disease of, 11 89 
causes of, 1190 
Cerumen, impacted, 326 
Cervical adenitis, contagious, 1058 
fsscia, 792 

gjands, swelling of, ro7i 
retraction. 1080 
ribs, detection of, 96 

double, a source of diagnostic error, 97 
pu se (variation) in, 489 
segments, 12 15 

veins, inspiratory filling of, 796 
Cestodes, 1134 
Ceylon sore mouth, 1063 
Chalicosis. 424 

roentgenogram in, 320 
Chancre, syptuliti:, 1106 
Chapman suction pump, 825, 826 
Character, change of, in paresis, 1252 
Charbon, 1122 
Charcot joints, 45, 12 55 

-Leyden crystals, 331. 347. 359 

in feces, 939 
on hysteria, 1277 
"Charlie horse," 63 

Chemical exchanges in the heart, 447, 464. 4^5 
Chemotaxis, 981 
Chest, air in, 302 

alar, 284 
Chest, anatomy of, topographic. 277 
banel-shaped, 283 352 
bulging, 734 
conformation of, 69 
deepening from above downward, 284 
deformity of, congenital, 283 

from adenoids, 340 
enlargement of, unilateral, 282, 283 
examination of, 282 

clothing arranged for, 277 



GENERAL INDEX 



1371 



Chest, examination of, in asthma, 360 
patient prepared for. 277 

expansion, deficient, 287, 288 

in athletes and consumptives, 285 
lesions checking it, 286, 287 
variations in, unilateral, 285, 287 

flattened, 352 

fluid in, 302 

form of. general, 282 

hollowing of, 2S2 

inspection of, 282 

localized changes in, 285 

measurements, 285 

movements, costal vs. abdominal, 285 
restriction of, 401 

normal, 291, 

Litten's sign in 286 

outline, changes in, 107. 284 

palpation of, 286 

paralytic, or pterygoid, 284 

percussion of, 289 

perforation of. by fistula. 374 

phthisicaj coniormation of, 267, 284 

rachitic, 283 284 

regional divisions of, 277 

retraction of, 285 
unilateral, 282 

shrinkage of, unilateral, 282', 283 

surface relations of, 281 

wail ruptured by fistula, 374 

winged. 284 
Cheyne-Stokes breathing, 801 

fatigue hypothesis of, 108 
for three years, 248 
Chiasm, lesions of. 1223 
Chickenpox, 77, 1102 

complications of, 11 03 

differential points in, 1103 

eruption of, 1102, 1103 

etiology and symptoms of, 1102, 1103 

in cachectic children, 11 03 

simulated by smallpox, 1095 
Chick-pea disease, 1132 
Chigoe flea, disease due to, 1148 
Chilblains, 1270 
"Child crowing," 344 
ChJdhood, curse of, 340 

diseases of, 58 
Children, blood examination in, 113 

cardiac diseases of, 799 

endocarditis in, 674 

examination of esophagus in, 826 

glandular fever in, 1058 

liver pulsation in, 809 

measles in, 1066 

number of, in mother's history, 62 

pancarditis In, 796 

percussion in, 291. 371 

pneumon as in, 394, 395 

rheumatism in, 1151 

smallpox m, 1098 

sudden death of, 176 

summer diarrhea of, 943 

tuberculosis in, 405 

valvular lesions in, 672 

vicious traits in, 341 
Chills, feigned, 1296 

malarial, 1037 

recurring, 11 19 



Chilliness, 78 

Chlamydozoan bodies, 1094 

Chloasma gravidarum. 17 

Chloral hydrate, poisoning by, 1304 

Chloride excretion in various diseases, 12 13 

retention in Bright's disease, 213 
Chlorine fumes, irritation from. 64 

gas poisoning in warfare, 348 
morbid changes from. 348 
symptoms of, agonizing, 348 
Chloroform anesthesia and blood pressure, 483 

as urine preservative, 230 

inhalations, 1303. 1307 
Chloroma, 161 
Chlorosis, 144, 148 

age in, 148 

asthenic, 148 

blood in, 127. 144. 150 

causes of, 149 

color in, 15, 150 

Egyptian, 1139 

environment in, 149 

etiology, 148 

incidence of, diminished, 148 

occupation in, 149, 150 

sex affected, 147. 148 

symptoms of, cardinal, 150 
Chlorotics, rosy, is 
Choked disc, 1227, 1228 

in cerebral aneurysm, 1249 
Cholangitis catarrhalis, 975 
Cholecystitis, acute. 975 

bacteriology of, 976 
pain in, 976 
symptoms of, 976 
typical case of, 976 
urine in, 976 

as complication of typhoid, 1012 

atypical, 9"6 

diagnosis of, 979 

in case of toxic heart, 646 

infection of, 1014 

tenderness in, 811, 9^6 
Cholelithiasis, 977 

diagnosis of, 979 

women susceptible to, 978 
Cholera, Asiatic, 1031 

in India, 103 1 

infantum, 943. 944 
mortality in, 944 
symptoms in, violent, 944 

low blood pressure in, 481 

morbus, 1032 

simulated by poisoning, 1303 

nostras, 1032 

sicca, 1032 

vibriones, 983 
Cholerine, 1032 
Cholesterin crystals in sputum, 331 

in gall-stones, 977 

tests for, 942 
Chordas tendineae, 418, 686, 691, 704, 746 
Chorea, age and sex in, 1274 

crossed, 1274 

diagnosis of, differential, 1275 

electrica, 1275 

feigned, 1294 

forms of, 1275 

heart murmurs in, 1274 



1372 



GENERAL INDEX 



Chorea, hereditary, 1274, 1275 
in precocious children, 1274 
maniacal, 1274 
microorganism of, 1273 
pandemic, 1276 
reflex irritation in, 1274 
rheumatic, 11 54 
rhythmic, 1275 
Sydenham's 1273 
symptoms of, cardiac, 1274 
mental, 1274 
Chromaffin system, 173, 1237 
inadequacy of, 176 
tissues, 1 164 
Chromidial body, 946, 947 
Chromium poisoning, 65 
Chrysomyia macellaria, 1148 
Chvostek's sign, 47 
Chyle, leakage of, 1141 
Chylothorax, 426 
Chyluria, 196, 1142 

Cigarette-paper method of preparing films, 114 
Cilio-spinal reflex, 1194 
Circulation and physical exertion, 463 
by anastomoses, 741 
collateral, 806 
in emphysema, 352 
lesser, obstruction to, 354 
of the blood, 455 

impediment to, 459 
switching of, 741 
systemic, 741 
within heart, 741 
Circulatory block, partial, 705 
equilibrium, 628 
phenomena, 497 
salvation, 739 
stasis, 162 

system, regulatory reservoir of, 767 
Cirrhosis, atrophic, 811 
diagnosis of, 97 1 
biliary, 972 

urine in, 973 
capsular, 969, 973 
fatty, diagnosis of, 971 
Glissonian, 811 
hepatic, with anemia, 155 
with splenomegaly, 155 
hepatogenous, 972 
of liver, 969 

alcohol a cause of, 969 
basic pathology of, 969 
congestion in, chronic passive, 970 
diagnosis of, 969 
etiology of, 969 
fatty, 970 

morbid anatomy of, 969 
pigmentation in, 175 
syphilitic, 969 
varieties of, 969 

with bronzing and glycosuria, 971 
portal, 970 
pulmonary, 423 
syphilitic, 969. 973 
City vs. country, 63 
Civil War, dysentery in, 949 
heart exhaustion in, 608 
wounds in, 802 
Claims for damages, 1281 



Claudication, intermittent, 763, 767 
spinal, 53 

of the heart, 768 
etiology of, 768 
morbid anatomy of, 768 
pulse in, 769 
symptoms of, 768 
Claustrophobia, 1179 
Clavicle, percussion of, 293 
Claw hand, 1219, 1264 
Climate as etiological factor, 67 

change of, for insomnia, 103 
Clinical mosaics, 5 

research, aid to, 497 

technic, 497 
Clinics, public, infection in, 414 
Clonorchis endemicus, 1134 
Clonus, ankle and true, 1195 

spurious, 1259 
Clothing, arrangement of, for examination, 277 

ill-fitting, 13 
Club-foot, 1265 
Clubbed fingers, 41, 353 
Clumsiness in a child, 1274 
Coagulation time in pernicious anemia, 152 

normal, 140 

retarded, 141 

test for, 141 
Coal miner's disease, 424 

-tar poisoning, urine in, 192 
Coarctation, 739 

diagnosis of, 741 

of the arch, 741 
Cocain habit, 62, 1286 

poisoning, 1304 
Cocci, pyogenic, 1078 
Coccidioidal granuloma, 1128, 11 29 
Cochin China diarrhea, 1063 
Cocktails, 61 
Cocotte, la, 1015 
Coffee, excessive use of, 61 
Cog-wheel breathing, 306, 417 
Cohn's standard measurements of heart, 429 
"Coin sound" of pneumothorax, 291, 299, 308 

over displaced viscera, 379 

test, Gairdner's, 309 
Colic, abdominal, 50 

afebrile vs. febrile, 90 

at height of digestion, 958 

blood pressure in, 485 

due to gastric ulcer, 87 

epigastric, 965 

gall-stone, 956 

lead, 1287 

mucous, 944 

pain of, 85, 86 

renal, 86, 956 

simple, treatment of, 957 

transitory, 85 

ureteral, 86 
Colitis, 945 

roentgen, study of, 848 
Collapse after perforation, 926 

diastolic jugular venous, 496 

fatal, in myocarditis, 667 

in cholera, 1031 
Collapse in cholera infantum, 944 

massive, of lung, 399 

surgical associations of, 109 



GENERAL INDEX 



1373 



Colloidal gold-test, 1082, 1244 
Colon bacillus infections, 10 14 
bismuth meal in, 847 
capacity, normal, 89 
colic, 87. 952 
course of, 807 

dilatation of, idiopathic, 817 
inflation, 86 

artificial, 814 

value of, 819 
obstruction of, 950 
respiratory descent of, 818 
roentgen study of, 846 
spasm of, 952 
tenderness over, 948 
transverse, palpation of, 808 
Color fields, 1227 

high, in girls, 16 

in the anemias, variations in, 145 
index in splenomegaly, 155 
of blood, in 
of skin, deceptive, 16 
of urine, 192 
scale, 116 

solution, standardized, 193 
test for albumin, 330 
vision, hysterical, 1280 
Colorimeter, 252 

Kuttner's, 119, 120 
percentage reading by, 252 
Columns, fundamental, 1189 
Coma, 1202 

and its congeners, 79 
breathing in, 79 
cases, ambulance, 79 

blind, 82 

blood examination in, 82 
vessels in, 81 

breath in, 82 

color in, 80 

convulsions in, 80 

diagnosis in, 82 

eyes in, 80 

lungs in, 82 

paralysis in, 81 

pulse in, 81 

temperature in, 81 

urine in, 82 
diabetic, 1166 
investigation of, 79 
of acidosis, 82 
recurrent, 1242 
uremic, 249 

in bon vivanl, 265 
vigil, 75. 79 
Comma bacillus, 1031 
Commissural fibers, 1191 
Compensation, attainment of, 683 
cardiac, 591, 625 
chief elements in, 683 
full recovery of, 637 
Compensatory changes, imperfect, 591 
defects, 591 

pauses, 510, 529. 543. 548 
"Complement," 983 
"Complement" (alexin fixation), 984 
deviation, 984 
-fixation, 142, 748, 984 

principles underlying, 980 



"Complement"-fixation, test, 969, 989 

in whooping cough, 1104 
Complex, fragmentary, 4 
Compression myelitis, 1260 
diagnosis of, 1260 
signs of, 1267 
Concato's disease, 796 
Concentric contraction, 885, 886 
Concretions, fecal, 942 
Conduction, impaired, 543 

period, 466 
Conduction time, delayed, 513, 533. 564 
normal, 513. 559. 565 
vagaries of, 371 
Conductivity of heart cells, 464 
Condylomata, rectal, 942 
Congenital anomaly, cervical ribs, 96 
asthenia, 68, 69, 148, 284, 404. 884 
abdominal flaccidity in, 805 
achylia in, 880 
and atony, 889 
and gastroptosis, 838 
chronic, 589, 595- 895 

and cardiac insufficiency, 650 
blood pressure in, 482 
protean symptomatology of, 8y? 
trained nurse in, 897 
universal, 482 
with weak heart, 621 
"drop" heart in, 148, 577. 656 
gastroscopy in, 831 
heart of, 594, 598 
in athletes, 592 

passage of stomach-tube in, 850 
pulse in, 490 

stigmata of, 621, 631, 650 
typical case of, 625 
universal, associated with mitral stenosis, 

688 
visceroptosis of, 884 
heart lesions, 732, 736 
diagnosis of, 736 
in general, 742 
sex incidence of, 74 2 
jaundice, 20 

hemolytic, 155 
kidney disease, 267 
laryngeal syphilis, 344 
polycystic kidney, 272 
stenosis, 898 
thyroid atrophy, 177 
Congestion, cerebral, 1241 

of the kidney, acute severe, 254 

chronic passive, 253 
of the lungs, 399. 400 
etiology of, 400 
hypostatic, 400 

passive, bilateral, 400 
pulmonary, with apoplexy, 401 
superficial, 1270 
Conjunctivas, injected, in measles, 1066 
Conjunctival reflex, 1194 

test, 413 
Conjunctivitis, 1228 
Consciousness, loss of, 80, 1202 
Consonance of rales, 310, 312 
Constipation, atonic, 952 

causes of, character of food, 951 
chronic disease, 952 



1374 



GENERAL INDEX 



Constipation, causes of, irregularity at stool, 952 
mechanical, 951 
reflex, 952 

in hyperchlorhydria, 868 

investigation of, 937 

roentgenologic diagnosis of, 847 

spastic, 945. 952 

with abdominal tumors, 815 
"Constitutio lymphatica," 175 
Consultation, attitude of physician in, 10 
Consumption, 401 

galloping, 406 

simulated, 1294 
Consumptives, chest expansion in, 285 
Continued fever, simple, 10 12 
Continuous fever, 73, 74 

temperature in, 78 
Contractility of heart cells, 464 
Contraction, anodal closure, 1200 

cathodal closure, 1200 
Contractions, fibrillary, 1264 

hepatic, 810 

of heart, extrasystolic, 543 
premature, 544 
Contractures, simulation of, 1295, 1299 
Control solution, 866 
Controls, 988 
Conus, arrested development at, 733 

arteriosus, congenital stenosis of, 728 
dulness over, 731 
Convalescence, guarding the patient in, 659, 676 

hurried, 658 
Convulsions, clonic, 1272 

eyes in, 80 

infantile, 49 

as reflex phenomena, 49 
predisposition to, 49 
symptoms of, 49 

simulated, 81, 1295 
Convulsive tic, 1275 
Copenhagen snuff, 61 
Copper poisoning, 65 
Coproliths, 942 
"Cor bovis," 442, 579, 718 

in case of endocarditis, 678 

mobile," 598 

pendulum," 431, 438 

-villosum," 793 
Cord, spinal, anemia of, 1254 

spinal, diseases of, 1237 
Corn, decomposed, poisonous, 1290 
Cornea, opacities of, 32, 1228 

sensitiveness of, 1302 
Cornu Ammonis, 11 24 

Coronary arteries, paroxysmal spasticity of, 768 
sclerosis of. 641, 768 

flow, impairment of. 750 

insufficiency, 676, 755 

sclerosis, 359 

pain in, precordial, 769 
right, 771 
Corpora quadrigemina, lesions of, 1212, 1245 
Corpus callosum and striatum, 1210 

ventriculi, 885 
Corpuscles, amyloid, 244 

elementary 993 
Corpuscles, human, injected into rabbits, 987 

initial, 993 

of Poggi, 126 



Corrigan pulse, 744, 748 

Corrosive acids, irritation from, 903 

sublimate, poisoning by, 1304 
Corset liver, 965, 978 

pressure and dyspnea, 640 

tight, a cause of obstruction, 898 
Cortex, 1 186 

areas of, motor, sensory, and silent, 1210- 

lesions of, 1191 
unilateral, 12 10 
Cortical centers, 1209 

Corynebacterium granulomatis maligni, 164 
Coryza in acute bronchitis, 345 

of hay fever, 336 

of measles, 1066 
Costal cartilage, ninth, tenderness in region of,. 

978 
Cough, barking, of puberty, 327 

brazen, 328, 775. 779. 800 

bronchial, 327 

causes of, diverse, 326, 327 

cessation of, as an ominous sign, 328 

dentition, 327 

diminuendo, 328, 352 

dry and moist, 327 

dyspeptic, 327 

hacking, 328 

hoarse, 328 

hollow or ringing, 328 

hysterical, 327 

in laryngitis, 343 

inspiratory whoop after, 328 

metallic, 328, 343 

modified by posture, 328 

noiseless or toneless, 328 

on touching sternum, 667 

painful, 327 

paroxysmal, 327 

pleural, 327 

pressure, 328 

reflex, 326 

smoker's, 327 

spasmodic, 1105 

stomach, 327 

suppressed. 327 

various types, 328 

whooping, 1 103 

winter, 347 
Count, leucocyte, 131 

of blood cells, red, 128, 129 
Counting chamber, 129 

Burker type, 133. 134. *34 
Burker-Neubauer, 133, 134 
Fuchs-Rosenthal, 133, 1243 
Gorgajew-Pappenheim, 129 
Neubauer, 130, 133, 134 
Thoma-Levy, 133 
Thoma-Zeiss, 129, 130 
Turck's, 132, 133 

cleansing of, 135 

plate, photographic, 136 
Cover-glasses in blood examination, 113 

washing of, 1009 
Cowpox, 1094 

virus, vaccination with, 1099 
"Crab-bite," n 18 
Crackles, curious, 454 

pneumocardial, 313 
Crackling, palpatory, 26, 351 



GENERAL INDEX 



1375 



Cramp colic, 46 

familial, 48 

muscular, 1162 

occupation. 46, 63 

transitory, 48 
Cranial nerves involved in meningitis, 1084 

lesions of, 12 19 
Cranio-tabes, 30, 117S 
Creatinin, 19s 
Creeping eruption, 1148 
Crenation of blood cells, 234 
Cremasteric reflex, 11 96 
Crepitation, 311 

crackling, 351 

in arthritis, 1156 

persisting, in a nephritic, 401 

pleural, 311, 313 

pneumocardial, 313 

showers of, 311 

simulated, 277 

tissue-paper-like, 26 
Crepitus index, 311 

redux, 311, 392 
Crescendo murmur, rumbling or thrilling, 459 

presystolic, 690, 695. 696 

thrilling purring, 744 
Cresson Sanatorium, urinary tests at, 195 
Cresyl blue solution, 140 
Cretin, appearance of, 177, 178 

sexual organs of, 178 
Cretinism, 176, 177 

age incidence of, 177 

endemic, 176, 177 

hereditary, 177 

infantile and juvenile, 177 

sporadic, 176, 177 
Cricoid cartilage, 901 
Crile, Dr., on shock, 109 
Crimean war, scurvy in, 171 
Crises, abdominal spastic splanchnic, 936 

cerebral arterial, 478 

Dietl's, 85, 86. 268, 956 

emotional, 180, 880 

gastric, 867, 899, 935- 1236 

gastrointestinal, 180 

intestinal and rectal, 936 

laryngeal, 1236 

of tabes, 87 

repeated, 79 

spastic, 764 

splanchnic, 87, 480, 485. 765 
abdominal, 771 

visceral, 1255 
Crisis, termination of disease by, 77, 78 
Critical faculty, 1 
Crombie's ulcers, 1064 
Croup, 343 

causes of, 343 

membranous, 344, 1074, 1075 

symptoms of, 343 
Crowding of heart, sensation of, 642, 755 
"Crowing" in croup, 105, 328, 343 

inspiratory, 328 
Crura, lesions of, 12 12 

crossed and tegmental, 1212 
Crural angina, 42 
Crus cerebri, lesions of, 1245 
Crutch pressure, 1268 
Cryoscopy, no, 240 



Cryplococcus gilchristi, 1127 
Crystals, Charcot-Leyden, 939 

hematoidin, 331 

in sputum, 331 

in urine, 231, 232 

thorn-apple, 233 
Culex as host of filaria, 1141 
Cultures, duodenal, 976 
Cupping, wet, scars from, 28 
Curiosities, medical, 7, 378, 904, 937 
Curschmann's spirals, 330, 347. 359 
Curvature of spine, lateral, 43 
Cyanosis, causeless, in babes, 176 

dusky red, 701 

grades of, 435 

gray, 701 

in pulmonary insufficiency, 731 

in bronchitis. 346 

in congenital heart disease, 352 

in emphysema. 352 

in pericarditis, 787 

in pleurisy, 365 

in venous stasis, 705 

in walking cases, 435 

indications of, 16 

of cardiac insufficiency, 649 

of ear, 33 

of erythremia, red, 435 

of foot, 42 

of nails, 16 

of pulmonary stenosis, 736 

of right heart, stasis, 649 

paroxysmal, 739 

profound, 736 

red, 16, 163, 164 

significance of, 80 

symmetrical, 1270 
Cyclosterion scarlatinae, 1069 • 

Cylindroid storms, 244, 265 
Cylindroids, mucous, 244 
Cynanche maligne, 1074 

Cystic degeneration of kidney, diagnosis of, 
272 

duct, stone in, 978 
Cystin, 233 

Cystitis, acute, etiology sources of, 273 
urine in. 273 

chronic, 273 

albuminuria in sources of, 273 
etiology of, 273 
symptoms of, 273 

infection of, 1014 

vs. pyelitis, 269 
Cysts, daughter. 1136 

dermoid, 423, 426 

distinguished from ascites, 24 

echinococcus, 271, 272 

hydatid, 425, 969. 1 136 

of brain, 1242 

of kidney, 272 

of scalp, 30 

ovarian, 817 

pancreatic, 964 

paranephric, 271, 272 

simple solitary, 271 
Cytodiagnosis, 143 

conclusions drawn from, 143 
Cytolysins, 982 
Cytorrhyctes variolae, 1094 



1376 



GENERAL INDEX 



Dalrymple's sign, 181 

Damages for injuries, 1281, 1292 

Damoiseau, curve of, 322 

"Dandy" fever, 1034 

Dardanelles jaundice, 18 

Dare's hemoglobinometer, 117. 119 

Dastre-Morat law, 463 

Davainea Madagascariensis, 1136 

Deaf mutism, 1235 

Deafness, 33, 335 

due to meningitis, 1085 
due to otitis media, 107 1 
hysterical, 1235 
nerve, 1234 
of arteriosclerosis, 766 
sudden, 1234 
uremic, 248 
Death, apparent, signs of life in, 1302 
approach of, 9 
"Blow," the, 1031 
certificates, absence of syphilis therein, 

75i 
conditions simulating, 1301 
forerunner of, 16, 435, 562, 667 
from use of sera, 993 

impending, conviction of, 360, 493, 756, 769 
proofs of, 1302 
resignation to, 9 
simulation of, 1301 
sudden, causes of, 765 

from acute dilatation of stomach, 897 
from aneurysm, 774, 775, 780 
from cardiovascular disease, 765 
from enforced posture, 756 
tendency to, 175 
withoirt apparent cause, 176 
thymus, 176 
Declaration, dying, 9 
Decompensation, cardiac, 1241 
electrocardiogram in, 533 
in auricular flutter, 559 
profound, 557 
cardiovascular, 419 
early evidences of, 632 
gross, protection from, 591 
signs of, 667 
initiation of, 659 
periods of, several, 694 
recognition of, 634 
secondary, 743 
sequence of events in, 625 
stages of, late, 631 
symptoms of, pulmonary, 699 
therapeutic aid for, 634 
Decubitus a cause of congestion, 400 
active or passive, 50 
and hypostatic pneumonia, 391 
dorsal, 50 
lateral, 50 
Defecation, painful, 949 

reflex action in, 1197 
Defensive responses, specific, 982 
Defervescence, 74, 76 
Deflection, cardiac, sources of, 519 
Deformity from contractures, 1266 
in leprosy, 11 21 
of chest, 282 



Degeneration in middle age, 59 
of nerve cells, 1190 
syphilitic, progressive, 1252 
Degenerative changes, sequence of, 1181 

processes, chronic, 566 
Delirium cordis (see also under "Fibrillation"), 
5Si. 554. 685, 701 
arrhythmia of, 543 
pulse in, 494. SSL 554 
Delirium, 1202 
forms of, 1202 

in children, readily excited, 75 
in febrile diseases, 75 
in pneumonia, 389 
in typhoid, 1005 
tremens, 1285 
Delirium tremens, mode of death in, 1286 
police cases of, 1286 
restraint in, 1286 
symptoms of, 1286 
Delusions, changeable or fixed, 1201 
of grandeur, 1252 
sane or insane, 1201 
uremic, 247 
Dementia, feigned, 1298 
paralytica, 1237, 1251 

diagnosis of, differential, 1253 
exhaustion in, general, 1252 
knee-jerks in, 1252 
morbid anatomy of, 1252 
primary exudative, 1253 
symptoms of, 1252 
epileptiform, 1252 
neurasthenic, 1252, 1253 
types of, variations in, 1253 
violent outbreaks in, 1252 
paretic, 748, 11 84, 1298 
Dendrites or dendrons, 1185 
Dengue, 1034 

differentiated from yellow fever, 1037 
etiology of, 1034 
fever resembling, 1059 
incubation period in, 1035 
joint affections in, 1035 
period of remission in, 1035 
symptoms of, 1035 
Dentition, 39 
cough, 327 
delayed, 38 
first, 1 1 57 
Dermacentor venustus (Andersoni), 1055 
Dermatitis, n 18 
Dermatophiliasis, 1148 
Dermoid cyst, pulsating, 423 
D'Espine's sign, 310, 422 

of the lung, 426 
Desquamations, 28 
furfuraceous, 1035 
lamellar, 1076 
Destruction, agent of, in warfare, 348 
Deutero-albumoses, 215, 857 
Development, arrested, 187 
Deviation, conjugate, 1232 
in apoplexy, 1247, 1248 
septal, 335 
Dexiocardia, 742 

concentric, 407 
Diabetes, acidosis in, 229 
acute, 1 168 



GENERAL INDEX 



E 377 



Diabetes, age and sex in, 1165 

among Hebrews, 69 

blood in, 121 

breath in, 249 

bronze, 17, 1 9 

bulimia in, 871 

coma in, 82, 244, 1167 

complications of, 11 66 

diet in, 1165 

diseases antecedent to, 1166 

exercise in, 1165 

fasting in, 1167 

hereditary, 68 

insipidus, 1168 

diagnosis of, differential, 1169 
idiopathic, 1169 
prognosis in, 1169 
urine in, 1169 

levulose in, 227 

lipogenic, 1165, 1166 

mellitus, 1163 
intractable, 1165 
severe true, 3 
urine in, 191 

neurogenous, 1164 

pancreatic, 1166 

prognosis in, 228, 229 

pulmonary gangrene in, 420 

race and heredity in, 69, 1165 

starvation in, 1167 

symptoms of, 1166 

uric acid showers in, 211 

urine in, 1168 

stain of, on shoes, 13 
Diacetic acid in urine, 228, 229 
Diagnosis at sight, 334 

by deduction, 6 

by exclusion, 6 

cardiac, instruments for, 276 

economy of time in, 276 

errors in, 6, 7, 1280 

essentials in, 7. 276 

hasty, a source of humiliation, 6 

in rare diseases, 7 

mental attitude in, 276 

methods and means employed in, 276 

mistakes in, serious, 276 
. modern scientific, aim of, 4 

multiple repetitions in, 276 

of chronic ailments, 7 

principles and problems of, 1 

"snap," 6 

"street car," 719 

tests in, 5 

therapeutic, 6 

thoroughness in, 276 
Diagnostician, overconfident, 743 
Di-amido-azo-benzol reaction, 865 
Diaphragm adhesions of, 324, 370 

ascent of, unilateral, 382 

connective tissue of, 792 

descent of, 809 

downward displacement of, 812 

fixation of, 323 

high position of, so, 596, 708 670, 785, 961 

immobility of, 368 

inflammation of, agonizing hiccough in, 108 

luminosity of underlying areas of, 961 

persistent low position of, 353 



Diaphragm, phenomenon, Litten"s, 286, 418 

spasm of, 356 

systolic drag upon, 437 
Diaphragmatic hernia, 382 

pleurisy, 373 
Diarrhea, achylia with, 880 

acute fermentative, 943, 944 
symptoms of, 944 

afternoon recession of, 881 

Cochin China, 1063 

frequent attacks of, 881 

investigation of, 938 

membranous, 944 

morning, 1063 

of high altitude, 1063 

rice-water, 103 1. 1032 

simulated, 1295 
Diastasis, 817, 953 
Diastole, initiation of, 458 

of heart, 456 
"Diastolic echo," 44s 
Diastolic events, 459, 5 24 

" jugular venous collapse," 503 

pressure, 472, 473 

determination of, palpatory, 474 
high, clinical significance of, 486 
index of, 474 
level, 475 

relatively high, 478 
relatively low, 478 

shock, 439 
Diathesis, furuncular, 12 

gouty, 1 1 74 

hemorrhagic, 45, 172 

significance of term, 12 

spasmophilic, 47, 49. 344 
of children, 360 

uric acid, 212 
Diazo-reaction, 195 

absence of, in certain diseases, 1007 

in advanced carcinoma, 932 

in tuberculosis, 406 

in typhoid, 1007 

limitations of, 1007 
Dibothriocephalus latus, 1135 
Dicotophyme gigas, 1144 
Diet, character of, 937 

diabetic, rigid, 3 

effects of, on HC1, 867 

fads in, 11 82 

purin-free, 11 72 
Dietl's crises, 85, 86, 268, 956 
Digestion, gastric, 852 

aids to, indirect, 852 

of fats, 857 

test, 856 
Digestive ferments, 851 

organs in febrile diseases, 75 

processes, extent of, 852 
Digitalis as therapeutic test, 603, 650, 652, 658 

diagnosis by, 6 

effects of, 538, 539. 553. 556 
cardiac, 550, 553 
in fibrillation, 532, 557 
in heart block, 514, 570 

heart block, 564 

in aortitis, resistance to, 753 

intolerance for, 672 

test doses of, in fatty heart, 670 



1378 



GENERAL INDEX 



Dilatation, acute, in a hunter, 654 
auricular, 682 
cardiac, abrupt increase in, 667 

acute, 401 

massive, 666 

minor, 662, 666 

obligatory, 591 

simple, 462 

without valvular murmurs, 433 
gastric, due to stasis, 885 
of aortic ring, 452 
of heart, right, 438 
of splanchnic vessels, 463 
of stomach acute atonic, 897 
symptoms of, 898 

mortality from, 898 

toxemic, 898 
Dimethyl-amido-azo-benzol solution, 864, 866 
Diminuendo cough, 328 
Diminuendo murmur, 708 

diastolic, 696, 697 
Diphasic current, 518 

waves, 527 
Diphtheria, 1074 

and Vincent's angina, 1077 
antitoxin, 344, 1075 

prompt use of, 1077 
as cause of myocarditis, 665 
blood pressure in, 480 
broncho-pneumonia in, 395 
carriers, 1074 
complications of, 1076 
death in, sudden, 463, 1076 
diagnosis of, cultural, 1076 

differential, 1076 
dissemination and distribution of, 1074 
dyspnea in, 1075 
enlarged glands in, 1075 
heart in, dilated, 287 
hypotension in, 481 
immunity, 990 

individual susceptibility to, 1074 
laryngeal. 344' I0 75 

hypo-tension in, 481 

stenosis in, 343 
morbid anatomy of, 1074 
mortality from, 1075. 1077 
nasal, 1075 

nervous system in, 1075 
of vagina and vulva, 1076 
paralysis in, 1076 
patch or membrane in, 1075 
prevention of, 990 
prognosis in, 1077 
pulse in, 1075 
Schick's test in, 1074 
simulated by tonsillitis, 342, 977 
stenosis in, nasal or laryngeal, 107s 
suffocation in, 1075 
suicide in, 1076 
symptoms of, 1074 
cardiac, 1075 
in throat, absent, 1074 
toxin. 981, 1074 
reaction to, 990 
ripened, 990 
without membrane, 1075 
Diplegia, spastic, 1258 
Diplococcus found in rabies, 11 24 



Diplococcus, intracellularis meningitidis. 245 

pneumoniae, 383 
Diplogonoporus grandis, 1135 
Diplopia, 1231 
Dipping, 24, 804 

palpation, 971 
Dipylidium caninum, 1135 
Dissociation, cardiac, 698 
Disc, choked, 1227, 1228, 1249 

pale, 147 
Discharge from ear, 34 

nasal, 33 
Discolorations, simulated, 1298 
Discomfort, referred, 641 
Disease bred by idleness, 66 

combined system, 1191 

etiologic factors of, 5 

focal, 1 191 

outward signs of, 11 

pathologic processes of, 4 
Diseases, antecedent, 937 

chronic, time limits of, 8 
diagnosis of, 7 

familial, 155. 1265, 1266, 1269 

hereditary, 1265, 1269 

infectious, 1000 
Diseases, mental photograph of, 6 

of unknown causation, 188, 1 163 

simulated, 1 293-1301 
Displacement of heart, 368 

of viscera, 379 
Dissimilation, 465 

Distention, abdominal, 439, 80s, 817, 820, 1004 
Distomum hepaticum, 1133 

lanceatum, 1134 
Dittrich's plugs, 330, 35Q 
Diuretic drugs, study of, 210 
Diuretin in abdominal crises, 936 
Divers' paralysis, 1239 
Diverticulum, Meckel's, 943 

of esophagus, 903 
congenital, 903 

traction, 903 
Dog bite as cause of rabies, 1124 

rabid, 1224 
Dogs, echinococcus disease in, 968, 1136 

parotitis in, 1068 
Dohle-Hellersche aortitis, 752 
Dohle's inclusion bodies, 125 
Dracontiasis, 1143 
Dracunculus, 1143 
Dreams, analysis of, 1202 

due to cerebral anemia, 1241 
Dress, significance of, 13 
Drinker, "sneak,"- 241 
Drinking, moderate, dangers of, 61 
Drinks, hot, esophagitis from, 903 

productive of pain, 921 
Dromedary gait, 53 
Drooling, 35, 1265 
Drop foot, 1218, 1219 

heart, 267 320, 482 

and displaced apex beat, 437 

and "drop" stomach, parallel between, 

574. 600, 601, 622 
and exertion dyspnea, 600 
and minor dilatation, 591 
and neurasthenia, 449. 606 
and "small heart," 573. 601 



GENERAL INDEX 



1379 



Drop heart and strenuous life. 440 

and tuberculous infection, 602 
and visceroptosis. 605 
aortic stenosis in, 581 
auricle in, 428 
borders of, 427, 428, 441. 698 

right, 572, 716 
calcified focus in. 434 
decided, 700 

dilatation of, 431. 432. 434. 573. 596, 
631 
shrinkage in, 603 
universal, 782, 784 
with hypertrophy, 626 
dorso-ventral aspect, 595 
enlarged, 646 
extreme, 433 

frequent occurrence of, 605 
from over-exertion, 433 
in business man, 600 
in case of influenza, 597 
in chlorosis, 150 
in infections, 782 
in interstitial nephritis, 629 
minor, 893 

modified, 573, 602, 604, 606, 884 
in athletes, 621 
insufficient, 622 
Drop heart, of congenital asthenia, 594- 656 
outline, narrow, 784 
overstrained, 573 
position of, central or lateral, 892 
pulsations, 581 

visible, 437 
recognition of, 651 
right-border change in, 574 
right ventricle in, 574 
roentgenography of, 57 '2 
sex incidence of, 601 
stenosis in, pure, 577 
symptoms in, 639 
toxic, 665 

tracheal tug in, 777 
with gastroptosis, 651 
with mitral systolic murmur in, 434 
wrist, 1219 
Dropsy, 20. 21 

epidemic, 1057 

nervous symptoms in, 1057 
simulated, 12Q6 
Drowsiness during day, 103, 1202 

in cerebral abscess, 1251 
Drug addiction, 11 12 

bastard symptom complex in, 62 
eruptions, 28 
habit, 30, 46, 1 1 84 

innocent victim of, 62 
habitues, color of skin in, 17 
headaches, 92 
poisoning, cyanosis in, 16 
treatment, justification for, 652 
Drugs, diuretic, study of, 210 
irritating, 254 
toxic irritation from, 123 1 
"Drunkards' catarrh," 906 

types of, 1285 
Drunken rounder, physiognomy of, 1053 
Dryness, secretory, abnormal, 35 
Duck hunting, cardiac dilatation during, 654 



Duct, common, malignant disease of, 975 

obstruction of, 978 

suppuration of, 979 
cystic, obstruction of, 979 
Ductus arteriosus, closed, 734 

in fetal life, 739 

patent, 734- 739 
Botalli, 28, 733 

aortic occlusion below, 806 

dilated, 739 

persistent, 739 

value of, 739 
Duke's fourth disease, 1072, 1073 
Dulness due to compressed lung, 367 
hepatic, 293, 294 
level of, in transudates, 367 
on percussion, modified, 292, 293. 
pulmonary, 299 
thoracic areas of. 379 
Dumdum fever, 1059 
Duodenal cap, 837 

deformity of, 842, 924 

of Cole, 922 
contents, bile in, 856, 978 

cultures from, 976 

examination of, 852 
disease, diagnosis of, 834 
feeding, 853. 856 

compared with rectal, 856 
Duodenal feeding, food substances for. 856 
findings, significance of. 856 
irritation, 844, 845 
secretion, color of, 854 

normal and chocolate yellow, 854 
tests, present field of, 852 
tube, 853 

anchoring of, 853 

capillary, 853 

passage of, 853 

on empty stomach, 854 
posture for, 854 
time of, 854 

possibilities of, 856 

therapeutic value of, 856 

use of, 914. 9i6 
ulcer, 842, 907 

anemia in, intractable, 919 

chronic, 842, 846, 914 

diagnosis of, 844, 

food retention in, 916 

gastric residue in, 846 

hunger-pain in, 914 

non-obstructive, 925 

old, adhesions from, 845 

perforating, 844, 919, 957 

radiography in, 916 

sign of, intermittent, 846 

symptoms in, dyspeptic, 919 

unrecognized, 70 
Duodenitis, acute catarrhal, 975 

epidemic, 975 
Duodenum, diverticulum of, 842, 844. 
erosion of, 919 
first portion of, 907 
hook-worms in, 1139 
lagging of bismuth in. 844 
palpation of, 834 
stenosis of, 950 
ulcer of, 925 



i 3 8o 



GENERAL INDEX 



Duplication of rare cases, 7 
Duroziez's disease, 577 

sign, 486, 710, 719 
Dust, infected, 968 
Dwarfs, 177. 187, 189 

pug-nosed, 189 

showman's, 187 
Dyes, staining, 115 

vital red, 140 
Dynamometric tests, 588 
Dysarthria, 1202 
Dysbasia angiosclerotica, 53 
Dysentery, 945 

acute catarrhal, 945, 948 
specific, 945, 948 

amebic, 94s 

bacillus of, 992 
Shiga's, 943 

chronic, 948 

diagnosis of, differential, 949 
laboratory, 945 

diphtheritic, 948 

diseases described as, 943 

etiology of, 945 

follicular, 948 

gangrenous, 1057 

hypotension in, 481 

malarial, 948 

mortality from, during Civil War, 949 

onset of, 948 

simulated, 1295 

stools in, 948 

symptoms of, 948 

tropical, 945 
Dyslexia, 1203 

Dysmenorrhea, right-sided, 958 
Dyspepsia after middle age, 977 

asthenic, 832, 870, 880, 893 

and associated visceroptosis, 894 

chronic painful, 920 

feigned, 1296 

in case of enlarged heart, 785 

in sprue, 1064 

nervous, 68, 651, 657, 870, 880, 890, 893. 896 

obstinate, and rest cure, 871 

psychasthenic, asthenic, 872 

recurrent painful, 909 

relieved by digitalis, 642 

specific inquiry in, 60 

symptoms of, obscure, 90 

visceroptotic, 911 
Dyspeptics, "incurable group" of, 1182 

nervous, 11 81 
Dysphasia, 902 

in aortic aneurysm, 585 

in cerebral hemorrhage, 1248 
Dysphonia, 344 
Dyspnea, circulatory, 105 

clinical definition of, 105 

expiratory, 360 

frequently recurring, 756 

from corset pressure, 640 

in aortic insufficiency, 721 

in asthma, 359. 360 

in uremia, 248 

in venous stasis, 706 

inspiratory. 343 

objective, 105, 647 

obstructive, 105, 296 



Dyspnea of aortitis, 756 

of recumbency, 107 

on exertion, 106, 146, 600, 670 
simulated, 1296 

orthopneic, 756 

paroxysmal, 106, 640 
in pericarditis, 787 

persistent, 106, 756 

production of, 480 

recurrent, 106, 640 

subjective, 105, 639, 675, 1307 
vs. apparent, 666 

sudden and urgent, 419 

suffocative, in young children, 176 
Dysthyroidism, 179 
Dystrophy muscular, 1265 
Dysuria, 191 

in cystitis, 273 

in locomotor ataxia, 1255 

persistent, 270 



Earache, 33 

Ears, gangrene of, 1270 

middle, disease of, 1240, 1251 

syringing of, dangers of, 1235 
Eaters, heavy, 669 
Eberth's bacillus, 1000, 1001 
Ebstein's cardiohepatic angle, 301 

percussion, 441 
Ecchondroses, nasal, 335 
Ecchymoses, 27 

in pertussis, 327 

in hemophilia, 170 
Echinococcus cysts, 271, 426, 968, Iig6, 
in dogs, 968. 1 136 
rupture of, 969 

granulosus, 968 

invasion, test for, 989 
Echo, diastolic, 445 

musical, 312 
Echthyma syphilitica, 1109 
Eclampsia, warning of, 253 
Ectasia, 824, 887 

obstructive, 899 

passage of stomach tube in, 850 

post-stenotic, 899, 900 

with gastroptosis, 887 
Ectopic gestation, 109 
Edema and chloride retention, 213 

angio-neurotic, 21, 1270 
familial, 1269 

bilateral, 22 

cachectic, 23 

cardiac, 21, 22 
secondary, 23 

cardinal signs of, 21 

cerebral, 1241 

diurnal, 22 

elusive, 22 

facial, 435 

fugitive, 401 

gravity, in sprue, 1064 

hydremic, 20 

in ankylostomiasis, 1140 

in carcinoma, 932 

in cardiovascular insufficiency, 648 

in dependent part, 21 

indurative, 1109 



GENERAL INDEX 



1381 



Edema, inflammatory, 20 

leathery, 22, 815 

marble, 22 

in nephritis, 22, 257 

nocturnal, 22 

non-inflammatory circumscribed, 22 

obstructive, 20 

of ankles, 13 

of extremities, diurnal, 646 
long-existent, 646 

of face, 32 

of glottis, 257 343 

of legs, 704 
diurnal, 632 

of malignant anthrax, 11 23 

of polymyositis, 1159 

passive congestion, 264 

pitting in, 649 

pulmonary, 301, 400, 1263 

infectious of inflammatory, 400 

renal, 22 

simulated, 1296 

transient, 21 

unilateral, 22 

vagaries of, 21 
Effusions, joint, 1271 

massive, 24, 287 

pericardial, fluoroscopic outline of, 782 

pleural, 287, 301 

sign of, 44 

small, 24 
Egophony, 309 

in pleurisy, 371 
Egyptian mummy, blood test in, 991 
Ehrlich's diazo-reaction, 245, 1007 

author's modification of, 245, ioq8 

in tuberculosis, 406 

in typhoid, 24s, 1007 

indol, test for, 193 

solution, 854 

triacid distinction, 945 
stain, 116, 123 
Eichorst's muscular atrophy, 1265 
Eimeria stiedas, 946 
Einhorn's gastric ulcer test, 943 

saccharometer, 226 

transillumination, 823 

tube, 853 
Elastic fibers in sputum, 331. 421 
Electric brush, 1299 

-car accident, 642 

potential, changes of, 521, 522 
Electrocardiograms, 520 

conduction tissue in, 536 

delayed, 533, 538 

events of, time relations in, 523 

interpretations of, 521, 522, 524 

marking and interpretation of, 525 

normal, 520, 522, 549, 553 

of arborization defect, 536 

of extrasy stole (auricular), 526, 527 

of extrasystole (nodal), 529. 531 

of extrasystole (ventricular), 527, 528, 529, 
530 

of fibrillation, 520, 529, 531, 532, 558 

of heart block, 531, 533, 535. 565. 267 

of nitral stenosis, 537 

of nodal rhythm, 531, 569 

of over-digitalization, 538, 539 

85 • 



Electrocardiograms of paroxysmal tachycardia, 
560 

of pulsus alternans, 561 

of sinus arrhythmia, 527 

of soldier's heart, 541 

phases of, 504, 525 
Electrocardiograph, 276, 497. 5 17. 519 

differentiation by, 547 

essential features of, 518 

sensitivity to, 518 
Electrocardiographic leads, 520, 521 

phases, 523 
Electrometer, capillary, 518 
Electromotive force, 517 
Elephantiasis, 25 

forms of, 1 142, 1 144 
Ellis curve or line, 364 
Eisner's gastroscope, 828, 829, 830 
Emaciation, causes of, 54 

due to vomiting, 879 

in achylia gastrica, 934 

rapid, in tuberculosis, 406 
Emboli, bacterial, 673 

formation, 673, 674 

in endocarditis, 677 

in systemic arteries, 739 
Embolism, 1245 

associated conditions in, 1250 

differentiated from apoplexy, 1249 

intestinal, 953 

of radial artery, 714 

of the cord, 1254 

pulmonary, 418 

septic or non-septic, 418, 419 
Embolus, paradoxic, 739 
Embryocardia, 449 
Emotion, psychical, 121 1 
Emotional crises, 180, 11 79 

jaundice, 18 
Emotions as cause of asthma, 356 

instability of, 1278 
Emphysema, 351 

atrophic or senile, 297, 355 
Emphysema, bilateral, acute, 35 1 

chest in, 283 

compensatory, 317 
acute, 351 

cough in, 328 

differentiation of, 326 

distended air-cells in, 297, 352, 353 

dyspnea in, 106 

interlobular, 351 

interstitial, 351 

localized, 351 

lung borders in, 296 

lungs in, voluminous, 766 

mediastinal, 454 

rationale of, 353 

senile (atrophic), 297, 355 

subcutaneous, 26, 351 

true, 296 

vesicular, 351 

hypertrophic, 352 

capillary obliteration in, 352 
cause and effects of, 352 
chronic bronchitis in, 352 
cyanosis in, 352, 354 

and dyspnea in, 352, 354 
epigastric angle, wide, 352, 354 



1382 



GENERAL INDEX 



Emphysema, vesicular, hypertrophic, expansion 
diminished in, 353 
fluoroscopic appearance in, 353 
heart in, 353 
inspection in, 352 

percussion and auscultation in, 353 
physical signs in, 352, 354 
right heart decompensation in, 352, 354 
slow advance of, 355 
state of lungs in, 353 
symptoms of, 352 
vocal fremitus enfeebled in, 353 
walking cases of, 352 
vicarious, 296, 351 
Emprosthotonos, 51, 11 26 
Empyema, 362 

aspiration in, 375 
blood findings in, 374 
differentiation of, 326, 961 
due to pneumonia, 385 
encapsulated, 376, 420 
frontal sinus, 338, 339 
in children, 375, 385 
in scarlet fever, 107 1 
interlobar, 315, 376 
neglected, 374, 376 
obscure, 375 
pneumococcus, 362, 388 
pyogenic organisms in, 374 
symptoms of, 374 
treatment of. surgical, 373 
with pulmonary gangrene. 421 
X-ray, 375 
Emulsion, bacterial, 996, 997 
Endarteritis, luetic, 748 
obliterative, 748, 763 
of the cord, 1254 
Endocarditis, acute, etiology of, 673 

followed by mitral stenosis, 6S7 
pathology of, 673 
simple, recurrences of, 677 
vegetative, a cause of aortic stenosis, 722 
advanced, 575 
aortic, following rheumatism. 683 

with insufficiency, 715 
bacterial, chronic recurrent. 6 
Endocarditis, bridging gap, 747 
chronic mitral, 690 

multiple lesions in, 747 
unsuspected, 676 
varieties of, 675 
vegetative mitral, case of, 683 
definition of, 672 
etiology of, 782 
fetal, 733, 74? 
heart sounds in, 676 
in children, 674, 796 
in chorea, 674 
in diphtheria, 1076 
in scarlet fever, 1071 
lenta, 258. ion 
lesions of, 672, 786 
malignant, 27, 677, n 19 
absence of fever in, 677 
blood cultures in. 677 
diagnosis of, 677 
preceded by tonsillitis, 675 
pyemic form of. 677 
murmurs of. 461 



Endocarditis, recurrent infective, 27 
malignant septic, 678 

cardiac changes in, 678 
differentiation of, 678 
prognosis in, 678 

rheumatic, 1152 

sclerotic, 674, 675 

sequelae of, 746 

simple, silent cases of, 676 
symptoms of, 675 

subacute, 676 

transient effect of, 673 

tricuspid, 690 

ulcerative, 10 11 

' petechias in, 27 

verrucose, 674, 675 

viridans type, 672 

with pancarditis, 786 
Endocrin disturbance, 1163 
Endogenous obesity, 188 
Endotnyces albicans, 112 7 
Endothelial cells, tesselated, 143 
Endotoxins, 980, 981 
Enemata before examination, 803 

bismuth, 959 

hot, for colic, 957 

of oil, 816 
Energy, conservation of, 462 
Engorgement, pulmonary, 296 
Enophthalmos, 32 
Entameba buccalis, 39 

coli. 946, 947 

hemolytica , 947 

histolytica, 945, 946, 947. 948, 1132 

{tetragena) as cause of hepatic abscess, 968 

tetragena, 865, 866, 94s, 946, 947, 948 
Entamebas, carriers of, 947, 948 

stage of, encysted, 947 
motile, 947 
Enteralgia, 950 
Enteric fever, 1000 

lesions, 1001 
Enteritis, 943 

clinical varieties of, 943 

divisions of, primary, 943 

infection of, 10 14 
Enteritis, membranous, 944 

morbid anatomy of, 943 

of infants, 943 

vs. colitis, 943 
Enterocolitis, 943 
Enteroliths, 942 
Enteroptosis, 953 
Environment, importance of, 69 

inquiry into, 60 
Eosinophile granules, 116 
Eosinophils in leukemia, 157 

"polymorphs," 123 
Eosinophilia. 139 

as a clinical sign, 139 140 

in echinococcus disease, 426 

in trichiniasis, 1138, 1160 
Epidemic aphthous stomatitis, 1057 

dropsy, 1057 

infantile paralysis, 1089 

influenza, 10 15 

parotitis, 1068 

psittacosis. 1012 

scarlet fever, malignant, 78 



GENERAL INDEX 



1383 



Epidemic, smallpox, 1098 
Epidemics in relation to residence, 66 

sources of, 67 
Epigastric angle, widening of, 962 

bulging, 790 

discomfort, 642 

a sign of cardiac disease, 90 

distress in myocarditis, 667 
upon arising, 928 

fullness, feeling of, 706, 798 

heave, 288, 684, 734 

impulse, origin in, 746 

oppression, 580, 897 

pain, 787 

pulsation, 438, 706 

over right Ventricle, 438 

reflex, 1196 

retraction, 795 

tenderness in hyperchlorhydria, 868 
Epiglottis, turban-shaped, 344 
Epilepsy, attacks similar to, 49 

aurae in, 104, 127 1 

convulsions in, 80, 1272 

heredity in, 1271 

hypertension in, 480 

indecency in, 1272 

infantile, 49 

Jacksonian, 1272 

major, 1271 

mental deterioration in, 1272 

minor. 103, 1271 

nocturnal, 1272 

simulated, 1296 
tests in, 1296 

vertigo in, 104 
Epileptic equivalents, 93 

psychical, 1271, 1272 
Epileptiform attacks, recurring, 565 
Epinephrectomy, experimental, 173 
Epiphora, 33 

Epiphyses, swelling of, 1175 
Epistaxis, 337 
Epithelial casts, 240 
true, 242 

cells, differentiation of, 236 
Epithelioma, 34 

of lips, scars from, 30 
Epithelium in the urine, 236 

from renal pelvis, 238 
Epstein's method of estimating sugar, 121 
Epulis, 38 
Equilibrium, 1188 

cortical center for, 1234 

functional and nutritional, 267 
Erb-Charcot disease, 1257 

-Goldflam syndrome, 1267 
Erb's juvenile muscular dystrophy, 1266 

motor points, 1198 

myotonic reaction, 1267 

syphilitic spinal paralysis, 1258 
Erepsin, 852 
Ergotism, 1289 
Erosions of stomach, 882 
Eructations, audible, 871 
Eruption, astacoid, 1095 

coppery or ham-co ored, 1108 

creeping, 1148 

drug, 28 

erythematous, 1095 



Eruption, erthematous, maculopapular, 1053 

forms of, 1095 

macular, leprous, 1121 

morbilliform, 1095 

of chickenpox, 1102, 1103 

of miliary fever, 1057 

of polymyositis, 1160 

of smallpox, 1095 

of yaws, 1 1 14 

petechial, in typhus, 1051, 1052 

purpuric, 1095 

scarlatiniform, 1095 

urticarial, 1095 
Erysipelas, 1118 

bullae and vesicles of, 11 19 

cases of, obscure, 11 18 
syphilitic, 11 18 

etiology and symptoms of, 11 18 

pathognomonic signs of, 11 18 

relapses in, 11 18 

skin in, 11 18 
Erysipeloid, 11 18 
Erythema, facial, 1035 

in pellagra, 1290 

infectious, 1073 

of miliary fever, 1057 
Erythremia, in, 163 

blood tension in, 480 

circulation in, 463 
• red cyanosis of, 163, 435 

secondary, 730 

Vaquez-Osler, 163, 813 
Erythroblasts, 127 

staining of, 116 
Erythrocyte count, 13S. 140, 736 

counter, 132 
Erythrocytes, 122 

basophilic, 128 

in red blood cell, 126 

in the sputum, 331 

in urinary blood, 234 

staining of, 116, 126 

unusual reactions of, 126 
Erythrocytometer, 128 
Erythrocytosis, 162 

megalosplenica, 163 
Erythrocytosis megalosplenica, 163 
albumin and casts in, 163 
diagnosis of, at sight, 163 
prognosis in, 164 
Erythrodextrin, 863 
Erythromelalgia, 1270 
Esbach's albuminometer, 220 
Escherich's infectious erythema, 1073 
Esmarch's bandage, 1295 
Esophageal hiatus, 827, 902 

lesions, organic, chief, 901 

neuroses, 904 

obstruction, 577 

pouches, 903 

sound, 824 

spasm, 904 

stenosis, 833 

strictures, 901 
Esophagitis, acute, 901, 903 

simple chronic, 904 
Esophagoscope, 824, 826, 902 

introduction of, 825 
Esophagoscopy, apparatus for, 313 



i3»4 



GENERAL IXDEX 



Esophagus, accessibility of. 824 

and bronchus, union of, 835 

carcinoma of, 904 

congenital atresia of, S35 

dilatation of, 902 

diseases of, 824, 901 

mistaken diagnoses in. Sa - 

displacement of, 585 

diverticulum of, 903 

malignant growth in, 902 

necrotic processes in, 902 

perforation of, 827, 902, 903 

varices of, 901 
Ether anesthesia and blood pressure, 483 
Ethyl chloride anesthesia, 483 
Ethmoidal headline. 92 

sinuses, 338 
Ethmoiditis, necrosing. 336 
Etiology of disease, 5 
Euchlorhydria, 867 
Eunuchs, 187 

Euphemisms of case-taking. 67 
European war, heart strain in, 607 

trench warfare in, 348 
Eustrongylus rigas. ::__ 
Euthanasia, 9 
Ewald's test breakfast, 859 

test meal, 876 
Ewart's crucial test, 367 
Exaltation, periods of, 1252 
Examination of abdomen, 803 

of blood, no 

of chest, arrangement of clothing for 277 
attitude for, 277 
change of posture in, 277 
proper light for, 277 

of duodenal contents, value of, 852 

of pelvis, 832 

of stomach, physical, 822 

of urinary calculi, 275 

of urine, microscopic, 223, 230 

physical, artificial light for, 823 
inspection in, 822 

posture of patient for. : ; - 

roentgenoscopy, 314, 571 
Ex-r.therr.atous diseases. i:a::-re= :ti:u in, 
1007 

syphilitic, 1 108 
Exanthems, 35 

of measles, 1066, 1068 

of rubella, 1072 

of scarlet fever, 1070 
Excitability of heart cells, 464 
Excitement and blood pressure, 476 
Excretion, deficient, 247 

in relation to disease, 251 

through the kidneys, 189 
Exercise, moderation in, 655 

regulated, 651 

unsuitable, 654 
Exertion during auscultation, 693 

dyspnea, 600, 606, 756 
in drop heart, 597 
temporary, 670 
Exhaustion psychosis, 76 
Exogenous obesity, 187 
Exophthalmic goiter, 179 

acute, 180 

age and sex in, 180 



Exophthalmic after fracture of thigh, 180 

atypical forms of, 180 

blood picture in, 183 

complicating symptoms, 183 

etiology of, 180 

exophthalmos, 32, 180 

pressure curve of, 486 

signs in, 181 

symptoms of, 180 

mental, 183 
nervous, 183 
unilateral, 32 

tests in, 181 

thrills in, 182, 439 

tremor in, 46, 179 

with cardiac involvement, 182 
Exostoses, nasal, 335 
Exotoxins, 980, 9S1 
Expansion, deficient, causes of, 287 
unilateral. 2S7 

upper-chest, in women, 288 
Expiration, prolonged, 306, 355 

fullness, 496 
Expiratory lagging. 2S7. 35^ 
Exploratory incision of stomach, 851 

:.;::::.;:; :: liver. 967 
Enci:;i:ns of energy, _:_ 
Ext tsure, unusual, a factor in disease, 63 
Expression, facial, 12, 288, 1211. 1234 

harassed, 159 
Zxrraeardial sources of deflection, 519 
Extrasystoles, 543 

auricular, 526. 544- 54> - 

■s m:r:ii thentmena, 55: 

clinical significance of, 546, 550 

differentiation of, electrocardiographic, 526, 
527. 528, 529, 530. 547- 549- 550 
polygraphic, 508, 509 

double consecutives. S45 

frcm tundle of His. 5-> 

interpolated. 546 

irregularity of, 550 

latent tendency to, 550 

origin of, 543 

recognition of, 544 

strength of, 469 

ventricular, 543, 545. 569 
characteristics of, 52S, 546 
interpolated, 546 
"asations, subperiosteal, 172 
Extremities, bizarre movements of. 1274 
lower, edema of, 21 
numbness of, 640 
Extremities, lower, and upper, contrasting pulse 
of, 806 

tremor of, 45 
Exudates, catarrhal, 394 

in broncho-pneumonia, 39^ 

chylous, 376 

coagulation of, 142 

fibrinous, 394 

in pleurisy, 361, 362, 373 

meningeal, 1078 

pericardial, 785 

peritoneal, encysted, 963 

pneumothorax, vs. pleuritic, 323 

purulent, 44, 376 

rapid withdrawal of, 374. 4§5 
Eye reflex, 338 



GENERAL INDEX 



I38S 



Eye strain and vertigo, 104 
Eyelids, baggy, 15 

dark circles under, 31 
edema of, 21, 31, 1288 
diurnal variations in, 15 
in nephritis, 263 
inflammation of, 31 
swelling of, 1138 
Eyes, artificial, 1221 

changes in. tabetic, 1221 
deviation of, 1232 
dry or moist, 32 

ecchymoses of, and apoplexy, 1228 
examination of, in bed patients. 1229 
fundus changes in, 1222, 1224, 1226 
illumination of, 1228 
image of, inverted, 1229 
in case of coma, 80 
in the anemias, 147 
inflammation of, simulated, 1296 
inspection of, 31 
irregularities in, 1220 
left, central artery of, 1222 
vein of, 1222 

embolism of, 1222 

thrombosis of, 1222 
motor nerves of, 1230 
muscles of, 1230 
nystagmoid movements of. 1235 
pain in, 1035 
puffy, 31, 1288 
pupillary shadow from, 122S 
pupils of, contraction of, 1221 
reflexes of, 1220 

of, light and accommodation, 1221 
refraction in, 1230 

errors of, 1229 
tests of, 1 23 1 

candle, 1232 



Face, bites of, animal, 1124 

deformity of, 1 1 1 8 

expression of, 12, 288, 1211, 1234 
in gastric carcinoma, 12 
loss of, 12 1 1 

florid, 17 

moon-shaped, 178 

tremor of, 45, 46 
Facial hemiatrophy, 1269 

nerve, 1233 

paralysis, 1233 

in apoplexy, 1247, 1248 
Facies, adenoid, 340 

asphyxial, in chlorine gas poisoning. 34S 

cachectic, 266 

Hippocratic, 956, 960 

hysteric, 81 

leontine, 1121 

of ankylostomiasis, 1139 

of angina pectoris, 769 

of. carcinoma, 929 

of heart disease, 433 

of myocarditis, 666 

of pellagra, 1290 

of scarlet fever, 1070 

of spasmodic asthma, 359 

of typhus fever, 105 1 



Facies of yellow fever, 1036 
renal. 263 
subicteric, 435 
wizened, senile, nil 
Fag, brain, 94, 102, 1179 

psychic vs. physical, 102 
Faget's sign, 1037 
Fahrenheit scale, 1308 
Faintness, feeling of, 911 
Fall a cause of coma, 79 
Falling to floor, 1246 
Falta on acromegaly, 184 

on pancreatic hormone, 1164 
Familial diseases, 1265 

angio-neurotic edema, 1270 
hemophilia, 69, 169, 170 
muscular atrophy, 1265 

dystrophy, 1265 
myotonia, 1266 
splenomegaly, 155 
transient paralysis, 1269 
Families, short- vs. long-lived, 68 
Family history, 67 
Faradic current, 1200 
excitability, 1200 
Farcy, acute, 1127 

buds, 1 127 
Fasciola hepatica, 1133 
Fasciolopsis buskii, 1134 
Fat-bearing casts, 241 
Fat belly, 804 

excessive, danger of, 187 
in feces, 877, 939, 941 
in sputum, 331 
in urine, tests for, 196 
nodules, 188 
people, short life of, 188 
Fatigue a cause of nephritis, 255 
chronic, 1162 
drowsiness, 59 7 
extreme, 665 

after usual exercise, 895 
from everyday tasks, 640 
gait due to, 53 

in heart disease. 629, 630, 631 
neuroses, 63, 342 
psychic, 1 1 83 
toxins of, 630 
Fats, digestion of, 857 
Fatty acid crystals, 331 
casts, 241, 242 

cirrhotic liver, diagnosis of, 972 
degeneration of the heart, 671 
Fatty degeneration of the heart, distinguished 
from fatty overgrowth, 671 
symptoms of, 671 
of viscera, 153 
deposits, 188 

conditions which invite, 668 
heart, hypertrophy of, 669 
in glutton and sot, 671 
loss of weight in, 670 
obscure and advanced, 670 
physical signs of, 670 
prognosis of, 670 
roentgenography of, 586 
symptoms of, 670 
with arterial hypertension, 670 
with gross decompensation, 670 



i 3 86 



GENERAL INDEX 



Fatty heart with nephritis, 670 

infiltration, 785 

overgrowth of heart, 668, 785 
"Fatty tail." cardiac, 758. 785 
Faught's formula, 478 
Febricula, 72 

Fecal accumulation, etiology of, 952 
hospital cases of, 95 2 

impaction, 815, 816 
channeled. 88 
massive, 950 

masses, retention of, 942 
stony, 815 

organisms, 877 
Feces, abnormal findings in, 938 

blood in, 875. 938 

color of, 938 

concretions in, 839 

emulsifying of, 946 

entamebag in, 947 

examination of, 937 
chemical, 941 
macroscopic, 940 
microscopic, 939, 940 
Schmidt's method, 940 
Steele's method, 940 

findings in, 940, 941 

form of, 938 

in pyloric carcinoma. 877 

normal content of, 938 

reaction of, 941 

specimen of, collection of, 939 

tests of, results obtained by, 941 
Feeding, duodenal, 853 
Feet, burning pain in, 1270 

elephantiasis of, 1142 

pudgy, 178 

soles of, desiccating. 1098 
Fehling's solution, objections to. 225 

test, 224 
Feigned states, commoner, 1293 
Femoral triangle, enlarged glands in, 43 
Fenwick, views of, on achylia. 884 
Ferment deficiency in gout, 212 
Fermentation acids, 862 

albumin, 941 

by bacteria. 857 

processes, 878 

sizzling or fizzing of, 833 

test, 941 
Ferments, digestive. 852 

in gastric contents of carcinoma. 933 
Fermillac-bismuth meal, 834 
Festinant gait, 53, 1276 
Fetal life, septal defects in, 732 
Fetus, leprosy in, 11 19 
Fever a cause of constipation, 952 

absence of, in disease, 74 

African tick, 1049 

agonal, 73 

and ague, 104s 

ante-mortem rise or fall of. 388 

as a symptom, 71 

black, 1059 

break bone, 1034 

causes of, 74 

cessation of, abrupt, 78 

correspondence of pulse with. 675 

crises, repeated, 79 



Fever, differential value of. 74 

elephantoid, 1142 

ephemeral, 72 

fall of blood pressure in, 484 

famine, 1049 

fastigium, 74. ?6 

Gibraltar, 1053 

glandular, 1058 

hectic, 73, 152 

in hysteria, 73 

intermittent, 73, 74 

irregular, 73 

jail, 105 1 

malarial, 1037 

malignant purpuric, 1079 

Malta, 1155 

of infection, 269 

of inundated lands, 1058 

petechial, 1079 

phenomena of, 75 

quotidian, 1041 

recession of, gradual, 78 

recurrent, 678 

relapsing, 1049 

remittent, 73, 74 

remittent, in broncho-pneumonia, 396 

sand-fly, 1059 

scarlet, 1069 

seven- day, 1049 

ship, 105 1 

simple continued, 1012 

simulation of, 1296 

spotted, 1055 

sthenic vs. asthenic, 76, 484 

thermic, 1283 

trench, 1065 

trypanosome, 1145 

types of, 73 

typhoid, 1000 

typhus, 105 1 

undulant, 1053 

yellow, 1035 
'Fibers, cilio-spinal, 1237 
Fibrillation, auricular, 551. 552, 554 

indicated in electrocardiogram, 529. 532, 551, 
552 
in polygram, 510, 55*. 552 

pulse in, 552 
Fibrin in blood, 114 

masses in sputum, 330 
Fibrinous casts, 241, 242 
Fibrinuria, 196 
Fibroid phthisis, 423 
Fibromata of brain, 1242 
Fibrosis interfascicular, 669 

and tuberculosis, 319. 320 

pulmonium, 583 
Field mice as carriers of contagium. 1058 
Fifth disease, 1073 
Filaria Bancrofti, 25, 1141 
diurna, 1140, 1142 
loa and perstans, 1141 
medinensis, 1142, 1143 
nocturna, 1140, 1141 
Filaria, sanguinis hominis, 25 
chyluria a sign of, 196 
Filariasis, forms of, 1140 
Filator-Duke's disease, 1073 
Filling defect, 918 
/ 



GENERAL INDEX 



1387 



Filling in stomach, 836, 837, 838 
Filth disease, 1032, 1040 
Filtration in kidneys, 189 
Finger-nails, cyanotic, 16, 390 

ulceration of. 41 
Fingers, abduction and adduction of. 1217 
clubbing of, 736 
cold or dead, 41 
drumstick, 353 
flexion of, 121 7 
gangrene of, 1270 
of equal length, 189 
rigidity of, 1270 
Fireman, valvular lesions in. 748 
Fish poisoning, 1288 

raw, in beri-beri, 1291 
tapeworm, 1135 
Fissures, interlobar, 278 
of tongue, 37 
syphilitic, 1109 
Fistula, anal, simulated, 1296 
recto-vesical, 193 
through chest wall, 374 
Fitness, physical, 654 
Fixation of complement, 142 
of dried preparation, 114 
Flagellata, 1132 
Flask profile, 783 
Flat-foot, 99. 12 18 

in malingerers, 1292 
Flatness on percussion, 292, 301 
Flatulence, 78s, 871, 977 
Fleas as intermediary hosts, 1058 

"jigger," 1 148 
Fleischl's hemoglobinometer, 117, 118 
Flexion, impaired, 12 17 

with hyperextension, 12 18 
Flexner and Strong, dysenteric forms of, 949 
Flexneria noguchii, 1089 

virulence of, 1089 
Flexner's serum treatment, 108 1 
Flickering, fibrillary, 551 
Flies, diseases caused by, 1148 
larva? of, 1148 
tsetse, 1 145, 1 146 
Flint murmur, 720, 744 
Flood fever. 1058 

mortality in, 1058 
symptoms of, 1058 
ulcers of, 1058 
Fluctuation wave, 24 
Fluids, regurgitation of, through nose, 1237 

serous, removal of, 368 
Flukes, 1 133 

lancet, 1134 
Fluoroscope, examination by, 314, 698 
of stomach, 823, 834 
in pericarditis, 783, 798 
in pneumothorax, 380 
in pulmonary insufficiency, 732 
Fluoroscopic fields, brightness of, 326 

screen, 314, 571 
Fluoroscopy in dilatation of stomach, 899 
in displacement of apex beat, 438 
in hour-glass contraction, 901 
in pleuritic adhesions, 375 
in tuberculosis, 411, 418 
intrathoracic, 314 
Flushing of face, 80, 389 



Flushing, unilateral, 17 
Flutter, auricular, 555 

indicated in electrocardiogram, 539 
in polygram. 512 
Focal infections, cryptogenctic, 782 
Folin's urea technic, 203 
Follicular stomatitis, 35 

tonsillitis, 1075 
Fontanelles, bulging, 30 
persistent, 11 75 
posterior, closing of, 30 
Fonticulus gutturis, 447 
Food, concentric movement of, 885 
detritus, 877 

microscopic findings in, 877 
ingestion of, pain in relation to, 932, 935 
liquid, 890 
loathing of, 934 
poisoning, 1288 

regurgitated through nose, 12 15 
residue, 877. 892, 938 

ancient, 900 
retention, 914 
period, 852 
sensitization in asthma, 356 
stagnation, 882 
Fools, attitude toward, 10 
Foot, abduction of, 12 18 
Foot-and-mouth disease, 1057 
-drop, 52, 1218, 1268 
extension, deficient, 12 18 
fistulas of, multiple, 11 29 
perforating ulcer of, 1255 
sensory nerves in, 1205 
Foramen ovale, closed, 736 
patent. 734. 738 
murmurs in, 739 
Forearm, atrophy of, 12 16 
Foreign bodies in bronchi, 321, 350 
in heart, 802 
in intestines, 88 
in nose, 337 
in rectum, 949 
in sputum, 330 
Formaldehyde, poisoning by, 1305 
Formication, 101 
Fourth disease, 1073 
castor oil in, 1073 
rash in, 1073 
Fractures, simulated, 1297 
"Frambcesia," 11 12 
Frankel's diplococcus pneumoniae, 383 

-Weichselbaum diplococcus pneumoniae, 383 
Fremitus, deductions concerning, 289 
diminished or increased, 289 
in broncho-pneumonia. 397 
in pulmonary congestion, 401 
laws of, 288 
"rhonchal," 288 
right and left, 288 
"tussive," 288 
"stenotic," 288 
variations in, bilateral, 289 

normal, 288 
vocal, 288, 353 
Friction fremitus, 788 

murmurs, crescendo and decrescendo, 789 
pericardial, 786 
inconstancy of, 789 



1388 



GENERAL INDEX 



Friction, perihepatic, 873 

peritoneal, 963, 966 
Friction, pleuro-pericardial, 313, 410, 794 
"Friction redux," 788 
rub, pericardial, 788 
sounds, 311 
causes of, 312 
distinctive features of, 313 
in broncho-pneumonia, 397 
in liver, 811 
in pericardial effusion, 798 

genesis of, 793 
pleuro-pericardial, 789 
variants, 369 
Friedlander's pneumobacillus, 383 
Friedreich's ataxia, 1256, 1257 

phenomenon, 298 
Fright a cause of dilatation of the heart, 98 
Frog-face, 13 
Frolich's syndrome, 189 
Frontal sinuses, transillumination of, 338 
Frontalis, action of, 1231 
" Fruity" breath, 34, 82 
Fuchs-Rosenthal counting chamber, 1243 
Fuld, edestin method of, 862 
Fuller's earth and bilirubin test, 854 
Functional inadequacy, 889 
Fundus of eye, changes in, 263, 1224 
Fungi, disease-producing, 11 27 

in urine, 236 
Furuncle on neck, 994 
Furuncular diathesis, 12 



Gabbett's method, 144, 332, 333 

solution and stain, 333 
Gagging, 853 

on passing stomach-tube, 851 
Gairdner's coin test, 309 
Gait, 49 

ataxic, 1207, 1255, 1256 
in various diseases, 52 
reeling, 53 
choreic, 52 
cross-legged, 52 
dromedary, 53 
drunken, 53, 1207 
examination of, 51 
festinant, 53, 1276 
hemiplegic, 1248 
high action, 52 
in myotonia, 1266 
limping, 51 
mowing, 52 
prancing, 52, 1268 
shuffling, of senility, 52 
spastic, 52, 1257 
stumbling, 12 12 
waddling, 12 18 
Galambro's bimanual technic, 804 
Gall-bladder, absence of, 965 
carcinoma of, 977 
diseases of, 975 
chronic, 870 
simulated, 645 
distention of, 977 
empyema of, 979 
enlargement of, 979 



Gall-bladder, lesion, sign of, 836 
palpable, 979 
percussion outline of, 808 
perforation of, 10 12 
position of, 809 
roentgen study of, 849 
tenderness of, 977 
tumors, 811, 819 
typhoid bacillus in, 1002 
-stone colic, 86, 956 
with chill, 979 
-stones among spinsters, 977 

and carcinoma, concurrence of, 977 

ball-valve, 978 

constituents of, 977 

crepitation from, 811 

findings at autopsy, 977 

followed by toxic heart, 645 

form, number and size of, 977 

frequency of, 977 

in cholecystitis, 976 

in common and cystic ducts, 979 

simulated by gastric ulcer, 910 

by intestinal obstruction, 806 
structure of, 977 
Gallop rhythm, presystolic, 448 

protodiastolic, 445, 448, 698 
Galvanic current, 1200 
Galvanometer, string, 517, 518 
Gametes, 1043 
Gametocytes, 1042, 1047 
Gander cough, 775 
Ganglion cells, 11 85 
Gangosa as form of yaws, 11 16 

treatment of, antisyphilitic, 11 17 
Gangrene in a drug habitue, 33 
in children, 1270 
in ergotism, 1289 
pulmonary, 420 

differentiation of, 326, 421 
sputum in, 329, 331 
simulated, 1295 
symmetrical, 1270 
without organic cause, 1270 
Gangrenous stomatitis, 36 
Garland's angle, 365 
Garrod's thread test, 1173 
Garrulity, check on, 71 
Gartner's tonometer, 472 

Gas, chlorine, a cause of obliterative bronchiolitis, 
347 
distention by, 949 
emboli, 1239 
formation, excessive, 872 
masks, 348 

on the stomach, 654, 834, 838 
poisoning, trench, 348 
Gaskell's bridge, 465, 466, 467, 468, 564, 565 
"Gassing," chlorine, 348 
Gastralgia, 85, 879 
Gastrectasia, 823 
Gastric acidity, normal, 867 
rise and fall of, 857 
anacidity, 933 
area, palpation of, 831 
atony, 832, 885 
atrophy, 161 

true, stomach contents in, 862 
capacity, bets on, 898 



GENERAL INDEX 



1389 



Gastric carcinoma, stenotic, 878 
catarrh, acute, 90s 
chronic, 90s 
obscure, 905 
secondary, 906 
carcinoma, 930 
Gastric carcinoma, absence of HC1 in, 933 
age and sex incidence in, 930 
at age of fifteen, 930 
chemical findings in, 933 
"chill and fever" in, 932 
diagnosis of, 934 
absolute, 935 
differential, 934 
early, 934. 935 
etiology of, 930 
exploratory incision in, 93s 
facial expression in, 933 
microscopic findings in, 933 
pain in, 93s 

persistent, 931, 932 
sites for, 932 
stomach contents in, 933 
symptoms of, 931. 934 

diagnostic, 934 
treatment of, antiluetic, 935 
tumor of, 933 
vomiting in, 932 
X-ray examination in, 935 
catarrh, chronic, morning regurgitations in, 

906 
contents, acidity of, 836 
bile in, 900 
blood in, 932 
discharge of, timely, 858 
examination of, 856 
in chronic ulcer, 915 
in congenital asthenia, 897 
odor of, alcoholic, 860 
"bready," 860 
like rancid butter, 860 
vile. 899 
propulsion of, effective, 858 
residual, 899 
tests of, chemical, 860 
qualitative, 860 
crises, 867, 899, 93s, 1236 
digestion, phenomena of, 857 
diseases, case history in, 857 

diagnosis of, 834 
erosions, 926 

absence of hydrochloric acid in, 930 
differentiation of, 926 
operation for, 929 
pain of, 930 
simulating ulcers, 930 
stomach washings in, 930 
symptoms of, 930 
treatment of, 926 
evacuation, delayed, 841 
ferments, absence of, 938 
gas content, 581 
hyperesthesia, 879, 926 
hypertonus, 844 
intolerance, 844 
lesion, post-pyloric, 907 
motility, determination of, 857 

test of, 858 
mucosa, hyperesthesia of, 868 



Gastric neuroses, combined, 893 

relief of pain in, 914 
residue, 841, 844, 858 

12 hour, 918 

in duodenal ulcer, 846 

in various diseases, 847 
resonance, areas of, 833 
secretions and digestion, 851 
spasm, 878 
stagnation, 878 
stasis, vomitus in, 874 
subacidity, 933 

tests, chemical and instrumental, 860 
tetany, 900 
tympany, 832 
ulcer, 841, 867, 804 

acidity in, 913 

acute, 909, 910 

adhesions in, 909 

age and sex incidence in, 907 

area of tenderness in, 911 

chronic, 909, 914 
lesion of, 918 

colic from, 87 

diagnosis of, basic principles of, 920 
devices for, 913 
differential, 920 
mistaken, 929 

effect of alkalies in, 921 
of oil in, 921 

etiology of, 907 

exsanguination in, 451 

HC1 in, 934 

healing of, 909 

hematemesis in, fatal, 912 

hemorrhage in, 912, 914, 929, 934 

hyperacidity in, 927 

insidious, 910 

location of, j 909 

malignant Change in, 931 

morbid anatomy of, 908 

multiple form of, 908, 909, 929 

non-recognition of, 926 

obstructive, 928 

on lesser curvature, 912 

operative cases of, 929 

pain in, 870, 910, 934 
relief of, 914 
typical, 911 

pathology of, 908 

perforation of, 840, 909, 929, 957 
complete, 926 

peristalsis in, 921 

postpyloric, 958 

predisposing factors in, 908 

radiography in, 916 

recurrent, 909 

scar of, 899 

simulation of, 879 

statistics of, 908 

stools in, 912 

string and bucket test in, 913 

subacute, 910, 917 

surface irritability in, 921 

symptoms of, classic, 915 

tenderness in, 870 

tumor in, 934 

varieties of, 908 

with low HC1, 929 



1390 



GENERAL INDEX 



Gastric wall, observation of, 834 
Gastritis, acid, 906 

as a dubious condition, 906 
diagnosis of, differential, 906 
prognosis in, 906 

acute, glandularis, 90s 
symptoms of, 90s 
toxic, 90s 

atrophic. 883, 932 

catarrhal, stomach contents in, 860 

chronic, 905 

differentiated from achylia, 883 

from carcinoma, 934 
hypertrophic, 906 

phlegmonous, 905 
Gastro-diaphany, 823 

-duodenal ulcer simulating biliary colic, 97S 

-enteric diseases, 395 

-enterostomy followed by ulcer, 846 

-intestinal disorders from venous stasis, 70s 
disturbances in the anemias, 14s 
symptoms, prominent, 870 
tract in cardiovascular insufficiency, 648 
roentgenology of, 834 
Gastroptosis, 824, 884 

and cardioptosis, concurrence of, 892 

associated with drop heart, 267, 679, 884 

fish-hook type, 884, 887, 892 

frequency of, 833 

in mitral stenosis, 695 

milder cases of, 891 

passage of stomach tube in, 850 

position in, after meals, 885 

proper, 887 

"steerhorn" type, 884, 887, 892 

symptomless, 381 

with "drop" heart, 601, 60s, 607 

with pyloric spasm, 268 

without marked atony, 894 
Gastroscope, 824 

dangers in use of, 827 

Eisner's, 828, 829 

in exploration of stomach, 826 

passage of, blocked, 827 
Gastroscopic field, 827 
Gastroscopy, anesthesia in, full, 829 

delicacy of technic in, 827 
Gastro-succorrhea, 900 
Gastroxynsis, nervous, 869 
Gaucher's disease, 155 
Gelsemium poisoning, 1305 
Genitals, elephantiasis of, 1144 

excoriations of, 1109 

external, worms on, 1138 
Geographic tongue, 38 
Gerhardt's sign, 299 
Gerlier's disease, 1270 
German measles, 1072 

temperature in, 77 
Gersuny's "adhesiveness sign," 816 
Giant cells in pulmonary tuberculosis, 402 
Giants, acromegalic, 187 

eunuchoid, 187 

length of life of, 57 
Gibraltar fever, 1053 
Giddiness, 103 
Giemsa stain, 115, 1045 
Gigantism, 184 
Gilles de la Tourette's disease, 1275 



Gin drinker's liver, 969 
Gingival "lead line," 87 
Girdle sensation, 100 
Girls, asthenic, 43 
Girth, maximum, 285 
Glanders, acute, 1126 

chronic, 11 27 

complement fixation test in, 98$ 
Glands, ductless, changes in, no 
diseases of, no 

enlargement of, 43, 158, 1058 
in diphtheria, 1075 
differentiation of, 160 
in Hodgkin's disease, 164, 165 

in sleeping sickness, 1145 

lymphatic, 158 

mediastinal, pressure from, 166 

of internal secretion, diseases of, 173 

peribronchial, swollen, 314 

pituitary, 184 

tuberculous, 29 
Glandular fever, 1058 
Glaucoma, 1226 

in nephritis, 263 
Glenard's disease, 953 
Gliomata of brain, 1242, 1244 
Gliosis spinalis, 1259 
Globoid bodies, 1089 
Globulin in spinal fluid, 1082 

test, 1082 
Globus hystericus, 102, 642, 897 
Glomerulonephritis, acute focal, 258 
Glossina morsitans and palpalis, 114S. 114* 
Glottic chink, tumors below, 107 
Glottis, closure of, 326 

edema of, 257, 343 
suffocation from, 343 
treatment of, 343 

paralysis of, 310 

proximity to, 301 

spasm of, 106, 1 126 
Glucose in urine, 224, 1164 

quantitative estimation of, 226 

substitute for diabetics, 227 

test for, 224, 225, 226 
Gluteal reflex, 1196 
Glutton, cardiac insufficiency of, 671 
Glycemia, 1167 
Glycosuria, 1163 

age and heredity in, 1168 

alimentary, 179 

arthritic, 1165 

clinical, 1164 

experimental, 1164 

gouty, 1 1 73 

in children, 1168 

intermittent, 1164 

prognosis in, 1168 

simple, 1 165 

test of, 1 165 

urine in, specific gravity of, 1168 

with cirrhosis of liver, 971 
Glycuronic acid, 228 
Gmelin's test, 942 

Gnat, transmission of infection by, 1058 
"Goat droppings," 938, 952 
Goat's milk as a germ carrier, 1053 
Goetsch's test, 181 
Goiter, exophthalmic, 32 



CENERAL INDEX 



1391 



Goiter, heart, dyspneic, 183 
Goldscheider's percussion, 441. 443 
Goll's tract, 1188 
Gonococcus'in th<? urine, 24.4 

infection, 989 
Gonorrhea, feigned, 1300 
Gonorrheal arthritis, 1155 

polyarticular, 1158 
Gordon's blood pressure table, 476 

reflex, 1196 
Gorgajew-Pappenheim counting chamber. 129, 

134 
Goundu due to yaws, 11 17 
Gout, 1 169 

acute, 44, 74, 1172, 1 173 

age incidence of, 11 70 

an aristocratic ailment, 11 74 

and a wine cellar, 11 70 

and extrasystolic irregularity, 550 

cause of, obscure, 212 

chronic, n 74 

changes in, permanent, 1171 
clinical signs of, 74, 11 72 
diabetic, 11 73 
effect of climate on, 1171 
etiology of, 1169 
exciting causes of, 11 73 
factors in, essential, 1171 
habits a cause of, 11 70 
hereditary, 69, n 69 
in diabetes, 1165 
in Great Britain, 1170 
in the joints, 44, 1172 
irregular, n 74, 11 75 
larval, 1172, 1175 
symptoms of, bizarre, 11 75 
juvenile, 11 70 

lesions in, cardiovascular, 11 73 
leukocytosis in, 11 73 
occupations predisposing to, 1171 
pain in, n 72 
poor man's, 1171 
retrocedent, 11 73 
symptoms of, cerebral, 11 74 

classical, 1172 
tophi of, 33, 1 172, 1 1 74 
transmission of, 11 70 
uremic, n 74 
uric acid in, 211, 212 
Gower's disease, 1256 

hemoglobinometer, 118 
muscular atrophy, 1265 
tract, 1 188 
Graefe's sign, 181 
Grains, microorganisms on, 425 
Gram's stain, 24s 
Granules in the blood cells, 125 
Granulomata, coccidioidal, 1128, n 29 
infective, 164, 1126, 1130 
malignant, 164 

syphilitic and tuberculous, 167 
ulcerating, 11 12 
Grape-sugar, 1163 
Grasses, microorganisms on, 425 
Grasset's sign, 1197 
Graupner. cardiac test of, 636 
Gravel, simulation of, 1296 
Graves' disease, 180, 744 i 
Gravity-edema, 701 



Greatpox ( syphilis), 1093 
Grippe, la, 1015 

Grocco-Koranyi paravertebral triangle, 294. 367 
Groin scars, 29 
Ground ailments. 70 
Growing pains, 5, 1093 
Growths, gastric, shape of, 824 
malignant, mediastinal, 781 
of the lung, 421 
of the pleura, 422 
new, of the heart, 802 

tenderness of, 816 
pleural, 366 
pyloric, 822 

vascular, with pulsation, 781 
Guarnieri, bodies or corpuscles, 993, 1094 

lacking in varicella, 1103 
Guinea-pigs, inoculation of, 1084 
sensitization in, 993 
serum from, 984, 98s. 986 
-worm disease, 1143 
Gummata, cutaneous, 11 10 
of brain, 1242 
of larynx, 344 
of liver, 811, 973 
renal, 271 

syphilitic, 424, 8n, 973, 1107, rno 
Gums, bleeding, 38, 1037 

diseases of, relation of to general ailments, 38 
in scurvy, 172 
line on, blue, 1287 

bluish-gray, 38 
painful in angina, 642 
Gunzberg's test, 861 
Gurgling, intestinal, 951 
Gyromele, Tiirck's, 823 



H 



Habits in relation to occupation, 64 

of patient, inquiry into, 60, 937 
Habituation, importance of, 664 

physical, 654 
Habitus phthisicus, 403, 404 
Haines' test for glucose, 224, 225 
Hair, brittle or falling, 1060 
Hairy tongue, 37 
Hallucinations, 1201 

alcoholic, 1085, 1286 

in meningitis, 1085 

of hearing, 1272 

of smell, 1220 
Hamburg, cholera in, 1031 
Handling, patient's fear of, 50 
Hands, burning pain in, 1270 

callosities on, 66 

claw, 1219, 1264 

pudgy, 178 

Simian, 12 17 

suggestive information from, 40 

trident, 41, 189 

wasting of, 41 
Handshake, indications of, 40 
"Hanging-drop" heart, 625, 628, 633 

method, 1008 
"Hanging" heart, 598 
Hanot's cirrhosis, 969. 972 
Harrison's grooves, 283, 399 
Harvard Expedition, 1062 



1392 



GENERAL INDEX 



Harvey's demonstrations. 4 
Havana, yellow fever, in, 1036 
"Hawking," 339 
Haycraft's test for bile, 224 
Hayem's solution. 129. 136 
Hayfever, specific sensitization to, 992 

symptoms of, 336 
Haygarth's nodosities, 1156 
Head, abnormalities of, 30 

flexion and rotation of. 1 2 1 5 

listless rolling of. 435 

rhythmic nodding of. _ _ 

tenderness of, 100 

tetanus of. 11 26 

tumors of, 30 
Headache, anemic. 91 

antrum of Highmore, 92 

i?:henic. 94 

bilious. 91 

consideration of, 90 

drug, 92 

ethmoidal, 92 

feigned, 1297 

frontal sinus. 91 

in arteriosclerosis. 92 

in brain tumor, and abscess. 91 

in middle-aged women. 93 

in pneumonia, 389 

misleading, in the anemias. 146 

of nephritis, 92 

periodicity in, 93 

psycha theme, 94 

sick, 92 

sinus, mistaken diagnosis of ; : 

sphenoidal sinus, 92 

temporal, 92 

::xemi; ;: 

uremic, 92 
Hearing, cortical center for. 1209. 1234 

Z2Z2 

tests of. 1232, 1234 
"Hearsay evidence," 11 
Heart, "action current" of. 506. 518. 519 
anatomic structure :: _ _ : 
and blood-vessels, diseases of, 586 

associated with syphilis, 586 

diagnosis of. 586 

pro'h^ri; in, 586 
aneurysm of. 802 
as a double pump, 455 
asthenic, 656 
atrio- ventricular bun i 
atrophy of. 669 
auscultation of. areas for, 449 
base, silhouette of, 574 
beat, absence of 5 _ 

determined by auscultation. 490 

number of, 463 

precocious, untimely -_ 

rapid, 561 

rhythmic. 559 

restored post-mortem. 465 
block, 514- 531. 543. 552 55* 

age periods in, 565 

and dissociation. 511, 566 

■-.-.' :- : .i^-iz~.. - \- 

branch 53 

complete, 466. 531, 564, 569 

:■: r. 1::: :. :\- : : ; --iz : .--~ ::' - : : 



Heart, block, death from. 565. 570 

digitalis, 564 

indicated in electrocardiogram, 531, 526 
533. 364. 567 
in polygram, 511, 566 

in pericarditis, 787 

intraventricular, 567 

latent, 570 

murmurs in, 685 

of mitral stenosis, 569 

partial, 466, 531, 565. 69S. - - 

physiologic, 559 

prognosis in, 570 

pulse in, 491 

recognition of, 567 

sex in, 565 

simultaneous systoles in. 569 

sino-auricular, 534, 564 

true, 565 

unilateral, 448 

unmasking of, 570 

vagus, 564 
"bob-tail," 586 
borders of, 427, 428, 439, 574 

changes in, 574, 575 
borders of, determination of. 638 

extended to left, 442 

hidden by sternum, 603 

u:rm=l. J.-Z. 444 

percussion of, 443 

recession of, 598. 662 
bulging of, 438, 440 
bullet wounds of, S02 
-burn, 102 

capacity of, for work, 463 
case, hopeless, abandoned, 652 
cells, contractility of, 464 

powers of, 464 

rhythmic chemical processes in, 464, 465 

stimulus production in. 464 

circumference of, ratio of diameter to, 638 
claudication of, 768 
conduction time, 468, 469 
configuration of, 717 

of, in aortic stenosis. 724 
contours of, puzzling, 601 
contractility of, failure of, 592 
contractions, 551 

conduction time of, 469 

coordinate, 466 

excessively rapid, 555 

extrasystolic, 543 

frustrated. 544 

intervals in, 466 

myogenic theory of, 464 

pause in, compensatory. 543, 548 

persistent, 550 

phases of. 521 

premature, 469. 543. 544. 545. 550 

rapid. 449 

refractors r _~ 
coordination of function in, 470 
crises, minor. 641 
currents, registration of, 518 
cycle, 545- 549 

compensatory pause in 

events of, 520 

normal, 546, 553 1 



GENERAL INDEX 



!393 



Heart, cycle, phases of, 504 

rest periods in, 545 
decompensation, 354 
degeneration of, fatty, 668 
demands of, 464 
diameters of, 428, 429, 430 

by radiograph, 594 

reduction of, 637 
dilatation of, 182, 432 

acute, 401, 638, 646 
in robust man, 654 

extreme, 667 • 

from fright, 98 

general, 586, 782 

massive, 666 

morbid, 592 

obligatory, 591 

residual post-operative, 182 

subacute, 638 

universal, 636 

wide, in an athlete, 621 

without murmurs, 636 
dilated, laboring, 643 
dimensions of, normal, 593, 594 
diseases of, amelioration of symptoms in, 638 

associated with dilatations, 639 

basic factors in, 462 

brown sputum in, 329 

chronic, 652 

congenital with acquired, 545 

danger signals in, 625 

diagnosis of, early, 632, 652 
limitations in, 589 

emotional strain in, 639 

factors in, extracardial, 641 
multiple, 641 

in author's clinic, 555 

in scarlet fever, 1071 

"indigestion" in, 642 

inspection in, 433 

management of, 634 

nomenclature of, 470 

physical exertion in, 639 

possibilities in, 590 

retardation of, 634 

simulated, 1297 

stimulation in, 639 

symptoms of, deceptive localization of, 640 
major, 625 
subjective, 639 

therapeutic initiative in, 625 
objective in, 471 

treatment of, 631, 653 

unusual effort in, 640 
displacement of, 323, 440, 802* 

by hypertrophied lung, 380 

by pleural effusion, 802 

rhythmic lateral, 368 

sounds indicative of, 446 

to left, 366 

to opposite side, 365 

vs. enlargement, 440 

"drop," 148, 267, 380, 431, 434, 404. 572, 
594 

and tuberculosis, 320, 404 

in a heavy woman, 622 

or pendulum. 572 

vascular tonus in, 482 
dulness, 293 



f 



Heast, elliptic type of, 581 

embryonic, automatism of, 465 
enlargement of, universal, 785 
enormous, 579 

absence of murmur in, 11 76 
examination of, 427, 439 
excessive slowness of, 491 
explosions of energy in, 464, 465 
failure, progressive, 795 

right, 670 
fatty, 586, 668, 781 

degeneration of, 631, 671 

infiltration of, 631 

overgrowth of, 668, 669 
fiber conduction in, 465 
fibers, naked, 465 
flutter, 492 
foreign bodies in, 8.02 
habituated to burden, 665 
"hanging," 598 
height and size of, 428, 429 
hyperesthesia of, 440 
hypertrophy of, 436, 628, 637 

left, 438 
hypoplasia of, 175 
impulse, 368, 55 1 

course of, 468 

transmission of, 551 
in athletes, 592, 654, 892 
in diastole, 457 

in infections, examination of, 76 
in inspiratory phase, 431 
in pneumonia, 325 

in relation to anterior thoracic wall, 432 
in soldiers, 429, 431 
in the healthy and robust, 431 
increase of strength in, 592 
independence of, 469 
infantile type, 539 
- inflammatory changes in, 668 
insufficiency of, general, 586 
laboring, 631 
layers of. 524 
leakage of, silent, 446 

small, 718 
left border notches of, 574 

ventricular enlargement of, 580 
lesions, acute, hypotension in, 485 

co-existent, 590 

congenital, 732 

common factors in, 742 

decompensated, 6 

detection of, early, 661 

diagnosis of, 571 
differential, 439 

double, 461 

epigastric distress in, 580 

in typhoid, 1002 

phasic changes in, 590 

preexistent. 664 

prognosis of, 570 

symptoms of, 590 
luetic process in, 586 
measurements, deceptive, 604 

normal, 639 

standard. 429, 430 

transverse, 431, 622 
mental image of, 458 
mobility of, 431 



!394 



GENERAL IXDEX 



Heart, murmurs, 449 

accidental, 450. 453 

definition of. 449 

differentiation of, 450, 461 

in aortic area. 450 

in embolism 1250 

miniature, 546 

misinterpreted. 450 

organic, rationale of, 455 

pleuro-pericardial. 454 

postural modifications of, 450 

presystolic, 451 

pulmonary and apex. 450 

short, 448 

transient, 450 

variations in timbre, 451 
muscle, activity and exposure of, 588 

anatomic alterations of, 590 

as vital point, 589 

degenerated, rupture of, 802 

demands upon, 624 

enfeebled, 449 

impairment of, 76 

irritability of, 580 

relaxation in. 524 

rest periods of, 465 

spirals of, 470 

strain of, 631 

tonus, 469, 592 
defective, 599 

rs. skeletal muscle, 58S 
mushroom, 665 
myogenic conduction in, 466 
neglect of, 676 

nerves of, sympathetic, 469, 470 
new growths of, 802 
normal, in diastole, 457, 688, 708 

in different individuals, 603, 604 

in systole, 679, 703, 722 

powers of, 464, 726 

size of, 593 

strength of, in emergency. 726 
nutrition of, 768 
of congenital asthenia, 598, 651 
of fat male asthenic, 625 
outline of, 432, 601 

decanter-shaped, 789 

in forced expiration, 892 

shrinkage of, 603, 638 

triangular, 581 
overdistention of, 592 
overstrain of, 83, 545, 580, 643 

sign of. 550 
pace-maker of, 466, 544 
palpation of, 439 
pang, 760 

without sclerosis, 755 
percussion of, 439. 440 

area of, 440 

Goldsch eider's, 441 

outlines of, 589 

strokes in, 443 

technic of, 442 
pericardium adherent to. 437 
physiology and pathology of, 497 
position of, changes in, 437. 524, 766 
profile, normal, 574 
pulsations, 436, 438 

paradoxic, right, 745 



""Heart, pumping power of, 464 
rapid, from emotion, 563 
regulation of, marvelous, 470 
residual infiltration in. 784 
response, 460, 462, 625 
test "current" of, 519 
rhythm of, 449 

tic ta^, 561 
right and left, affection of, 679 

chambers of, 712 

decompensation of, 712 

dilatation of, 360. 766 

effect of leakage in, 705 

enlarged, 693 

failing, 705 

hypertrophy of, 766 

in emphysema, 353 

involvement of, 460 

strain on, 698 
roentgenography of, 429, 571 
rupture of, 802 
self-protection of, 593 
shadow, decanter shape, 581 

squat oval shape, 581 
silent, 645, 646, 704 
silhouette, determination of, 427. 57 1 

in nephritis, 586 
size of, 412, 429, 594 

affected by posture, 428 

excessive. 594. 704 

variations in, 429 

"slow," 491 
"small," 428, 573. 601 

and visceroptosis, 601 

of asthenia, 662 
softening of, 668 
soldier's, 607 
sounds, 650 

abnormal, 589 

absence of, 444 

accentuation of, 444 

amphoric, 309 

audibility of, maximum, 447 

blended, 457 

changes in timbre of, 445, 45 1 

division of, 447, 448 

fetal, 446 

first, 444, 457, 458 

characteristic at apex, 691 
impurity of, 704 

in pericardial effusion, 798 

muffled, 446, 650, 704 

murmurish, persistent, 446 

normal, 444, 447, 638 

pulmona*ry and aortic, accented, 444 
second, 692 

quality of, \\<\ 

reduplication of, true, 447, 448 

registration of, 500, 524 

ringing, 446 

second, 448, 457. 458 

split, 448 

-second, 448, 449 

third, 445, 448 

variations in, 638 

watching of, 675 
-spleen residue, 982 
stimulation of, 400 
stimulus production in, 545 



r.KXERAL INDEX 



I 595 



stitches over, 647 

.. acute, 640 
in emphysema. 35- 
in modern warfare, 607, 608 

-■ ^55 
report on. 591 
transient. 591 
strength and body weight. 660 
measure c: 

.y, technic of, 5 J : 
tenderness over or within. 439 

tic.. 518 

tones, abnormal, 666 
at apex and base. - - 

447 
in acrti. insufficiency, 710 
second, clanging, 759 
tonicity of, impaired, 453 592, 624 

loss of. 656 
"too large : 
toxic 646, :_■ 

- tonsil removaJ ,587 
:__re ::'. -47 
mbuemes ur.cn. 54: 
transr. csiticn ::'. congenital - - 
transverse diameter ::'. 45: 
' tnnnz 

$02 
feminine, 892, S95 
valv. 433 

damare to. rheumatic, ::-: 
valvular diseases of , 428 ;*_ 
• entricnlai contraction of, 457 
: : 

: : - : 
Heartburn, 871, 5; a 

Heat exhaustion, 1233, 1284 

sensations of. 102 
Heatstroke. 79 

Heavin; origin, 7_: 

-.odes, 1156 

nod:; fries in gout, ::-_ 
Hebrews, iiabetes am ong, 69 
Hectic fever. 73 

Hedin-Da.a-.i, hema:::rit ::'. 136 
Heel, pain in. 100 
Height and weight, relations of. 56 

standard table ::'. 54, 55 
Heintz s uric add test, 211 
Heller's test, 218, ::: 
Hemameba, 1037 

: : : 
Hematemesis, B74 

deception concerning, 879 

in various diseases. 5 J 

sim - 1297 

; -j. 
Hematc:hy'.uria, ::_: 

; : > 
Hematology, no 
Hematoma amis, 53 

internal mening : 

Hematomyelia, 1239 
Hematoporphyrin, 192 



Hematorrhachis. 1239 
Hematuria. 222. 223 
endemic. 1234 
from tumor of bladder 

1277 
in renal infarct. 270 
Hemianesthesia, 1204 
cortical, 120S 
crossed, 120S 

crical, 120S 
in apoplexy, 124I 
of opposite side. 1213 
with he™:: 
Hernia:::;, da, 1212 

lateral homonymous. 1244 
varieties of, 1223 
Hemiatrophy, facial, 1269 
Hemicrama, 92, 93 
Hemiopia and hemianopia, : a - 
Hemiplegia, brachio-crural. 1213 
complete, 12 12 
crossed, ::cS 
hysteric, 1249 
in case ::" end.::.: rditis _ : 
trans ient :_ ; 
with hemianesthesia, 1208 
Hem: tenia. : :c 

Hemocytometer, 128, 134, 135, 136 
counting chambers. 131 
varieties of, 128, 129, 133, 134 135 
Hemoglobin-erythrocyte ratios, 144 

estimation of, by specific gravity. 117. ng 

directions for, 120 
in anemia 144 

pernicious, 152 
tests for, 116 
Hemoglobinometer, varieties of , 116. 117, 11S. no 
Hemoglobinuria. :::. 223 

and associated conditions. : : 
Hemolysis. o$5 
bacterial, 98 1 
in splenomegaly, 156 
intractable and fatal, 151 
tests for, 854 

negative and positive, 984 
Hemolytic amboceptor, titration of. 985 
resistance. :c: 
system. PS4 
addition ::". f 
efficiency of. 986 
unit. cS: 
Hemophilia, 69, 169 

are ;:: sex in, : - : 
blood examination in ::: 
coagulation time in. 170 
diagnosis of, at birth. 170 
etiology of, 169 
heredity in. 170 
prognosis in, 170 
symptoms ::'. 17c 
Hemcpneumcthcrax. 3-: 
Hem: ctysis _: 7 405 4:1. S75 
in bronchiectasis 
hysterical. 1277 
simulated. 1297 
vs. hematemesis. B74 
?rem:rrbares a cause ::' bypertensi::: _^: 
of low press -re 4I 
:s sior. of nicer, 920 



1396 



GENERAL INDEX 



Hemorrhages, capsulo-ganglionic, 1245 

cerebral, 1245 

concealed, 109 

cutaneous, multiple, 677 

extrameningeal, 1238 

from gastric ulcer, 912 

from lenticulo-striate, 1246, 1247 

from piles, 942 

from stomach, 840, 882 

in chronic ulcer, 914 

in gastric carcinoma, 932 

in hemophilia, 170 

in purpura, 169 

in smallpox, 1097 

in typhoid fever, 1002 

intrameningeal, 1238 

massive, 912, 914 

nasal, 337 

ocular, preceding apoplexy, 1247 

pontine, 1306 

profound, in diphtheria, 1076 

renal, 271 

retinal, 147, 171 

simulated, 1297 

spontaneous, 170 

subcutaneous, 26, 168 

unexplained, in leukemia, 157 

visible, 481, 912, 914 
Hemorrhagic diathesis. 45, 172 
Hemorrhagic infarct, 418 
Hemorrhagic pneumonitis, 395 
Hemorrhoids, etiology of, 942 

internal, 942 

simulated, 1297 
Hemothorax, 362 
Henoch's purpura, 169 
Hepatic area, enlargement of, 966 
percussion of, .293 

dulness, superficial, 810 

flexure, 808 

hyperemia, chronic, 967 

pulsation, direct expansile, 707 
Hepatitis, acute, etiology of, 965 

jaundice in, 965 
Hereditaria tarda, 344 
Hereditary ataxia, 1256 

defects, 11 90 

diabetes, 68, 1165 

disease, 18, 68, 1265 

gout, 69 

jaundice, 18 

predisposition, 1190 

spastic spinal paralysis, 1258 

splenomegaly, 155 

structural defect, 889 

syphilis, 750 
Heredity, alternatives in, 67 

in disease, 69 

cardiovascular, 68 

in hemophilia, 69, 170 

in tuberculosis, 69, 70, 403 

nervous system in, 68 

neuropathic, 1278 
Hernia, diaphragmatic, 382 

differentiated from pneumothorax, 381 

incomplete, 913 

obscure, vomiting of, 873 

pain of, 910 

simulated, 1297 



Hernial openings, 80s 

rings, relaxation of, 873 
weak, 90 
Herpes, 34 

in neuralgia, 94 

in pneumococcus infections. 389 

in pneumonia, 389 

labialis, 406 

in malaria, 1045 
zoster, 1 163 

mistaken for neuralgia, 95 
pain in, 1269 
Herz, cardiac test of, 635 
Hetero-albumoses, 857 
Heterochylia, 870, 882 

in congenital asthenia, 897 
Hiatus esophagus, 827, 902 
Hiccough, agonizing, 108 
causes of, 108 
exhaustion from, 108 
in diabetes, 108 
High living, 17, 971 
Hill diarrhea, 1063 
Hilus region, deceptive, 370 

shadows, 314, 646 
Hip-flexion sign, 1197 
Hippocrates on influenza, 1015 
Hippocratic countenance, 109 

succussion, 312, 379 
His, bundle of, 465, 466, 467, 468, 469, 491, 522, 
534- 552, 564, 56S 
changes in, 567, 570 
extrasystoles from, 548 
impaired conduction of, 567 
on heart action, 465 
Hiss and Russell, "Y" strain of, 949 
History, family, 67 
Hoarseness, 12 15 

chronic or recurrent, 343 
of laryngitis, 344 
Hobby, value of, 66 
Hodgkin's collar, 166 
disease, 51, 164 
■ acute, 166 
blood in, 166 
bronzing in. 167 
diagnosis of, differential, 167 
differentiated from plague, 1034 
dyspnea in, 167, 756 
eosinophilia in, 166 
etiology, 164 
fever in, 166 

glandular enlargement in, 164, 165, 166 
historic note on, 164 
pain in, 167, 756 
picture of, histologic, 164, 165 
pressure symptoms in, 166, 423 
prognosis in, 167 
symptoms of, 166 
synonyms of, 164 
Home, the situation of, 67 
Homicide, self-defense in, 1297 
Homogeneity, structural, 289 
Honesty vs. ignorance and dishonesty, 11 
Honey test. 227 
Hooklets, echinococcic, 968 
Hook-worm disease, 1139 
Hoover's sign, 1197 
Horismascope, 219 



GENERAL INDEX 



1397 



Hormone, pancreatic, 1164 

production, 1163 
Horn cells, anterior, 1191 

ts. posterior, 11 89 
Horse, disease of, 1127 

-power, deficient, 664 
Host, intermediary, 1035 
Hot flashes, 102 
Hour-glass stomach, 840, 841, 901 

operation for, 929 
Housemaid's knee, 63 
Howell's bodies, 128 
Humidity and heat exhaustion, 1284 
Hunchbacks, 282 
Hunger-discomfort, 914 

pain, 868, 897. 912, 958 
in chronic ulcer, 914 

temperature, 74 
Huntington's chorea, differentiation of, 1275 
Hutchinsonian syndrome, 1 1 1 1 

teeth, true, 39 
Hyaline casts, 235 

cylinder showers, 241 

degeneration, 239 
Hydatid cysts, 425, 811, 968, 1136 

disease, 67 

of dogs, 968, 1 136 

thrill, 272, 426, 969 
Hydatids of spleen, 813 

pulmonary, 425' 

symptoms of, general, 969 
Hydremia, in 

in chlorosis, 150 
Hydrocele, simulated, 1298 
Hydrocephalus, 30 

acute, 1086 

congenital, 1241 

cry of, 1083 

in adults, 1242 

in meningitis, 1086 

primary idiopathic, 1086 

simulated by achondroplasia, 189 
Hydrochloric acid, absence of, 862 

content, effects of diet on, 867 

deficit, 866 

determination of, 866 

free and combined, 857 
tests for, 861 

in stomach, diminished, 863 

neutralization of, 866 

percentage, 866 

poisoning, 1302 

secretion, 857 

test for, quantitative, 864 

values, 893, 910, 915 
high, 907 
Hydrocyanic acid poisoning, 1305 
Hydronephrosis, 272 

differentiated from cyst, 271 

etiology of, 273 

intermittent or persistent, 273 

tumors of, fluctuating, 815 
Hydropericardium, 21, 791 
Hydrophobia, 11 24 

carrier of, 11 24 

esophageal spasm in, 904 

hyperesthesia in, 11 24 

imaginary, 1125 

incubation of, 1 124 
86 



Hydrophobia, nervous system in, 11 24, 1125 

pseudo-, 1125 

reflex irritability in, 11 24 

simulated, 1298 

spasm in, 11 24 

terminal stage of, 1125 

tests for, 1 1 24 

virus of, 1 1 24 
Hydropneumothorax, 376 

recovery from, 377. 378 
Hydrothorax, 21, 382 
Hygiene, bad, 147 

Hymenolepis diminuta and nana, 1135 
Hyoscyamus, poisoning by, 1307 
Hypalgesia, 1209 
Hyperacidity in gastric ulcer, 911, 915 

indicated by diarrhea, 881 

of stomach, 860, 863 

simple, 920 
Hyperacusis, 1233, 1234 
Hyperchlorhydria, asthenic cases of 868 

differential diagnosis in, 869 

in gastric ulcer, 841 

proper, 867 

recovery in, 869 

secondary or complicating, 868 

simple, 867 

simulating other conditions, 860 

stomach content in, 868 

symptoms of, 868 
Hyperesthesia, 1204 

and hyperalgesia, 1209 

cutaneous, 955 

gastric, 879, 926 

laryngeal, 1236 

of intestines, 950 

residual, 642 

in angina pectoris, 771 
Hyperidrosis, 20 
Hyperinosis, 115 
Hyperkinesis, 871 
Hypermetropia, 1229 
Hypermnesia, 1201 
Hypernephroma, 271 

age incidence in, 271 
Hypernutrition, 404 
Hyperperistalsis, 845, 922 

gastric, 845 
Hyperpituitarism, 184 
Hyperpyrexia, 72, 73 

in malingerers, 72 

record case of, 73 
Hyperresonance at apex, 416 

diffuse and uniform, 406 

extreme extension of, 379 

in emphysema, 292, 297, 355 

in general miliary tuberculosis, 300, ion 

over lung tissue, 297 

with cyanosis, 300 
Hypersecretion, alimentary, 869, 928 

chief syndromes of, 869 

chronic, 869, 927 

determination of, 927 

gastric, 867 

in chronic ulcer, 915 

periodic recurrent, 870 
Hypersusceptibility, inherited, 992 
Hypertension and life insurance, 477 

arterial, 471 



1398 



GENERAL INDEX 



Hypertension, arterial, of lead poisoning, 478 

cardiorenal, a toxemic manifestation, 486 
conservative effects of, 486 

chronic, increased by excitement. 478 

extreme, significance of, 262 

in apoplexy, 1246 

in nephritis, 256, 262 

misleading, 479 

of pulse, 77 

silent, 262 , 
Hyperthyrea, 183 
Hyperthyroidism, 179 

capillary pulse in, 434 

larval, 11 84 

marked, signs of, 744 

tests of importance, 181 
Hypertrophic biliary cirrhosis, 972 
Hypertrophy, auricular, 682 

cardiac, of single chamber, 725 
true, 669 

in acromegaly, 185 

laggard, 754 

left ventricular, 553 

of heart, 438, 462 

of ventricles, 460, 727 

primary right ventricular, 706 

pseudo-muscular, 1265 

"work," 592 
Hypinosis, 115 

Hypoacidity as excluding gastric ulcer, 913 
Hypoadrenia, congental, 173 
Hypochlorhydria, senile, 883 

in various diseases, 870 
H3-pochondria, 404, 11 79 
Hypodermic punctures, 30, 62 
Hypodermoclysis in poisoning. 1302. 1307 
Hypogastric tenderness, 100 

tumor, 817 
Hypoleucocytosis, 11 1 
Hypophysis, tumor of, 1168 
Hypopituitarism, 187 
Hypostasis, change of posture in, 401 
Hypotension following relief of abdominal pres- 
sure, 484 
Hypotension following removal of pleural effusion, 
484 

in tuberculosis, 482 

persistent, in acute infections, 481 

treatment of, by epinephrin, 481 
Hypothyroidism, 176, 179, 189 
Hysteria, abdominal examination in, 804 

after dog bite, n 25 

age and sex incidence in, 1279 

as a pathological state, 1276 

as a psychoneurosis, 1277 

Charcot's teachings on, 1277 

clavus of, 93 

coma in, 81 

contractions in, 1279 

deafness in, 1235 

diagnosis of, 1280 
mistakes in, 1277 

differentiated from chorea, 1275 
from epilepsy, 1273 
from neurasthenia, 1183 
from strychnin poisoning, 1307 

discipline in, value of, 1278 

diverse views concerning, 1277 

early training in, 1278 



Hysteria, fever in, 73 

gait in, 52 

heredity in, 1278 

in young women, 1279 

phantom tumors in, 817 

phenomena of, 1278 

prognosis of, 1280 

pseudo-ataxia of, 50 

racial tendency to, 1279 

reaction to stimuli in, 1278 

sensations interpreted as. 642 

sexual factors in, 1279 

sign of, 334 

simulated, 1277 
in uremia, 248 

simulating organic disease, 1280 

sputum in, "crushed raspberry." 329 

stigmata of, 1235, 1249, 1277 

sympathy in, harmful. 1278 

symptoms of. 1279, 12S0 
mental, 1280 

temperament in 1278 

traumatic, 1280 

after trivial injury, 1281 
circulatory disturbances in, 1281 
physiognomy in, 1281 
psychical depression in, 1281 

treatment of, surgical, 1280 

vomiting of, 872 

with organic disease, 1279 

zones of, 1209, 1279 
Hysterical seizures, 48 

spastic paraplegia, 1259 
Hystero-epileptic seizures, 1279 



Ice cart drivers as steady drinkers, 671 

fatty heart in, 671 
Ichthyosis, buccal, 38 
"Icterus gravis," fatal, 19 

in splenomegaly, 155 

neonatorum, hereditary, 18 
mild, 19 

progressive, 974 

urobilin, 194 
Idiocy, amaurotic family, 1259 
Idiosyncrasy, 992 

drug, 28 

to tea, coffee, tobacco, 61 
Idleness as a disease breeder, 66 
Ileocecal valve as a barrier, 89 
Ileo-colitis, acute, 948 

dysenteric, 944, 945 
Ileum, location of, 807 

lower, obstruction of, 950 
Iliac fossa, right, tenderness in, 1005 
Illnesses, previous, importance of, 70 
Illusions, 1201 
Immune-opsonins, 982 
Immunity, acquired, 981 

active, 981 

by vaccination, 1101 

doctrine of, present status of. 98© 

Ehrlich's theory of, 9S0 

from malaria, 1038 

natural, 981 

passive, 981 

principles underlying, 980 



GENERAL INDEX 



J 399 



Immunity, production of, 981, 982 

to disease, woman's, 60 
Immunization of animals, 985 
Impactions, channeled, 815 

fecal. 816 
"Impfbohrer" of Von Pirquet. 413 
Impostures, 1291 
Impressions, retinal, 1223 
Impulse conduction, 522, 524 
Impulses, centrifugal, 1186 

centripetal, 11 86 
sensory, 1193 

epigastric, 746 

motor and sensory, 1185, 1186 

transmission of, 1185, 11 86, 1193 
Incisurae in gastric outline, 841, 918 
Inclusion bodies of Dohle, 125 
Incompensation, advanced, sign of, 648 

cardiac, 625 

in "drop" heart, 606 
periods of, 606 
Incontinence, rectal, 1197 

urinary, 13 

vesical, reflex, 1197 
Indecency in epileptics, 1272 
Indecision, morbid, excessive, 1179 
Index of urea excretion, 199, 210 
India, cholera in, 103 1 

fakirs of, 1301 

-rubber-ball sound, 312 
Indican in the urine, diagnostic value of, 192 

tests for, 193 
Indicanuria, 88, 193 

in gastric carcinoma, 932 
Indigestion, acute, vomiting of, 873 

after duck shooting, 654 

flatulent, 977 

nervous, 56 
Indoxyl, increase in, 950 

potassium sulphate, 193 
Indurations, brawny, 171 

satellite, 1107 
Infancy, diseases of, 58 
Infantile meningitis, 1086 

paralysis, 1089 
Infantile paralysis, specific virus of, 982, 
1089 

spinal palsy, 1191 
Infantilism, 187 

pancreatic, 187 

types of, 187 
Infants, hardening of, 345 

malaria in, 1048 

scurvy in, 171 

spastic paralysis of, 1258 

weighing of, 56 

whooping-cough in, 1105 
Infarcts, coronary, 802 

hemorrhagic, 418 

cf brain, 626, 672 

of kidney, 609, 270, 672 
left, 691 

of lung, 418 
right, 691 

simulating lobar pneumonia, 391 
Infection, definition of, 980 

individual susceptibility to, 996 

interaction of, 73 
Infections, acute, blood pressure in, 481 



Infections, heart block in, 566 
heart sounds in, 446 
major, 665 
onset of, 78 

simulated by leukemia, 159 

termination of, 78 
arbitrary divisions of, 980 
ascending vs. blood-borne, 268 
blood-stream, 998 
buccal, 823 
chronic, a cause of nephritis, 241 

latent, 665 

unrecognized, 217 
cryptogenic, 356 

a cause of disease, 60 
due to colon bacillus, 1014 
focal, a cause of neuralgia, 94 

hidden, 148 
immunity to, 651 
localized, 998 
meningeal, 1077 
mixed, 100 1 

activity of, 195 
myocardial toxemia in, 657 
obscure, diagnosis of, 10 10 

shown by temperature, 72 
of kidney, blood-borne, 269 
of leprosy, 11 20 
of tonsils, 823 
overwhelming, 78 
principles underlying, 980 
prostrating, 588, 889 
resumption of activity after, 589 
structural continuity of, 782 
terminal, 10 14 

tuberculous, prevalence of, 415 
watching the heart in, 676 
Infectious diseases, 1000 
Inferior maxillary, lesions of, 1232 

neuralgia of, 94 
Influenza, 1015 

age and sex, 1017 

and acute hemorrhagic pneumonitis, 1021 

and cardiac strain, 664 

bacillus of Pfeiffer, 10 16 

contagiosity, 10 17 

coryza-like attacks in, 1019 

cultural tests in, 1016 

diagnosis of, 1018 

endemic-epidemic, 10 17 

epidemic, true, 1017 

epidemic variants, 1015 

etiology of, 10 16 

historic note on, 10 15 

immunity from, 1017 

incubation period in, 1017 

misnomers of, 1016 

mortality in, actual vs. relative, 1030 

pneumonias of, 386, 394. 395. 1021 

prognosis in, 1030 

roentgen examination, 1022, 1029 

simulating other diseases, 1018 

typhoid, 1 013 
symptoms of, 1018 

blood, 1020 

circulatory, 1019 

coryza and bronchitis, 1019 

cough, 102 1 

cutaneous, 1020 



1400 



GENERAL 1XDEX 



r.osis. 1020 
r, 1019 
gastrointestinal, 1020 
genito-urinary, 1020 
nose-bleed, 1021 
onset, 1018 
pain, 1019 
prostration, 10 19 
pulse. 1020 
respiratory, 102 1 
synonyms for, 10 15 
types of, 10 1 7 
nira clavicular regicn. rescrance ::" :;•; 
Int'undibula, dilacaticn ::. ; ; : 
Ingesta, barium-laden, 846 
Inhalation, chloroform, 1303, 1307 
of dust, 329. 422, 423 
:: irritants, z: : 
: : 5 z c t 329 
pneumonias, 394 
Injuries, compensation for, 1282 

simulated, 1292 
Innervation, disturbances of, 951 
Inoculation, animal. 332. i::_ 
in meningitis, 1083 
:: typhus, 1051 
of leprosy. 1120 
~it- sna'dr :- ::;_ 
Inoscopy, 143 

Insane, the paralysis of, 125 1 
Insanity, general paresis in, 1254 
hereditary, 68 
in pellagra. :; ;: 
c: Bright': disease :_" 
simulated, 1298 
Insolation, 1283 
Irscnnia. :202 

and frequent urination, 192 
causes of, 103 
forms of. 103 
of cerebral anemia, 1241 
relief of, 103 
Inspeccitn. general. importance 0: I22 
in heart disease, 433 
: : chest, 276 
tangential, 435, 781 
value of. 11 
Inspiration, forced, chest outline of, 284 
Inspiratory diminution, 496 
lagging, 287 
retraction 352 
atelectatic, 399 
Instruments for cardiac research. 49: 
for punctures, 112 
nociern recording, nob. u - - 
of precision, diagnostic 7, 497. 49 5. r 1 
Insufficiency, cardiac, production of, 656 
cardiovascular, treatment of, 652 
stenotic, 900 
Insurance requirements, chest expansion. 285 

risks, first-class, 1107 
Intercostal nerves, lesions of, 12 19 

neuralgia, 95, 1163 
Intercostal neuralgia, distinguished :"r;m angina 
95 
veins, internal, visible, 28 
Intermittent claudication, 42, 53 

Eevei 74 75 
Iniermiiiierende hinken, 53. 647, 763, 767. "'- 



Internal capsule, lesions of. 12 11 
later:; a - - ..-.-. j . r. -■ ..-. ; . ■:..-. - a. 
pulsation over, 437 
systoUc recession of, 706, 795 
third left, split tone in, 448 
tugging ;:". -95 
Interventricular sen-tun, patent, 732 
Intestinal coils, contraction of, 963 
coils, protrusion of, 817 
crises, 936 

disturbance dud to stomach, 938 
hypermotility, 844, 847 
indigestion, acute. 943. 944 
of gastric origin, 944 
stools in, 944 
kinks. 951 

as cause of dilatation, 898 
motility normal i_: 
mucosa, erosions of, 954 
neurasthenia, 950 
neuroses, miscellaneous, 949 
obstruction, acute. 87. 959 
: eric cry gnu in. 1 : : 
chronic, 5 5 ; 

synrtcns of. 05 : 
diagnostic 7. tints, 5 i 
from drug: i; 
front — cms. it 
parasites, 85, 1132 
putrefaction, if: 
sand, 942 

tract, protozoa of, 946 
tumors, catharsis for. 816 
Intestine: ceils of, "lacier pattern 5- 
em'c clisn of c 5 3 
"horseshoe curve" of, 87 
paralysis of, 950 
perforation of, 1003 

by worms. 1137 
small, obstructions of 950 
"spilling" of. 805 
strangulated, s i 
syphilis of, 953 
thrombosis of, 953 
tuberculosis of, 953 
Intoxications, the, 1283 
Intracardial short-circuiting. 524 
Intracranial pressure, 479. 1085, 1086 
Introspection, 1181, 1183 

pernicious, 197 
Intucatcn 1075 

in mem'crancus croup. ;-__ 
Intussusception, chronic. 951 

of intestines, 89, 956 
Invalids, ambulatory, 11 81 
Invertase, 851 
Iodid tests, 864 
I: iin pci: :ning. i_ 

sterilization ~it'n :: So 
It dcphilia, 125 
Icn-prcteii : ::n"cinati:n: uc 5 
Iris, examination of, 1228 
Iritis, symptoms of. 1228 
Ircn in the liver. 153 
in the urine, 214 
Irritants as cause of asthma, 356 
Irritation, cerebral, 121 1 
Island of Refl, growths m, ic__ 
Island: c: L a r. g rhans. 1163 



GENERAL INDEX 



14OI 



Isospora bigemina, 946 
Itching, anal and genital, 1138 

in various diseases, 101 
Ivy poisoning, 1132 



J 



Jackson, Dr. Chevalier, apparatus of, 313, 829 
Jacksonian epilepsy, 480, 1271, 1273 

seizures, 121 1 
Jackson's gastroscope, 828, 829 
Jakoby-Sohns, ricin method of, 862 
Japan, endemic diseases of, 1058 
Japanese river fever, 1058 
Jaquet's sphygmocardiograph, 501 
Jaundice, acute febrile, 974 

catarrhal, 975 
chronic, 975 
recurrent, 972 

congenital hemolytic, 155, 194 

in abscess of liver, 966 

in cardiovascular insufficiency, 648 

in gall-bladder disease, 975, 979 

in pancreatic disease, 965 

in yellow fever, 943, 1036, 1037 

obstructive, 975 
renal cells in, 238 

resembling pigmentation, 175 

simulated, 1298 

symptoms of, 19 

toxemic, 19 

types of, 18 
Jaw, angle of, enlarged glands at, 1075 

clonus, 1264 

deviation of, 1232 

-drop, 1232 

-jerk, 1 194 

locked, 1125, 1307 

lumpy, 1 13 1 

muscles in strychnin poisoning, 1307 

spasm of, 40 

upper, hypertrophy of, 185 
Jejunum, location of, 807 
Jenner, Dr. Edward, 1094, 1099 
Jenner's stain, 115, 245 
Jigger (sand flea), 1148 
Joints, abscess of, 1154 

affections of, etiology of, 44 

Charcot, 45 

contractures of tests of, 1295. 1299 

diseases of. bacterial cause of, 1149 
infectious, 11 49 

effusions of, intermittent, 127 1 

examination of, 43 

exudate from, 1149 

fixation of, simulated, 1299 

hysterical, 45 

inflammation of, acute, 1149. 1151 

metatarsophalangeal, gout in, 1172. 1173 

painful, in Malta fever, 1054 

relaxation of, 1158 

rheumatic, inflamed, 587 

tenderness of, 101 

uratic deposits in, 1172 
"Jolly bodies," 128 
Jolly's myasthenic reaction, 1267 
Journalistic standbys, 48 
"Jug sound," 298 
Jugular collapse, diastolic, 79 

fossa pulsation, 765 



Juguiar pulsations, direct systolic, 697 
pulse, 707 

visible, 569 
tracings, 504, 548 
vein external, engorged, 703 
wave, 502 
double, 548 
presystolic, 697 
systolic, 552 
"Jumpers," 54 
Juxtapyloric ulcers, 915 
diagnosis of, 920 
hypersecretion in, 922 
retention in, 922 

K 
Kala-azar, 1059, 1060 

infantile, 1061 
Kaltzenstein, cardiac test of, 636 
Keidel vacuum tube, 1010 
Keith and Flack, sinus node of, 467, 469. 544 

on blood volume, 141 
Kelling's lactic acid test, 861 
Kemp's retention meal, 858 
Keratitis, 13 
Kernig's sign, 1081 

in lethargic encephalitis, 1088 
Ketonuria, 1164 

Kidneys, ability of, to excrete urea, 208 
activity of, affected by disease, 190 
functional, 250 
normal, 189 
secretory, 251 
amyloid, 266 

associated conditions, 266 
differentiation of, 266 
posture for examination in, 266 
syndrome of, 266 
urinary findings in, 266 
arteriosclerotic, 762 
congestion of acute severe, 254 
chronic passive, 253 
albumin in, 253 
microscopic findings in, 253 
morbid anatomy in, 253 
urine in, 253 
mild arterial type, 254 
passive, 705 
sign of, 209 
cyanotic induration of, 253 
cystic degeneration of, 272 
cysts of, 271 

degeneration of, 271 
unilateral, 272 
diseases of, 189 

focal arteriosclerotic, 261 
urea determinations in, 201 
displacement of, lagging, 818 
examination of, posture for, 814 
excretory function of, measure of, 205 
floating, 267 

and drop heart. 884 
crossing median line, 813 
Dietl's crises of, 86, 268 
function of, impairment of, 209 
gouty, 261, 1173 
hemorrhage from, 223 
in cardiovascular insufficiency, 648 
in typhoid, 1002 



1402 



GENERAL INDEX 



Kidneys, infarcts of, 270, 672, 683 

integrity of, 189 

irregularly contracted, 271 

lesions of, in nephritis, 255 

location of, 809 

mobility of, degrees of, 267, 813 

movable, 266, 267. 813 

characteristic features of, 814 
delayed descent of, 809, 814 
symptoms of, 268 

of pregnancy, 254 

of stasis, 253 

pain over, dragging, 270 

palpation of, posture for, 813 

pelvis of, blood from, 223 

percussion of, 813, 814 

polycystic congenital, 272 

relations of, posterior, 809 

replaceability of, 814 

secondary contracted, 260 

senile type of, 261 

small white, 260 
in bon vivant, 265 
interstitial changes in, 260 
microscopic findings in, 260 
morbid anatomy in, 260 
symptoms of, general, 260 
urinary findings in, 260 

syphilis of, 271 

tubules of, cell action of, 189 

tumors of, 271, 272 
bilateral, 818 
vs. splenic tumor, 819 
Kinks, intestinal, 951 

ureteral and vascular, 86 
Kjeldahl's nitrogen apparatus, 200 

method, 199 
"Klebs symptom," 816 
Knee-chest position, 805 

-elbow position, 24 

-jerk, 1 194 
loss of, 1 195 

occupation disease of, 63 
Knock-me-down fever, 10 
"Knock-out-drops," 1304 
Koch's comma bacillus, 103 1 

law, 402, 1000 

tubercle bacillus, 401 

tuberculin, 2 
Kocher's sign, 181 
Koplik's spots, 35, 1066, 1067, 1073 
Koranyi-Plesch percussion, 443 
Koratkow's auscultation method, 474 
Korsakoff's psychosis, 1285 
Krabbea grandis, 1135 
Kraft-Ebing on syphilis, 750 
Kronig's method of percussion, 294, 295 
Kuttner's colorimeter, 119, 120, 252 
Kymograph, 500 
Kyphoscoliosis, deformity due to, 766 

heart vessels in, right, 768 

pulmonary affections in, 766 
Kyphosis, 43, 185, 188 



Lab ferment, test for, 882 
Labium, elephantiasis of, 1142 
Labor in bleeders, 170 



Laboratory, clinical, urinary analyses in. 204, 207 

experiment, conflicting evidence in, 3 
Lachrymation due to formaldehyde, 1305 
Lacquer poisoning, 1132 
Lactic acid reaction, 865 

tests, 861, 862, 878 
Lactose, 851 

in the urine, 228 
Laennec's cirrhosis, 969, 970 

physical signs of, 970 

symptoms of, 970 
Lagging respiration, 287, 352 
"Laking" of blood and water, 140 
Lamblia intestinalis, 946 
Lameness, intermittent, 42 
Lancet, spring, with trocar point, 112 
Landmarks, vertebral, 12 14 
Landry's paralysis, 1262, 1263 

artificial respiration in, 1263 

cyanosis in, 1263 

symptoms and prognosis of, 1263 
Lane's kink, 951 
Larvae, air-breathing, 1038 
Laryngeal nerves, 1236 

pressure symptoms upon, 577 

stenosis, 343 

vertigo, 104 
Laryngismus stridulus, 343, 344 
Laryngitis, acute, 342 

atrophic, 343 

chronic, 342 
of speakers, 63 

lupoid, 344 

simple, 342 

subacute, 342 

symptoms of, 343, 344 

syphilitic, 344 

tuberculous, 344 
Laryngology, technic in, 334 

Larynx and naso-pharynx, anatomy aad pathol- 
ogy of, 334 

diseases of, 14, 342 

examination of, 334 

food in, 12 1 5 

inspiratory descent of, 105 

paralysis of, 1236 

sessile growths in, 344 

tumors of, 344 

ulceration of, 409 
in typhoid, 1003 
Lateral sclerosis, primary, 1257 
Lathyrism, 1132 

Laveran on malarial organism, 1037 
Lazear, Dr., self-sacrifice of, 1035 
Lead acetate, poisoning by, 1305 

colic, 1287 

lead line in, 87 

encephalopathy, 479 

paralysis, types of, 1287 

poisoning, 65 
and gout, 11 70 
anemia in, 1287 
blood pressure in, 478 
chronic. 1286 

etiology of, 1286 
gums in, 38 
in paresis, 1253 
symptoms of, cerebral, 1287 
renal and vascular, 1287 



uFXERAL index 



1403 



Lead, workers in, 479 
Leaning backward, 52 
Leg, affections of. 42 

atrophy of, 1130 

edema of, 20 

extension, impaired, 12 17 

rotation, outward, impaired. 1217 

sensory nerves of, 1206 

weakness of, progressive, 1266 
Legal's test for acetone, 229 
Leishman- Donovan bodies. 1060 
Leishmaniasis, 1059 

cutanea, 1061 

furunculosus she tropica. 1061 

history of, 1059 

infantum, 1061 

liver and spleen in, 1060 

mortality in, 1059 

symptoms of, 1060 
Lenses for blood counting, 135 

oil-immersion, 1009 
Lenticulo-striate region, 1247 
Leonine brow. 31 
Leontiasis ossea. 31, 186, iSS 
Leprosy, 67. 1119 

absence of perspiration in, 11 22 

anesthetic, 1121 

as a vanishing disease. 11 19 

communicability of, 1119. 1120 

development of, 1120 

diagnostic criteria in, 11 22 

forms of, 1 120 

germ invasion in. 1267 

in children, 1120 

incubation period of, 11 20 

loss of fingers and toes in. 1121 

mixed, 1122 

nodular. 1120. 1121 

of nose, 1120, 1121, 1122 

sex in, 1120 

symptoms of, constitutional. 11 20 

white. 1121 
Leptomeningitis, 1079 

:. 748 
Leptothrix, 878 

Lerche's esophagoscope, 825. 826 
Lethargic encephalitis, 1086 

diagnosis, 1088 

duration, 1088 

etiology, 1087 

Kernig's sign in, 1088 

paralysis in, 1088 

pathology, 1087 

prognosis, 1088 

symptoms, 1087 

temperature, 1087 
Lethargy. ; y 
Leucin, 233, 234 
Leucocyte content of fluids, 143 

count, 131. 134 
in pneumonia, 389 
normal, average of, 137 

increase, preagonal, 137, 159 
Leucocytes, classification of, 122. 123 

in sputum, 331 

number of bacteria in, 997 

polymorphonuclear, 116 

washed, 997 
Leucocytic field, lymphocyte dominant in, 159 



Leucocytic inclusions. 1069 
Leucocytometer, 128 
Leucocytosis. 111, 124, 137 

differentiated from leukemia. 138. 156 

digestion, 137 

diseases associated with. 138 

in appendicitis, 955 

in cerebro-spinal meningitis. 1080 

in cholera, 1032 

in empyema, 374 

in endocarditis, 67 S 

in gastric carcinoma. 932 

in hepatic abscess. 967 

in pyemia, 11 19 

in tuberculosis, 674 

marked, in certain diseases. 138 

physiologic. 137 

polymorphonuclear, 1070 
Leucoma, buccal, 3S 
Leucopenia, 111, 139 

diseases associated with. 138. 139 

in measles, 1067 
Leucoplakia buccalis, 38 
Leukanemia, 161 

Leukemia, differentiated from leucocytosis, 138, 
156 

forms of, transition. 16 r 

history of, 156 

lymphatic, 156, 15S, 167 

myelogenous, 157 

myeloid. 156. 157 

pathogenesis of. 156 

prognosis in, 162 

pseudo-, 164 

uric acid in, 211 
Leukoplasia, syphilitic, 11 11 
Levulose in diabetes, 227 
Levulosuria, 227 

Lew's, Thomas, on extrasystoles. 550 
Lice, body, 1148 

as intermediary hosts. 105 1 
Lieben's test for acetone. 229 
Life expectancy in cardiac cases. 653 

in mitral insufficiency, 687 

in syphilitics, 751 
Life insurance companies, attitude of. towards 
hypertension, 1246 
towards sunstroke, 1284 
towards syphilis, 751 
towards tuberculosis, 69 
towards weight, 56, 669 

examinations for, 478 
Life, mode of, 60 

open-air, intelligent regulation of. 345 

signs of, in apparent death, 1302 
Lifting test, 1266 
Light-field, retro-cardial, 584 
Light, pupillary response to, 1302 

reaction to, 1220, 1221. 1254 

reflex, 1228 
Limping, simulated, 1299 
Lineae albicantes, 806 

nigra, 806 

transversa?, 807 
Lines, midclavicular, 278 

parasternal, 279 

red, in lymphangitis, 23 

scapular, 279 

sternal, 279 



1404 



GENERAL INDEX 



Lines, surface- verticals, 279 
Lipase, test for, 863 
Lipomata of brain, 1242 
Lips, epithelioma of, 34 
Lips, frothy, 81 

swelling of, 34 
Lipurea, 196 
Liquor drinking, 1284 
Lister's discovery, 4 
Lithemia as irregular gout, 212 

use of term, 11 74 
Lithiasis among mothers, 977 
Litten's sign, 286, 353. 418 

clinical significance of, 286, 411 
test, 416 
Little's disease, 1258, 1259 
Liver, abscess of, 966 

amyloid degeneration of, 974 
anomalies of, congenital, 965 
atrophic, 971 
auscultation of, 809 
carcinoma of, secondary, 968 
cirrhosis of, 969 
corset, 965. 978 
diseases of, 965 

urea excretion in, 201, 202 
displacement of, 798, 810 
dulness, absolute, 279 
echinococcus disease of, 968, 1136 
edge of, in cirrhosis, 811 
engorgement of, 70s, 971 
enlargement of, 966, 967 

excessive, 811 
fixation of, 820 
flukes, 1 134 

gummata of, syphilitic, 973 
hard and smooth, 974 
hobnail, 969 

in cardiovascular insufficiency, 648 
in Leishmaniasis, 1060 
in typhoid, 1002 
inflammation of, 965 
inspection of, 809 
location of, 279 
movement of, direct, 818 
nodular, 810, 968, 969. 973 
nutmeg, 648, 968, 972 
outline of, irregular, 810 
palpation of, 809 
parasitic involvement of, 968 
percussion, dulness in, 810 

outline of, 808, 809 
position of, in children, 807 
pulsation of, 727 
expansile, 706, 809 
systolic, 746 
puncture of, 1060 
exploratory, 967 
shrunken, 974 
situs inversus of, 965 
surface irregularities in, 810, 967 969 972 

rough, 811 
swellings of, elastic, 811 

fluctuating, 811 
tropical, 965 
tumors of, cystic, 968 
upper area of, diminished, 810 
Lividity in pleurisy, 365 
Lobar pneumonia, 383 



Lobelia, poisoning by, 1305 
Lobes of the brain, lesions of, 12 11 
Lockjaw, 1 1 25 
Locomotor ataxia, 1254 

and the nervous system, 773 

blood pressure in, 480 
Charcot joint in, 45 

crises of, 870, 913 
visceral, 1255 

diagnosis of, differential, 1256 

etiology of, 1254 

gait in, 52 
luetic, 748 

morbid anatomy of, 1254 

pain in, 1255 

pathology of, 1254 

ptosis in, 1 23 1 

reflexes in, deep, 1255 

stages of, ataxic, 1255 

swaying in, 49 

symptoms of, cerebral, 1256 
ocular, 1254 

trophic changes in, 1255 

vomiting of, 913 
Loeffler and Frosch, virus of, 1058 
Loeffler's centrifugation method, 332 
Loewis test, 965 
Longevity, 669 

estimation of, 187 

in aortic stenosis, 726 

in tricuspid stenosis, 728 
Loose tissues, edema in, 21 
Lordosis, 43, 1266 

causes of, 52 

spinal, lower, 12 17 
Love sickness, 147, 149 
Ludovici, angulus, 277 
Lues venerea, 13, 1105 

as cause of aortic stenosis, 722 

cardiovascular, 748 
Lugol's solution, blue reaction from, .877 
Lumbago, simulated, 1299 
Lumbar pain, 99 

puncture, 1082, 1083 
dangers in, 1083 
in differentiation, 10 12 
in meningitis, 1085, 1086 

tenderness, 100 
Lung excursion, deficiency of, 286 

fever, 383 

fields, bright, 326 
shadows in, 314 

fluke disease, 425 

stone, ejection of, 330 

tissue in pleurisy uninvolved, 370 

ventilation, deficient, 756 
Lungs, abscess, 326 

air exchanges of, 354 

airlessness of, 283 

and heart, relation of, 455 

anterior and posterior surfaces of, 291 

apex of, muscular waste in region of, 282 
resonance of, 278 
retraction of, 285 

as filter and purifier, 455 

bases of, compressed, 296 
congestion of, 1005 

boundaries of, 278, 279, 280 
lobar, 387 



GENERAL INDEX 



I405 



Lungs, borders of, high inferior, 296 

position and mobility of, 294, 295 

respiratory changes in, 296 
capacity of, 285 
carcinoma of, 421 
cavity in, 300, 301, 302, 319 
collapse of, 377 

massive, 399 
compression of, 296, 798 

abrupt and excessive, 378 

breathing in, 308 

by tumors, 399 

counter-pull of, 323 

degrees of, 798 

in pleurisy, 366, 367, 370 

picture of, 961 
congestion of, 384 

active, 400 

passive, 400 

persisting, 699 
consolidation of, 300, 319, 384, 390 
cysts of, 425, 426 
diseases of, 345 
edema of, 400 

engorgement of, primary, 390 
equality of movement between, 296 
examination of, 282 

roentgenographic, 314 
expansion of, impaired, 306, 352 
expulsive power of, 306 
hepatization of, gray, 384 

red, 384 
hilus shadows, 314 
honeycombed, 349 
hypostasis of, 400 
infiltration of, 315. 424 

tuberculous, 316 
left, hypertrophy of, enormous, 802 
lobes of, delineated, 281 
malignant growths in, 307 
movement of, limitation of, 407 
overinflated, 353 

inelastic, 284 
resonance of, 278 

right, tuberculous excavation of, 802 
sarcoma of, primary, 421 
shrunken, 424 

sound and emphysematous, 423 
state of. in atresia, 733 

in cardio-vascular insufficiency, 648 
topography of, 278 
tumor of, 321, 421 
Lupinosis, 1132 
Lupus, scars of, 29 
Lymph, bovine and human, 1101 
channels, syphilitic, 751 
glands in syphilis, 11 11 
glycerinated, 11 01 
nodes in yaws, 11 14 
Bcrotum, 1 142 
Lymphadenie, 164 
Lymphadenosis, 164, 167 

leukemic. 167 
Lymphangitis, acute septic, 23 

and phlebitis confounded, 23 
Lymphatic leukemia, 158 
acute, 158, 159 

blood picture in, 160 

fever and hemorrhage in, 160 



Lymphatic, acute, simulating an infection, 159 
splenic enlargement in, 160 

blood findings in, 158, 159 

essential features of, 158 

insidious onset of, 159 

symptoms of, 158 
Lymphatics, palpable, 23 
Lymphatism, 175, 11 02 

cause of, 176 

historical note, 176 
Lymphedema, endemic, 25, 26 

sporadic, 25, 26 
Lymphoblasts, pathologic, 125 
Lymphocytes, giant, 125 

mononuclear, 122, 123 
Lymphocytosis, 111, 137, 139 

after pilocarpin, quinin, and thyroid, 139 

in Addison's disease, 174 

in infancy, 139 

in typhoid fever, 1007 

in whooping cough, 1104 
Lymphomata, 158 

simple, 167 
Lymphosarcomatosis, 164, 167 
Lysis, 78 
Lyssa, 11 24 
Lyssophobia, 1125 



M 



McBurney's point, 808 

in appendicitis, 83, 85, 954, 955 
Mackenzie ink polygraph, 499 
McLean's urea index, 203, 204 
McMonagle's maneuver, 955 
Macrogametocytes, 1043, 1047 
Macula cceruleae, 1148 
Macules, syphilitic, 1108 
Madura hand, 1130 

foot, 1 129 
Madurella mycetomi, 1130 
" Magensteifung," 822, 899 
Magnetic field, 518 
Main en griffe, 12 19 
Maize, poisoning from, 1290 
Mai, grand and petit, 1271, 1272 
Malaise, general, preceding typhoid, 1005, 1006 
Malaria, 1037 

a cause of dysentery, 948 

anopheles the carrier of, 1038 

blood examination in, 1045, 1049 

chronic, 1048 

clinical divisions of, 1040 

complications of, 1048 

diagnosis of, 6, 1049 

differentiation of, 1012 
from Malta fever, 1054 
from Weil's disease, 975 
from yellow fever, 1037 

estivo-autumnal, 1045 

forms of, choleraic, 1048 
comatose, 1048 

hematuric or hemoglobinuric, 1048 
pernicious, 1048 
severe and obscure, 1058 

headache of, 92 

historic note on, 1037 

human and mosquito cycle in, 1042 

hypotension in, 484 



1406 



GENERAL INDEX 



Malaria, immunity, 1045 
in infants, 1048 

incidence of, conditions governing, 1038 
mortality in, 1038 
periods of, apyrexia in, 1040, 1042 
racial immunity to, 1038 
simulated by endocarditis, 678 
sweating in, 1037 
tertian, erythrocytes of, 128 

fever in, 74 
therapeutic test in, 1049 
Malarial fever, bilious remittent, 1048 
estivo-autumnal, 1043 

tertian, 1046 

double, 1041, 1042 

tropical, 1043 
infection, triple quartan, 1042 
organisms, classification of, 1039 

cycle of development of, 1039, 1041, 1046 
estivo-autumnal phases of, 1046 

examination of blood for, 1045 

observation of, 114 

pigmented, 1045 

quartan, 1040 
rarity of, 1042 

ring bodies of, 1046 

segmentation of, 1050 

sporulation of, 1041 

tertian, 1040, 1046 

treated with Wright's stain, 1050 
parasites, cultivation of, 1043 

developmental cycle of, 1044 

estivo-autumnal, 1047 

quartan, 1047, 1050 

tertian, 1047, 1050 
paroxysm, 1040, 1042 

stages of, 1045 
Plasmodia, "pernicious spots" on, 1045 
Malignant disease, abdominal, 422 

color in, 145 

leucocytosis in, 138 

retroperitoneal, 422 
growths, intestinal, simulated, 815 
Malingerers, 12, 80, 81, 804, 1291 
diseases feigned by, 1293, 1300 
exposure of, 1301 
hysterical, 1279, 1281 
temperature in, 72 
Malnutrition a cause of convulsions, 49 

persistent, 958 
Malta fever, 992, 998, 1053 
blood cultures in, 1054 
diagnosis of, differential, 1054 
etiology of, 1053 
history of, 1054 
incubation period in, 1054 
morbid anatomy of, 1054 
prognosis in, 1054 
relapses in, repeated, 1054 
specific test for, 1054 
symptoms of, 1054 
Maltose, 228, 851 

Mammary veins, internal, visible, 28 
Mania a potu, 1285 
Bell's. 75 

differentiation of, 1298 
frenzy of, 1298 
post-convulsive, 1272 
Manila water supply, amebae from, 946 



Manson on epidemic dropsy, 1057 

on hill diarrhea, 1063 

on Leishmaniasis, 1059 

on malaria, 1037 

on sunstroke, 1284 
Manubrium, area of, inspection of, 435, 437 

dulness over, 176 

percussion of, 439, 777 

pulsation of, 437 
Marches, forced, 640 
Marechal's test for bile, 224 
Marey's sphygmograph, 497 
Marie's disease, 184, 1257 
Marriage, question of, in case history, 62 
Marrow cells, 123 

giant, 124 
Marshall's urea method, 202, 203 

urease method, 207 
Massive collapse of lung, 399 
Mastication, 1232, 1233 
Mastication, imperfect, 823 
Mastitis as complication of mumps, 1069 
Mastodynia, 97 
Mastoid suppuration, 1240 
Mastoiditis, 1251 
Matthews' microscope lamp, 112 
Maurer's spots, 128 
Meals, night, heavy, a cause of asthma, 356 

relation of pain to, 910, 958 

time consumed at, 937 
Measles, 1066 

black, 1068 

broncho-pneumonia in, 395 

complications of, 1067 

contagiousness of, 1066 

desquamation in, 1067 

definition and etiology of, 1066 

diagnosis of, 1068 

eyes in, care of, 1067 
red, 31 

mortality of, 1066 

organism of, unknown, 1066 

rash of, 1066 
syphilitic, 1068 

stages in, duration of, 1067 

symptoms of, 1066 

temperature in, 76, 77. 1066 

urine in, 1067 
Measurements, abdominal, 285 

chest, 285 

"rule of thumb," 429, 43 1 
Meat eaters, gastric acidity in, 867 

fibers in stools, 939, 941 - 965 

ingestion of, false reaction from, 876 

poisoning, 1132 
Meckel's diverticulum, 943 

Mediastinal abscess distinguished from aneurysm, 
423, 780 

displacement, 378 

glands, enlargement of, 583. 756 

growths, symptoms due to, 776 

symptoms, 423, 759 

tumors, 321 

differentiated from aneurysm, 585 
posture in, 107 
pulsation in, 437 
Mediastinitis, indurative, 496, 792, 795 
Mediastino-pericarditis, 795. 796 

adhesive, 496, 792, 793 



GENERAL INDEX 



1407 



Mediastino-pericarditis, systolic retraction in, 

437 
Mediastinum, abscess of, 423 
rupture of, 423 

enlarged glands in, 166 

malignant growths in, 781 
Medication, antiluetic, 759 
Medicine, study of, modern methods, 1 
Mediterranean fever, 1053 
Medulla, 1186, 1189 

infiltration of, 1091 

lesions of, 1245 

oblongata, lesions of, 12 13 
Megakaryocetes, 124 
Megaloblasts, 126, 127 
Megalocytes, 126 
Megastoma entericum, 1132 
Melancholia, differentiation of, 1298 

facial expression in, 12 
Melanemia, 125 

urine in, 192 
Melanin, 194 
Melano-sarcoma, 17 
Melanosis, arsenical, 17 
Melena neonatorum, ulcer a cause of, 907 
Membrane, diphtheritic, 1075 

laryngeal, false, 1074 
suffocation from, 1075 
Membranous croup, 344 

enteritis, etiology of, 944 
Memory defect, alcoholic, 1285 

disorders of, 1201 

loss of, 1201 

in impostors, 1298 
Mendelsohn, cardiac test of, 635 
Meniere's disease, 49, 1235 

vertigo of, 104 
Meningeal affections, 1077 
Meningitis, acute, rigidity in, 50 

alcoholic, 1085, 1285 

basilar. 1078 

cerebro-spinal, 1078 

chronic remittent, 1086 

differentiated from apoplexy, 1249 
from typhoid. 1012 

doubtful cases of, 1085 

due to otitis media, 107 1 

forms of, 1077 

infantile, 1086 

morbid anatomy of, 1078 

pressure symptoms in, 1085, 1086 

secondary, 1078, 1085 

serous, 1078, 1086 
circumscribed, 1085 

simple or sporadic, 1077 

stages of, irritative, 1085 

suppurative, 1084 

joint swelling in, 1084 

syphilitic, 1078. 1079. 1084 

tuberculous, 1077. 1078 

wet, 1086 
Meningococcus, exudate from. 1078 

intracellularis meningitidis, 1079 

of Weichselbaum, 1077. 1078 

test 991 
Menopause, obesity after, 189 
Menstruation in bleeders, 170 

vicarious, 337, 874 
Mensuration, 276 



Mental condition in febrile diseases, 75 

development, retarded, 341 

strain of occupation, continuous, 64 
Mercuric chloride, poisoning by, 1304 
Mercury in aortitis, 753 
Merycismus, 871 
Mesaortitis, chronic productive, 751 

luetic. 750, 752 
pain in, 755 
pathology of, 752 
soft arteries in, 759 
subiective expression of, 755 
sudden death in, 759 
symptoms of, general, 754 
with aneurysm, 774 
aortic, 778 

productive, of Welch, 760 
diagnosis of, early, 760 
mortality from, 760 

silent cases of, 760 
Mesaortitis, productive, syphilitic, 748, 754, 773 
Mesarteritis, 748 

basic factors in, 751 

vs. atherosclerosis, 75 1 
Mesenteric glands, enlarged, 963 
in typhoid, 1003 

masses, 819 

superior, thrombosis of, 953 
Mesencephalon, region of, 1191 
Mesoblasts, 127 
Metabolism, carbohydrate, 1164 

disturbed, in gout, 1171 

faulty, poisons from, 74 

in exophthalmic goiter, 179. 181 

general depression of, 768 

protein, 198 
Metallic chink, 309 

clacking, 446 

note, 298 

salts, solutions of, 834 

tinkling, 312, 379 
Meta-myelocyte, 124 
Metastases, 931, 1190 

malignant, 321 
Meta-syphilis, 748 
Meteorism, 949 

in pneumonia, 389 

in typhoid 1014 

pressure from, 446 
Methemoglobmuria, 223 
Methylene blue for renal tests. 250 
Metric equivalents, table of, 1308 
Microblasts, 126. 127 
Micrococcus catarrhalis, 245, 345 

lanceolatus, 383 

melitensis (Bruce), 1053 

rheumaticus, 1149. H53. 1274 
Micro-colorimeter, universal, 119. 120 
Microcytes, 126 
Microgametocytes, 1043, 1047 
Micrograph, 500 
Micromegaly. 188 

Microphone and string galvanometer 524 
Microscope, handle-arm, 113 

in examination, 589 
urinary, 230 

lamp, 112 
Microspores furfur and minutissimum, 1127 
Micturition, frequency of, 191 



1408 



GENERAL INDEX 



Micturition, reflex action in, 1197 
Middle-age, angina in, 647 
athletics in, 654 
diseases of, 59 
split second sound in, 663 
Midsternal line, 427 

Miescher's modified hemoglobinometer, 117, 118 
Migraine and epilepsy, relations of, 93 ■ 
heredity a factor in, 92 
symptoms of, 93 
Miliary fever, 1057 

intermediary host in, 1057 
tuberculosis, acute, 406 
Military service, self-mutilation in, 1292 
Milk fever, 1057 

mother's, discolored, 19 
of Maltese goat, 1053 
sickness, 1057 
Milroy's edema, 20 
Mimicry, 1275, 1276 
Mrad blindness, 4, 1203 

deafness, 1203 
Mineral poisoning, 64, 1302 

tremor of, 46 
Miner's nystagmus, 63 
Miniature men and women, 187 
Minkowski type of jaundice, 18 
Minnesota State Medical Society, 157, 812 
Miosis, 1220, 1221 
Miracles, modern, 465 

Mirrors, laryngoscopy and rhinoscopic, 334 
Mite, Kedani, as carrier of fever, 1058 
Mitral and aortic insufficiency combined, 754 
regurgitation, co-existing, 747 
stenosis, co-existent, 747 
area, 449 

endocarditis, acute vegetative, 672, 673 
chronic, with vegetations, 691 
residual, 747 
incompetence, 678 
insufficiency, 678 

associated signs in, 680 

blood pressure in, 680 

cardiac outline in, 575, 576, 679 

changes in cardiac area in, 686 

differential characteristics of, 681 

effects of, secondary, 682 

electrocardiogram in, 533. 

etiology of, 682 

in a "drop" heart, 633 

in advanced endocarditis, 575 

juvenile type of, 682 

left cardiac border in, 575 

lesions of, variations in, 684 

murmurs in, 452, 679. 684 

prognosis in, 687 

pulse in, 679 

rationale of, 681 

relative, 682, 743 

roentgenography of, 575 

symptoms of, subjective, 687 

terminal, 687 
thrill in, systolic, 681 
typical cases of, 678 
leakage, 680 
secondary, 460 
signs of, 684 
triple effects of, 682 
lesions, 712 



Mitral lesions, accentuation of sounds in, 445 
cyanosis in, 650 
effects of, 745 
following rheumatism, 701 
incompensatory stage of, 5 1 
sphygmogram of, 514 
terminal, 435 
murmur, soft, 604 
obstruction, murmurs of, 690, 691 
reflux, endocarditic, 743 
maximal at apex, 743 
regurgitation, 678 
atypical, 451 

combined with aortic, 581 
endocarditic, 452 
free. 748 

compensation in, 683 
frequency of, 461 
heart sounds in, 445, 446 
lesions of, 676 
misleading color in, 435 
murmurs in, 450, 680, 681 
roentgenography of, 581 
regurgitation, typical, 685 
stenosis, 577, 687, 737 

acute toxic dilatation, 647 

affecting young females, 687 

anatomic types of, 689 

and coexistent leakage, 700 

and regurgitation, 688, 694, 746, 1178 

area of audibility in, 695 

audible eddies in, 696 

auricular fibrillation in, 697 

overload in, 698 
auscultatory picture of, 694 
blood volume in, 696 
cardiac outline in, 577. 700 
clinical divisions of, 697 
decompensatory stages of, 688 
degree of, 696 
dominant, 699 
effects of, on heart sounds, 700 

secondary systemic, 701 
flutter-arrhythmia in, 697 
frequency of, 461 
funnel type, 651 
gallop rhythm in, 698 
heart block of, 569 
in "drop" heart, 694 
in the robust, 577 
incompensated, 747 
infarcts in, 701 
involving tricupsid, 692 
left auricle in, 577. 705 

ventricular dilatation in, 577 
lesions in, associated, 688, 744 

isolated, 688, 693 

slight, 695 
manifestations of, 550, 688 
murmur of, 459. 697. 698 

audibility of, 697 

modified by pressure of, 692 

quality and character of, 697 

thrilling 789 

transmission of, 695 

typical, 697 
organic, 720 
oxygen deficit in, 435 
"P" apex of, 549 



GENERAL INDEX 



1409 



Mitral stenosis, peculiarities of, 687 
percussion in, flat-finger, 693 
presystolic element in, 696 
progress of, 688 
pulse irregularity in, 697 

rapidity in, 697 
pure, 577. 694. 695 

cardiac changes in, 698 
compensated, 700 
in girl of, 19, 694 
rheumatic, 688. 1152 
roentgenography of, 573. 577 
rosy cheeks in. 435 
sign of, 448, 520 
silent, 695 
thrill of, 568, 696 

pathognomonic, 691 
typical case of, 690 
undulatory appearance in, 436 
vermicular contraction in, 577 
valve, 456 
area of, 433 
button-hole, 689 
closure of, 506 
disease of, brown sputum in, 329 

color in, 145 
"fish-mouth," 691 
funnel form of, 689 
insufficiency of, 789 
Modesty, measure of, 277 
Moebius's sign, 181 
Mohr's test, 212 
Moisture, buccal, abnormal, 35 
Mollites ossium, 43 
Monkey hand, 12 17 
Monkeys and infantile paralysis, 1089 
immunity of, to yaws, 11 16 
inoculated with measles, 1066 
whooping cough in, 1104 
Monkshood, 1303 
Monocytosis, 158 
Mononuclear cells, 143 
Monoplegia, 1210 
brachial, 12 11 
crural, 121 1 
in apoplexy, 1248 
with aphasia, 1248 
Monro, foramen of, 1079 
Montagu, Lady Wortley, 1094 
Montana, spotted fever in, 1055, 1056 
Moral sense, defective, 1201 
Morbilli, 1066 
Morbus Addisonii, 173 
Morbus ceruleus, 742 

Werlhofii, 169 
Morning nausea, 971 
Moro's test, 412, 413, 414 
Morphin habit, 1270, 1286 

habitues, public patients, 483 
poisoning, coma in, 79 
Morphinism, blood pressure in, 483 

itching in, 101 
Mortality in bleeders, 170 
in diphtheria, 1077 
in measles, 1066 
in pericarditis, 800 
in rheumatism, 11 55 
in smallpox, 1098 
in spotted fever, 1056 



Mortality in typhus fever, 1052 

in whooping cough, 1105 
Morton's foot, 97 
Morvan's syndrome, 1260 
Mosaics, diagnostic, 5 

Mosquito as intermediary host,- 1035. 1037 
characteristics of, 1038 
color preferences of, 1038 
evolution of malarial organism in, 1042 
-infested regions, clothing for, 1039 
larvae, destruction of, 1036 
transmission of yellow fever by, 1035 
Mother, disease transmitted by, 1265 

yaw, 1 1 14 
Moth-midge as carrier of infection, 1059 
Motility in congenital asthenia, 897 
Motor areas, conduction in, 1186 
Rolandic, 1244 
centers, 1209 

for speech, 1203 
decussation, 1187 
defects, 1041, 1042 
disturbances, 878 
impulses, 1185, 1186 
insufficiency, 832 
post-stenotic, 898 

complications of, 900 
differentiation of, 900 
symptoms of, 898, 899 
lesions, central, 1192 

peripheral, 1192 
neurons, atrophy of, 1264 

central and peripheral, 1192 
oculi, paralysis of, 1230 
points of Erb, 1198 

arm, shoulder and hand, 1198, H99 
head and neck, 1198, H99 
leg, 1 198, 1 199 
tracts, direct, 11 86 
indirect, 1187 
spasms of, 1272 
Moulds, 425 
Mouneret's pulse, 495 
Mountain fever, 1057 

sickness, 1282 
Mouth breathing, 335, 340 

conditions in relation to dyspepsia, 60 
dry, in mumps, 1068 
open, 34 
tapir, 1266 
Movable kidney, 266, 267, 813 
Movements, athetoid, 48, 1248 
choreic, 1248, 1258 
convulsive, 80 
slowing of, 1240 
uninhibitable associated, 1197 
Mowing gait, 52 
Mucin in urine, 219 
Mucocele, 338 
Mucor corymbifer, 1127 
Mucormycosis, 1127 
Mucosa, hyperemia of, 356 

swelling of, 356 
Mucous colic, 944 

masses, molds of, 945 
membranes, acid stains on, 1302 
buccal, pigmented, 174 
destruction of, 1117 
gastric, friability of, 882 



1410 



GENERAL INDEX 



Mucous membranes, gastric, vulnerability : : ; 3 i 
hemorrhage from, 157. 1097 
redundancy of, 937 
patches. 34, 38 
syphilitic, 1109 
Mucus from buccal cavity, 874 
gastric, 873 

in stomach contents. 906 
in stools, 939 
Multiple neuritis, 1262 
alcoholic, 1268 
differentiation of, 1263 
recurrent, 1268 
sclerosis, 1239 

differentiation of, 1240 
symptoms of, bulbar, 1240 
Mummy, Egyptian, blood reactions from, 991 
Mumps, 1068 

affecting only submaxillary, 1068 
definition and etiology of, 1068 
incubation period in, 1068 
symptoms of, 1068 
virus of, filterable, 1068 
Munich, beer drinking in, 671 
Murder cases, epileptic, 1272 

Mumurishness," 645, 650, 667 
Murmurs, absence of, temporary, 685 
accidental, 453 
anemic. 146, 452, 603 
aortic diastolic. 709 
musical, 716 
quality of, 713 
systolic, 433 
time of, 715 
area of audibility of, 692, 702, 709 

transmission of. 692 
asthenic, 457 
audible in back only. 685 
autoaudible, 715- 724 
bizarre combination of, 79 1. 797 
blowing systolic, 679 
blubbering, 744 
cardiac, 449 

intensity of, 451 
cardiopulmonary, 452, 7S9 
crackling, showers of, 454 
decrescendo, 747 
diastolic, 459. 461, 744 
aortic, 433 

imperfectly developed, -_; 
in mitral stenosis, 694 
pure, 461 

within apex -beat. -__ 
diminuendo . _ - ; 

duration, pitch, and quality of, 684 
en i:;ari::::. _:?:. J.50 
Flint, 720 
foraminal, 739 
friction, 789 

general dissemination of, 741 
hemic, 451 
hissing, 715 
in left heart, 743 
in neck, 729 

in pairs and triplets, 788 
intensity of, on raising arms, 716 

variation in, 685 
loud vs. soft. 451 
maximal at base. 461 



Murmurs, minia:ure 
multiple, 743 
musical, 451, ~;_ 
obstructivr 

of anemia and asthenia, 450 
of aortic insufficiency, 708 

time of, 708 
of mitral obstruction, 689 
stenosis, 692 

logical basis of, 695 
quality of, 690 
rationale of, 694 
of profound anemia, 736 
of pseudo-aortic-stenosis, 769 
of relative insufficiency, 685 
organic, 455 

with first sound, 461 
valvular, deductions from, 459 
pericardial, 788 
;le..ro-pericardial, 454 
post -systolic, 740 
presystolic, 459. 461 
crescendo, ~_~ 
thrilling vibratory, 698 
production of, 455 
registration of, 524 
regurgitant, -}- : 
respiratory variation in, 740 
rhythm of, 461 

;fe-saw," 709, 720 
short diastolic aortic, 663 
silenced, :_- 
spurting, 822 

systolic, 459. 461, 685, 742 
accidental, 681 
apex, 451 
in chlorosis, 150 
in mitral stenosis, 694 
multiple. 675 

suggestions concerning. -_;- 
whiffing, 4 S 3 
timbre of. 451 
time of. variations in, 685 
tiny crackling, 454 
::-and-fro, 710 
Transmission of. 452, 686, 716 
areas of, 679 
continuity of, 686 
maximal, 710 
to back, 686. 694 
typical presystolic, 690, 695 
valvular, causative factors of, 461 
variations in, 451 
vibratory, 744 
with second sound, 461 
Musca, volitantes, 1227 
Muscle antagonism test. 635 
contraction pain, 99 
cramp from fatigue, 640 
fatigue, pain from. 640 
movement, waves of. 520 
sense. 1192, 1204, 1206, 1260 
sounds, 304 
tonus, cardiac, 469 

neurogenic theory of. 469 
Muscles, bronchial, spasm of, 360 
contraction of. 1200 
cramps in, 1162 
diseases of, bacterial cause of, 1149 



(iKXERAL INDEX 



I4II 



Muscles, diseases of. infectious, 1149 
syphilitic, 1161 
electric excitability of, 1302 
examination of, 1200 
fatty deposits in, 1266 
flaccid, in fatty heart, 670 
groups of, paralysis of, 1287 
hollow, pain in, 772 

inspiratory, spasmodic contraction of, 356 
masseter, pain in, 975 
pain and tenderness in, 1138 
papillary, 704 
power and tone of. 1200 
proximal, in polymyositis, 1159 
trichinae in, 1138 
Muscular atrophy, progressive, 1263 
scapulo-humeral, 1266 
types of, facial, 1266 
peroneal. 1265 
Werdnig-Hoffmann, 1265 . 
contraction, vermicular, 48 
development, 430 
dystrophy, clinical forms of, 1265 
juvenile, Erb's, 1266 
progressive, 1265 
insufficiency, 789 
irritability, 47 
power, loss of, 1264 
rheumatism, 1162 

differentiation of, 98 
rigidity in appendicitis, 955 
tremors, 1057 

viscera, hollow, pain in, 755 
weakness in the anemias, 145 
Musculature, abdominal, 805 
relaxed, 832 
in laboring people, 805 
inefficient, 889 
Mushroom heart, 665 

poisoning, 1305 
Musical instruments, use of, callosities from, 

66 
Mussel poisoning, 1288 
Musset's sign, 719 
Mutilations of self, 1292, 1297 
Myalgia, sites for, 1162 
Myasthenia, 888 
gravis, 1267 
Mycetoma, 1129 
Mycoses, 1127 
Mydriasis, persistent, 1220 
Mydriatics, 1229, 1230 
Myelin, masses of, 331 
Myelitis, acute, 1261 

age and sex incidence, 1261 

course of, 1263 

diagnosis of, differential, 1262 

regional, 1262 
foci of, disseminated, 1262 
pain in, 1260 

sphincter involvement in, 1263 
symptoms of, 1261 
types of. 1 26 1 
Brown-S6quard, 1261 
compression, 1260 
forms of, 1260 
primary chronic, 1262 
Myeloblasts, 124, 160 
Myelocytes, granules of, 123 



Myelocytes, significance of, 124 

staining of, 116, 123 
Myeloid leukemia, 157 
acute, 156 

blood findings in, 157 
hemorrhages in, 157 
symptoms of, 157 
Myeloma, 161 
Myiasis, cutaneous, 1148 

ver Macaque, 1148 
Myocardial blood supply, 768 
defects, 461 

degeneration, 412, 554, 590, 768, 792 
acute parenchymatous, 665 
age incidence in, 561 
chronic, 668 

frank symptoms of, 4 
common forms of. 546 
in men, 627 

without coronary sclerosis, 771 
degenerative processes, 590 

post-mortem composite of, 590 
impairment, 748 
inflammation, true chronic, 590 
insufficiency, 590 
chronic, 641 
early diagnosis of, 651 
frank, 760 
involvement, luetic, 753 
lesions, symptoms of, 590 
overstrain. 630, 653 
parenchymatous degeneration, 768 
reserve, limitation of, 758 
tone, recovery of, 588 
toxemia, 79, 566, 657 

chronic intermittent, 588 
in endocarditis, 676, 677 
subjective weakness in, 666 
weakness, 76, 146 
Myocarditis, absence of murmurs in, 667 
acute, 665 

morbid anatomy of, 665 
simple, convalescence from, 668 
heart sounds in, 666 
minor. 666 
pain in, 667 
symptoms of, 666 
unsuspected but fatal, 666 
urine in, 667 

vasomotor symptoms in, 667 
chronic, 590 
residual, 668 

diagnosis of, 668 
transition stage, 668 
fatal, causes of, 665 
indicated in electrocardiogram. 542 
in diphtheria, 1074, 1076 
masked, 665 
permanent, 665 
pulse in, 667 
rheumatic, 665 
secondary, 478, 792 
septic, 666 
silent transient, 665 
Myocardium, damaged by rheumatism, iijr 
rupture of. 786 
toxemic, inadequacy of, 588 
Myofibrosis. 668 
Myogenic theory, 464 



1412 



(xEXERAL INDEX 



Myoidema, 48 
Myokymia, 48 

Myomalacia cordis, 668, 768, 802 
Myopia, 1229 

Myositis, acute primary suppurative, 1160 
sepsis in, 1161 
symptoms of, 1161 

fibrosa. 1161 

from occupation, 63 

interstitial, 11 59 

ossificans, 1162 

suppurative, 1160 

syphilitic, 1160, 1161 

tuberculous, 1161 
Myotonia, 48, 1266 
Mytilotoxin, 1288 
Myxedema, 176 

acute, with exophthalmic goiter, 178 

adultorum, 177 

co-existing with acromegaly, 17S 

diagnosis of, 179 

hands in, 40 

in adult, duration of, 178 
symptoms of. 178 

larval, 11 84 

masked, 179 

operative, 177 179 



N 



Xaegeli's blood cells, 124 

myeloblasts, 160 

reports on tuberculosis, 415 
Nail-shedding, 42 
Napoleon, facial expression of, 12 
Narcolepsy, 1272 
Narrowing of cardiovascular field of response, 756 

auscultation and percussion in, 757 

physical signs of, 756 
Nasal catarrh, 335 

congestion, 337 

cough, 327 

discharge, purulent, 337 

irritation due to fumes, 1305 

obstruction, 335 

polypi, 336 

secretion in leprosy, 1122 

septum, leprosy of, 1120, 1121 

sinuses, accessory, inflammation of, 91 
blocked drainage of, 91 

syphilis, 336 
Naso-pharynx, examination of, 334 

infection of, 1089, 1090 

obstruction of, 69 
Naso-pharyngeal vertigo, 104 
Nates, prominent, 12 17 
Nausea, nervous mechanism of, 872 
Navel as a landmark, 807 

care of, 1125 
Neapolitan fever, 1053 
Necator Amerieanus, 1130 
Neck, back of, tender, 100 

inspection of, 435 

rigidity of, 50, 1084 

scars, 29 

sign in meningitis, 1197 
Necrosis, exudation, 1153 

in typhoid, 1006 

nasal, syphilitic, 336 



Necrosis of facial bones, 11 18 
of leprosy, 1121 
of thoracic tissues, 774 
superficial, 1270 
syphilitic, 752, mi 
Needle, exploring, 375 
Negri bodies, 1124, 1125 
Neisser, gonococcus of, 1158 
Neoplasms, gummatous, 1110 
Nephrectomy in renal tuberculosis, 270 
Nephritides, blending of lesions in, 250 

mixed, 250 
Nephritis, acute, 254 
and septic foci, 217 
and subacute, casts in, 243 
arterial tension in, 256 
as complication of scarlet fever, 107 1 
blood pressure in, 478 
causes of, 254 
clinical aspect of, 255 
complications of. : 5 J 
convalescence from, casts in, 243 
edema in, 256, 257 
etiologic factors of, 254 
from nervous influences, 255 

interstitial non-suppurative, 258 
macroscopic appearance in, 256 
microscopic pathologic findings, 256 
morbid anatomy of, 255 
of pregnancy, 254, 255 
onset of, 256 
"pasty" face in, 256 
portentous signs of, 258 
precautions in, 257 
recovery from, 258 
slow heart in, 492 
stages of, 257 
symptoms of, general, 256 
urinary findings in, 257 
albumin absent in, 215 
and cerebral hemorrhage, 1245 
arterial hypertension of, 1241 
chronic diffuse arteriolar. 762 
early urea in, 202 
exacerbations of, 258 
interstitial, 261 

arteriosclerosis in, 261 
blood pressure in, 262, 265, 478 
cardiac failure in, 263 
chronicity of, 265 
circulation in, 262 
congestion in, passive, 265 
early stages of, 263 
edema in, 263 

ehmination in, defective, 265 
etiology of, 261 
fundus oculi in, 263 
heart in, supported, 265 
heralds of death in, 265 
microscopic changes in, 261 
morbid anatomy of, 261 
prognosis in, 265 
respiratory tract in, 263 
subacute attacks of, 265 
symptoms of, cardiac, 265 
frank, 4 
general, 262 
renal, 265 
synonyms for, 261 



GENERAL INDEX 



141, 



Nephritis, chronic, interstitial, systolic pressure 
in, 262 
terminal stage of, 265 
unrecognized, 262 
uremia in, 262 
urine in, 262, 264 
parenchymatous, 258 
albumin in, 260 
blood pressure in. 478 
casts in, 243 

epithelial, 260 
etiology of, 258 
exacerbations in, 259 
microscopic findings in, 259 
mixed type of, 260 
morbid anatomy of, 259 
prognosis in, 260 

stages of, active and inactive, 259, 260 
symptoms of, 259 
urinary findings in, 259 
termination of, 461 
toxemia in, 767 
unrecognized, 258 
complicating scarlet fever. 484 
heart silhouette in, 586 
in polymyositis, 1160 
interstitial, 22 

angina pectoris in, 480. 

772, 773 
arterial blood pressure in, 460 
arterio-capillary fibrosis, 761 
circulation of blood in, 460 
color in, 145 

confused with diabetes, 1169 
heart conditions in, 629 
high pressure of, 720 
in lead poisoning, 1287 
in tricuspid stenosis, 72S 
urine in, 191 
with hypertension. 93 
mixed, 260, 263, 265 
pallor in, 15 

persisting crepitation in, 401 
prognosis in, based on urea index, 210 
signs of, obscured, 648 
sine albuminuria, 202 
terminal chronic, with achylia, 883 
trench, 266 

urea concentration in. 204 
Xephrolysins, 247 

Xerve cells, degeneration of, 1091, 1190 
effect of trauma upon, 109 
grouping of, 1185 
regeneration of, 1191 
deafness, 1234 
Nerves, auditory, 1234 
eleventh, 1236 
facial, course of, 1233 
fourth, 1231 
fifth, 1232 

germ invasion of, 1267 
glosso-pharyngeal, 1215, 1235 
hypoglossal, 1214, 1237 
inflammation of, 1267 
involvement of, in meningitis, 1085 
laryngeal, 1236 
lesions of, symptoms of, 1233 

tests for, 1 23 1 
ninth and tenth, 1235 

87 



Nerves of eye, abducens, 1230, 1231, 1232 

motor oculi. 1230, 1231 

patheticus, 1230 
ophthalmic division of, 1232 
peripheral, 1187 
sensory, in skin of foot, 1205 
seventh, 12 15 
sixth, 1231, 1232 
spinal, lesions of, 12 18 
sympathetic cardiac, 469 
third, 1 23 1 
twelfth, 1237 
Nervous depression in diphtheria, 1075 
dyspepsia, 657 

in relation to gastric ulcer, 920 

symptom fragments of, 894 
excitement and high blood pressure, 47^ 
exhaustion and prostration, 1176 
system, anatomy of, 1185 

and malingerers, 1291 

and syphilis, 1190 

changes in, degenerative, 1191 
pathologic, 1 191 

diseases of, 1185 

classification of, 1191 
symptomatology of, 1191 

in anemia, 146 

in asthma, 360 

in febrile diseases, 75 

in heredity, 68 

in rabies, 1124 

in typhoid, 1003 

sympathetic, 1237 

syphilis of, 1254 
tension in aviators, 1283 
Nervousness in case of enlarged heart, 785 
Neubauer's ruling, 130, 133 
Neuralgia, cervico-brachial, 95 
cervico-occipital, 95 
digital, 97 
femoral, 98 
hypostatic. 950 
intercostal, 95 
lumbo-abdominal, 98 
of inferior and superior maxillary, 94 
of stomach, 85 
ophthalmic, 94 
pains of, character of, 94 

miscellaneous, 97 
peripheral, intense, 1238 
plantar, 97 
sciatic, 95 

tender points in, 94 
trifacial, 94. 1232, 1233 
Neurasthenia, 11 76 

as a bastard syndrome, 606 

as euphemism for "don't know," 756 

basic assumption in, 11 84 

brain fag in, 11 83 

causes of, cardiac, 11 83 

drug habit, 1184 

luetic, 1 1 84 

reflex, 11 S3 

sexual, 1 183 
clinical features of, 657 
comment on, 11 76 
described by Stiller, 11 79 
diagnosis of, 1177. 1183 

errors in, 1180 



1414 



GENERAL INDEX 



Neurasthenia, diagnosis, rarity of, 1178 

existence of, doubtful, 11 76 
infrequent, 1178 

focus and source of, 1182 

free use of term, 11 80 

morbid states in, 11 79 

nutrition in, 1179, 1181 

organic diseases diagnosticated as. 11 So 

painful areas in, 642 

passive, 595 

so-called cases of, 117 7 

surgery in, futile, 1182 

symptoms of, 651 

in cardiorenal disease. 11 77 
in cardiovascular syphilis, 11 76 
localization of, 1181 
psychic, 1 18 1 - 

syndrome of, 1176, 11 79 

treatment of, 652 

with "drop" heart, 449 
Neurasthenic arch, keystone of. 11 79 
Neurasthenics as bane of practitioner, 11S1/1182 

fatty overgrowth in, 758 

structurally deficient. 651 

vagaries of, 1181 

visceroptotic, 1182 
Neuraxons, 1083, 1084, 1085 
Neuritis, 1267 

alcoholic, 1285 

atrophy of, 41 

differentiation of, cautions, 1267 
from hysteria, 1209 

in beri-beri, 1291 

in leprosy, 1121 

multiple, 98, 1262 
recurrent, 1268 

pain of, 98 

peripheral, 1190 

relation of, to neuralgia. 98 

sciatic. 95 

symptoms of, 1267 

tenderness on pressure in, 1267 

trophic changes in, 98 

with myositis, 1 159 
Neurogliomata of brain, 1242 
Neuron theory, 1185 
Neurons, central, 1192 - 

motor, atrophy of, 1264 
lower, 1263 

peripheral, 1186, 1192 
Neurophagocytosis, 1091 
Neuro-retinitis, 1224 

albuminuric, 24S 
Neuroses, anxiety, n 79 

esophageal, 904 

fatigue, 63, 342 

gastric, 68 

traumatic, 1209, 1280, 1281 
Neutrophile granules, 116 
Neutrophiles, polymorphonuclear, 122, 123 
New-born, the icterus of, 19 

leucocytosis in, 138 
Newton's rings, 130, 134 
New York Life Insurance Company, standard 

tables of, 54. 55 
Niche on lesser curvature, 841 
Night sweats, 410 

terrors, 1273 
Nigrilies lingua, 37 



Nile sore, 1061 

Nipple a useless landmark, 278 

Nissl's tigroid substance, 1185 

Niter poisoning, 1306 

Nitric acid poisoning, 1302 

Nitro-benzol poisoning, 127 

Nitrogen balance, study of, 204 

excretion, 204 

increased and diminished, 199 
total, 198, 199 

intake, 207 

restriction of, 210 

output, determination of, 204 
percentage of, 201 

retention, 199 

saturation, 1239 

total, estimation of, 250 
Nitroso-indol reaction, 1032 
Nitrous oxid anesthesia, 483 
Nitze's irrigation cystoscope S29 
Nocardia, 425 

asteroides, 1130 

madurce, 1130 
Nocardiosis. _: - 
Nodal rhythm, 569 
Nodding spasm, 47 
Nodes, auriculo-ventricular, 466 

cutaneous, in endocarditis, 67S 

Heberden's, 1257 

of Tawara. 469 

"pacemaker," 544 

rheumatic, n 53 

sino-auricular, 466, 467 

syphilitic, 42 
immovable, 30 
Nodose arteriosclerosis, 761 
Nodules, cutaneous, on extremities. 27 

fibrous, over ventricle, 683 

of leprosy, 11 20 

of liver, 968, 970, 973 

rheumatic, 41 

tender, transient, 41 

tuberculous, 314 
Noguchi's allergic test, 748 

antigen, 982 

complement fixation method, 98S 

experiments, 1089 

modified Wassermann test, 9S7 

rabies virus, 11 24 
Noma, 36 
Normoblasts, 126 
Northwestern Life Insurance Company, blood 

pressure statistics of, 477 
Nose, big, in the Tropics, 11 17 

-bleed in pertussis, 327 
in typhoid, 1004, 1005 

diseases of, 335 

examination of, 334 

foreign bodies in, 337 

hemorrhage from, 337 

leprous, 1 1 22 

nodules in, 1126 

pug, in dwarfs, 189 

redness of, 33 

-rubbing, 62 

ulcers in, 1126 
Nostalgia, 147 

Nostrils, infection through, 11 26 
Nuclein, 211 



GENERAL INDEX 



HI5 



Nuclein, in the food, 1172 
Xucleo-albumin, 215 
test for, 219 

-protein, 211 
Nucleus cuneatus, 1188 

gracilis, 11 88 
Numbness. 10 1 
Nurses, pulse records of, 489 

temperature of, 72 
Nutmeg liver, 648, 968, 969 

diagnosis of, 972 
Nutrition, general, 945 

impairment of, 709. 463 

in aortic insufficiency, 720 

in carcinoma, 929 

in the anemias, 147 
Nutritional balance, restoration of, 623 

barometers, 604 

deficit, 895, 1 181 

depression, chronic or recurrent, 8S9 

instability in asthenics, 404 

level, 1 18 1 
Nux vomica, poisoning by, 1307 
Nylic standard table of heights and weights, 54, 

55 
Nystagmus, 32 

"caloric" horizontal, 1086 



Oatmeal breakfast, 858 
Obermayer's reagent, 193 
Obese, the life expectancy of, 187 
Obesity in diabetes, 1166 

and cardiac disease, 668, 669 

endogenous, 188 

exogenous, 187 

in women, cultivated, 188 

remarkable cases of, 188 

tendency to, 54 
Obscenity, 1276 
Obsessions, 11 79 
Obstruction, aortic, 739 

gastric, by mucous membrane, 937 

intestinal, for 30 years, 806 

of inferior vena cava, 27 

of lower bowel, diagnosis of, 89 

pyloric, 840, 919 

rectal, 952 

venous, 16 
Obstructive jaundice, 18 
Occlusion, intestinal, by foreign bodies, 88 
Occipital area, lesions of, 1244 
Occiput, boring, 1079 
Occupation a cause of appendicitis, 954 

active vs. sedentary, 63 

callosities due to, 66 

diseases due to, 63, 65, 66, 422, 423, 1123, 
1127 

involving changes of temperature, 761 
excessive heat, 65 

laborious, and the heart, 664 

poisoning, 64 

predisposing to tuberculosis, 403 

relation of habits to, 64 

suggested by dress, 13 
Ochronosis, 33 
Odors as cause of asthma. 356 

mousy, 1053 



Odors, rotten straw, 105s 
Office examinations, 638 
Oidiomycosis, 425, 1128 
Oidium albicans, 35, 1127 

coccidioide, 11 29 
Old age. diseases occurring in, 59 
Olfactory nerves, test of, 12 19 
Oligemia, in 
Oligochromemia, 1 r r 
Oligocythemia, in 
Oliguria, associated conditions, 191 

relation of, to color, 191 
to specific gravity, 191 
Oliver's hemocytometer, 136 

hemoglobinometer, 118, 119 
Omentum, adherent, 963 

tumors of, 819, 963 
Onychia, syphilitic, 1109 
Open-air life, 345 
Operations, exploratory, abuse of, 959 

in gastric ulcer, 929 

scars from, 29 

unnecessary, 869 
abdominal, 916 
Ophthalmoscope, use of, 1230 
Ophthalmoscopy, 1227 

direct and indirect, 1229 

tests in, 1294 
Opisthorchis felineus and sinensis, 1134 
Opisthotonos, 51, 1126 
Opium habit, 62, 1306 

poisoning, 1306 
Oppenheim-Babinski sign, 1197 

reflex, 1196 
Oppenheim's traumatic neuroses, 1281 
Oppression after meals, 580 

precordial, 664, 675 

sensation of, 101, 755 
Opsonic index, 3, 995 

in chronic infections, 99S 
technic of taking, 996 
test solutions in, 997 

theory, 994 
Opsonins, function of, 982 
Optic disc, observation of, 1229 

nerve, 1220 

atrophy of, 1226 
fibers, course of, 12 12 
lesions, 12 11 

neuritis, 562, 10S3 

in cerebral abscess, 125 1 
in endocarditis, 677 
primary, 1227 

thalamus, 12 11 
lesions of, 1245 
Optical apparatus in gastroscope, 829 
Optimism, 8 

scientific, 2 
Orange, retention of, in stomach, 933 
Orchitis as complication of mumps, 1069 

bilateral, 1069 

followed by atrophy, 1069 

in Malta fever, 1054 
Organisms, scintillating motility of, 1032 
Organs, hollow, roentgenizable, 834 

movable, palpation of, S04 
Oroya fever, 1062 

hemolysis in, 1062 
Orthodiagrams of heart, 429, 430. 431 



1416 



GENERAL INDEX 



Orthodiagraph^ outlines, 443 
Orthodiagraphy, 571 

modified, 571 
Orthopercussion, 290, 441, 442 

rectilinear, 638 
Orthopnea, acute, 50 

anginal, 776 

in pericarditis, 787 

obligatory, 756, 776 

of recumbency, 107 
Orthopneic variant, dyspnea in, 435 
Osier's views on albuminuria, 216 
Osseous development, 429 

tissues in syphilis, 11 10 
"Ossified man," 1162 
Osteitis deformans, 31, 186, 18S 
Osteoarthropathy, pulmonary, 40, 189 

hypertrophic, 186 

of hand, 186 
Osteomata of brain, 1242 

Osteomyelitis mistaken for rheumatism, 44, 
1255 

operation in, 1155 
Otitis media, chronic, 13 

in typhoid, 1004 

overlooked, 33 

suppurative, 10 71 
Ovarian cyst, 817 

simulated by gall-bladder tumor, Sn 
Ovaries, inflammation of, 956 
Ovaritis as complication of mumps, 1069 
Overexertion, avoidance of, 664 
Overstrain, cardiac, 677, 653, 664, 669 

Indian summer, 655 

mental, 64 

muscular, pain from, 640 
Overweight and life insurance, 669 

causes of, 5 7 

percentage of, 54 
Oxalates, excretion of, 214 
Oxalic acid poisoning, 1306 
Oxaluria, 214 
Oxidation, impaired, 16 

processes, 200 
Oxyacids in the urine, 194 
Oxybutyric acid in urine, 228 
Oxycephaly, 31 
Oxygen and CO2 exchanges, 649 

deficit, 656, 1282 

demand, 1283 
Oxyuris vermicularis, 113 7 
Oyster beds, infected by sewage, 1000 
Ozena, 336 

feigned, 1299 



Pacemaker of the heart, 466, 559, 563, 569 
Pachymeningitis, cerebral, 1237 

intracranial pressure in, 1238 
symptoms of, 1238 
external, 1238 
hemorrhagic, 1237 
subdural, 1238 
unilateral, 1249 
pseudo-membranous, 1238 
purulent, 1238 
spinal, 1237 
Paget's disease, 31, 188 



Pain, abdominal, 805 

and thoracic, alternating, 764 

absence of, misleading, 85 

anginal, 664 

with hyperesthesia, 771 

area of, in angina, 770 

as a purely subjective symptom, 83 

at inside of knee, 99 

atrocious, in appendicitis, 956 

bilateral, of angina pectoris, 731 

boring or gnawing, 85 

burning, after eating, 927 

cardiac, misleading, 90 

character of, in relation to diagnosis, 84 

-complexes, cardiovascular, 755 

denoting surgical emergency, 85 

diffuse, 869 

dull, 84 

dysmemorrheal, 958 

effect of posture on, 911 

epigastric, 100 

extreme, a cause of shock, 109 

from pressure, 755 

gastric, associated with hemorrhage, 920 
due to food contact, 914 

gnawing, remittent, 779 

gouty, 763 

growing, 1093 

hunger, 912 

in fold of groin, 99 
Pain, in gastric ulcer, 910, 911 

in hyperchlorhydria, 868 

in lower abdominal quadrant, 100 

in neuritis, 98 

lightning, 480 

median dorsal at shoulder level, 100 

misleading localization of, 45 

of inflammatory disease, 84 

paroxysmal, 85, 100 
cardiovascular, 647 
of sciatic type, 647 

radiating, 84 

referred, 84, 641, 911 
in angina, 771 
relieved by exudate, 84 
by taking food, 912 

sacral and mid-lumbar, 99 

sacro-iliac, 96 

simulation of, 1299 

site of, 84, 99 

subsidence of, 109 

terms descriptive of, 83 

transposed, 84 

variants, 868 
Painful zones, deceptive, 83 
Palate, high-arched, 40. 340 

paralysis of, 12 15, 1237 

perforation of, 13 
syphilitic, 1109 

reflex, 11 94 

soft, condition of, 40 
Pallor, ashen, 710 

earthy, of carcinoma. 933 

sudden, 15 

superficial. 720 
Palm, eruption of, syphilitic, 1109 
Palpation, abdominal, 816 
preliminaries to, 803 
vital points in, 804 



GENERAL INDEX 



1417 



Palpation, calamitous results of, 287 
concurrent, 834 
in pneumothorax, 378 
in pulmonary disease, 286 
of arteries, 763 

of chest, formal methods of, 287 
results of, 287 
technic in, 287 
of heart, 439 

and related organs, 439 
of kidney, bimanual, 266 
of liver, "dipping," 971 
of spleen, 805 

proper use of hands in, 803 
Palpitation in thoracic aneurysm, 701 

of heart, 491 
Pal's splanchnic abdominal crises, 771 
Palsy, bilateral, 1234 
birth, 1258 

cortical vs. peripheral, 1237 
ocular, 32, 1084 
pseudo-bulbar, 1265 
scrivener's, 46, 63 
shaking, 1276 
Panama Canal Zone, six-day fever in, 1059 
Pancarditis after rheumatism, 1152 
in children, 668, 783, 796 
secondary, 792 
Pancreas as secretory gland, 1162 
carcinoma of, 964 
diseases of, 964 

hypochlorhydria in, 870 
sign of, 856 
surgical, 965 
test for, 965 

urinary examination in, 964 
gangrene of, 964 
hemorrhage from, 964 
modern hypothesis concerning, 1163 
necrosis of, primary, 964 
palpation of, 815 
tumors of, 818 
Pancreatic cysts, 964 

extract in infantilism, 187 
ferments, activity of, 857 

tests for, 853 
inadequacy, 938 
secretion, 857 

regurgitated into stomach, 859 
Pancreatitis, acute hemorrhagic, 964 
diagnosis of, 964 
etiology of, 964 
symptoms of, 964 
suppurative, 964 
chronic, 964 
metastatic, 1069 
Panniculus, 820 
Papillary muscle insufficiency, 452 

transmission, 686 
Papillitis, 1227 
Papillomata, venereal, 11 09 
Papillo-retinitis, 1224 
Pappataci fever, 1058 

temperature chart of, 1059 
Papules, lichenoid, 1108 
orbicular, 11 09 
"shot-like," 1096 
syphilitic, 1107 
tubercular, 11 09 



Paracentesis, 323, 485 

abdominalis, precautions in, 485 
Paragonimus westertnanii, 425, 1134 
Paragraphia, 1203, 1204 
Paralysis agitans, 46 

diagnosis of, 1276 

arsenical, 1268, 1288 

ascending motor, 1262 

asthenic bulbar, 1267 

brachial plexus, 1268 

Brown-Sequard, 1192, 121 1 

bulbar, 1236 

circumflex, 1268 

crossed, 1230, 1234 

diaphragmatic, 1076 

diphtheritic, 1076, 1268 

divers', 1239 

Erb's, 1218 

facial, 1 211, 1233 

feigned, 1299 

flaccid, 1 192 

forms of, combined, 1287 

gait in, 13 

general, of the insane, 1251 

glosso-labio-laryngeal, 1213, 1264 

hypoglossal, 121 1 

hysterical, 1277, 1279, 1299 

in coma cases, 81 

infantile, 1089 
virus of, 982 

Landry's, 1262, 1263 
Paralysis, laryngeal, 1236, 1287 

lead, 1268, 1287 

motor, in myelitis, 1261 

musculo-spiral, 1268, 1287 

oculo-motor, 1208, 1212, 1220, 1230, 1305 
alternating, 1249 

of accommodation, 1076 

of cranial nerve of opposite side, 1248 

of jaw, 40 

of larynx, 1215 

of palate, 1237 
soft, 40 

of pharynx, 341, 12 15 

of scaleni, 12 15 

of vasomotor center, 480, 1074 

periodic transient, 1269 

peroneal, 1287 

pressure, 1268 

progressive symmetric ascending, 1263 

segmental, 12 13 

spastic, 1244 
of adult, 1257 
secondary, 1258 
spinal (family), 1258 

sternocleidomastoid, 121 5 

supranuclear, 1233 

symptoms of, 1231 

uremic, 1249 
Paramnesia, 1201 
Paramyoclonus multiplex, 48 
Paranoia, delusions in, 1201 

differentiation of, 1298 
Paraphasia, 14, 1203, 1204 
Paraplegia, ataxic, 1256 

cerebral spastic, 1258 

hereditary spastic, 1258 

hysterical, anesthesia in, 1260 
spastic, 1 259 



I4i< 



GENERAL INDEX 



Paraplegia, spastic, 1256 

transient, 248 
Pararrhythrriias, 543 
Parasites, animal, 1132- 

in liver, 968 

intestinal, 1133 

vegetable, in stomach, S77 
Parasitic diseases, eosinophilia in. 139 
Parasitization, 947 
Para-syphilis, 748 
Paratyphoid, agglutination reaction in, 992 

bacillus. 1001 

fever, 1001 

differentiation of, 1001, 10 13 
Parenchyma, insensitive, 84 
Paresis and civilization, 750 

depressive. 12 

etiology of, 749 

expansive, 12 

general, 12, 1251 

in Berlin, 749 

luetic, 748 

universal, 1240 
Paresthesia, 101, 1204 

in hematomyelia, 1239 

of intestines, 950 
Parietal area, lesions of. 1244 
Pariser's method, 945 
Parkinson's disease, 1276 
Parotitis, 1068 

in scarlet fever, 107 1 
Paroxysmal tachycardia, 556, 1057 
Parrots, enteritis of, 1012 
Parry's disease, 179. 180, 7 44 

pigmentation in, 175 
Pars pylorica, 821 

Pasteur treatment of rabies, 11 24, n 25 
Patches, mucous, 1109 

white, horny, nil 
Patella, displacement of, 186 

floating, 44 
Patellar clonus, 1195 

reflex, 1194 
Patent interventricular septum, 132 

ventricular septum and foramen ovale, 73 7 
Pathologic processes of disease, 4 
Patient as a "risk," 8 

benefit of, a fundamental factor, 9 

chest examination of, 277 

cooperation of, 9. 10 

dreaded type of, 404 

dropping of, out of sight, 659 

first impression of, 11 

frankness with, 8 

sensations of, 639 
Pavement cells, 331 
Pectoralis major, location of, 278 
Pectoriloquy, normal, 309 

whispered, 309 
Pedagogy, spoon-feeding in, 1 
Pediculus capitis and corporis, 1147 

pubis, 1 148 
Peliosis rheumatica, 169. U54 
Pellagra, 1289 

cachexia in, 1290 

diagnosis and prognosis of, 1290 

erythema in, 1290 

in United States, 1290 

insanity in, 1290 



Pellagra, symptoms of, 1290 
Pelvic disease simulating appendicitis. 956 
Pendulum heart, 572 
Penis, elephantiasis of, 1142 
Penman's cramp, 63 
Pension bureaus and malingerers, 1291 
Pentose in the urine, 228 
Pepsin acidity and activity. 862 
and pepsinogen, tests for, 863 
in relation to HC1. 862 
test, 856 
Peptones, 857 
Peptonuria, 216 
Percussion, accuracy in. 443 

and auscultation, combined. 443 
apex, 293, 294 
areas, 280, 293 
auscultatory, 291, 294 

in aneurysm. 7:7 
author's preferred method of, 442, 443 
axillary, 291, 293 
cardiac, skilful, 638 
clavicular, 293 
descriptive terms in, 292 
dulness, 292 

dulness, misleading, 298 
patches of, 417 
retraction of area of, 775 
factors in, cardinal, 292 
flat-finger, 280, 290, 439, 440, 441. 684 
flatness, 292 
hepatic, 293 

immediate and mediate, 289 
in appendicitis, 955 
in emphysema, 353 
Percussion, Kronig's method of, 294, 295 
light or moderate, 291 
methods, correct, 745 

modern, 662 
note amphoric, 298 
drumlike, 298 
inequality of, 416 

.-•...■.'. 7.:-.'. _;- : 
~ : iilcations of, 29S 
pitch of, 298 
tympanitic, 298 
of heart, 439, 440 
of skull, 1 25 1 
of stomach, 832 
palpatory, 366 
position of patient for, 291 
pounding, 291 
resistance to, 441 
rod pleximeter, 290, 291 
roentgenographic outline, 638 
sounds, characteristics of, 292 
intensity of, 292 
normal, 292, 293 
pitch and quality of, 292 
spinal, 296, 297 
stroke, 290, 442, 443 

staccato vs. sustained, 289, 290 
strong, 290, 291 
technic of, vital points in, 290 
threshold, 441, 638 
thrill, hydatid, 969 
tone elicited by, 290 
zones, spinal, resonance of. 296 
ration, gastric, acute and subacute. 926 



r.KXERAL INDEX 



1419 



Perforation, chronic. 926 

into peritoneal cavity, 925. 067 
of hepatic abscess, 966 
of hydatid cyst, 1137 
of soft palate, 40 
Pericardial adhesions, 79^. 793 

limiting, 799 

partial or universal, 795 
cavity, obliteration of, 792. 795 
effusion, 769 

aspiration of. 800 

blood pressure in. 48 2 

bloody, 797 

cardiac outline in. 797 

cough in, 800 

diagnosis of, 800 

in a railroad brakeman, 800 

large vs. small, 798 

lung compression in, 798 

massive, 599 

obscure, 799 

percussion in, 301, 799 
dulness in, 790 

pressure effects of, 798 

serous, 794 

small, 790 

— ptoms of, 789 

variations in, paradoxic, 7 98, 799 
exudate, 792 

absorption of, 794 

fibrinous, profuse, 794 

flooding, 797 

purulent, 791 

serous, 797 
friction, 788 

. rub, transmission of, 789 
sounds, audibility of, 793 
genesis of, 793 
recession of, 794 

superficial, 788 
inflammation, 792 
lubrication, perfect, 791 
murmurs, 788 

posturally induced marginal, 794 

time of, 788 

variations in, postural, 794 
relationships, 791, 792 
sac, big-bellied decanter shape, 7S9 
secretion, checked, 793 
serous membrane, 792 
surfaces, dry and harsh. 794 
Pericarditis, 781 
acute, 800 
afebrile, 786 
after rheumatism, 1152 
age and sex incidence in, 7S3 
as a complication, 783 
as a secondary disease, 786 
autopsy reports of, 786 
chest diameters in, 799 
cyanosis in, 787 
diagnosis of, 799 

fundamental factor in, 799 
dry, 784. 799 

and wet, symptoms commor. 

search for effusion in, 802 
. enormous distention in, 790 
etiology of, 782 
exudative, 581, 705 



Pericarditis, fibrinous, 7S4 

idiopathic, 786 

in public clinics, 799 

level of dulness in, 790 

mortality in, 800 

myocardial involvement in, 796 

obscure, 799 

pain of, localization of. 787 

pallor in, 787 

pathology of, 792 

pressure symptoms in, 790 

profile percussion in, 789 

prognosis in, 800 

pulse in, -> _ 

rationale of, 79 1 

resolution and repair in, 795 

scorbutic, 790 

septic, 786 

silent, 786 

subacute, 800 

symptoms in, warning, 801 

unrecognized, 786 

wet, 784, 786 

with effusion, 580, 787 

with pulmonary tuberculosis, 782, 786 
Pericardium adherent to heart. 437 

anatomic structure of, 793 

autopsies upon, 799 

normal surface of, 79i 

structural continuity of. 792 

sudden flooding of, 797 
Perigastritis of ulcer, 931 
Perihepatitis, acute, 973 

chronic. 969 

friction sounds in, 811. 973 
Perinephritic suppurations, 815 
Perionychia, 11 09 
Periostitis, multiple with splen : 

of facial bones, 11 18 

osteoplastic, 11 17 

syphilitic, 439 
Peristalsis, 885 

fierce, 806 

gastric, 822 

"ladder-pattern," 806 

normal, 806 

of colon, 951 

persistent interruption of, 91S 

spontaneous, 836 

visible, 806, 951 
Peristaltic knobs, 817 

unrest, 871, 949 
Perisystole, 885 

Peritoneal cavity, exudate in. zj. 
perforation into, 925. 967 

friction, 809 

tuberculosis, chronic, 819 
Peritoneum, cancer of, 963 

lesser, in appendicitis. 961 
Peritonitis, acute, 959 
diffuse, 959 
general, 959 
local, 959 
posture in, 50 

adhesions in, 960, 962 

as blanket term, 953 

chronic, 062 

etiology of, 960 

forms of, misleading. 960 



1420 



GENERAL INDEX 



Peritonitis, friction areas in, 960, 962 
general, in appendicitis, 955 

symptoms of, 925 
hysterical, 960 
infection of, 1034 
localized, 961 
organisms found in, 960 
pelvic, 956 
perforative, 960 
primary, 959 
restlessness in, 1300 
secondary, 792, 959 
septic, 960 

in typhoid, 1002 
simulated, 1300 
symptoms of, 960 
tuberculous, acute miliary, 962 
age and sex incidence in, 962 
chronic fibroid, 962 

ulcerative, 962 
diagnosis of, differential, 963 
exudate in, 963 
involvement of prostate in, 962 

of seminal vesicles in, 962 
pathologic manifestations, 963 
pigmentation in, 963 
primary focus in, 962 
simulating typhoid, 1013 
tumor in, 963 
vomitus in, 960 
wasting in, 960 
Pernicious anemia, Addisonian, autopsy findings 
in, 153 
blood in, 152, 153 
diagnosis of, 153 
etiology of, 151 
heart in, 152 

lemon-yellow color in, 151 
onset of, insidious, 151 
simulated by other diseases, 153 
symptoms of, striking, 152 
urine in, 153 
age and sex in, 151 
and achylia, 883 
and "drop" heart, 631 
aplastic, 154 

autopsy findings in, 154 
blood and color index in, 154 
etiology of, 154 
blood in, 144, 855 
cure in, false, 162 
diastolic murmur in, 452 
hemolytic, 194 
hemorrhage in, 1254 
leucocytosis in, 137 
plastic, 151, 854 
prognosis in, 162 
"Personal equation" in prognosis, 8 
Perspiration, changes in, qualitative, 20 
checking of, 1284 
in rickets, 1175 
Pertussis, 1103 

associated with measles, 1067 
Peru, fever in, 1062 * 

Pessimism, 8 
Pest, 1032 

Pestis major, symptoms of, 1033 
varieties of, 1034 
minor, 1034 



Petechias, 27 

bleeding from, 35 
in endocarditis, 677 
Petit mal, 104, 1272 
simulated, 664 
Peyer's patches, lesions of, 1002 
Pfeiffer's bacillus, 383, 1016 
discovery, 1008 
method, 1032 
reaction, 983 
Phagocytic activity, index of, 995 
Phagocytosis, 994 
Phantom cells, 234 
-pulse, 706 
tumor, 816 
chronic, 817 
crucial test of, 816 
Pharyngeal plexus, 1215, 1216 
Pharyngitis acute and chronic, 339 
atrophic, 339 
follicular, 339 
in scarlet fever, 1071 
syphilitic, 341 
Pharyngology, technic in, 334 
Pharynx, diseases of, 339 
examination of, 334 
paralysis of, 341, 12 15 
reflex, 1194 
tumors of, 341 
vertical red band in, 341 
Phenolphthalein solution, 864 

test of total acidity, 864, 865, 866 
Phenolsulphonephthalein excretion, percentage 
of, 208 
test, 121, 203, 209, 210, 251 

clinical application of, 252, 265 
color reaction in, 252 
technic of, 252 
Philippines, seven-day fever in, 1059 
Phletitis, acute septic, 23 
migratory, 23 
saphenous, 1004 
septic, 1240 
Phlebosclerosis, 499. 763 
Phlebotomus fever, 1058 
Phlebotomy in erythrocytosis, 164 
Phloridzin test, 251 
Phobias, inveterate, 1179 
Phonocardiograph, 524 
Phosphates, excretion of, 213 

increased or decreased, 214 
in urinary sediment, 230 
in the urine, 222 
Phosphaturia, 213, 214 
Phosphorus poisoning, 65, 1306 

differentiated from Weil's disease, 975 
Photography, mental, 6 
Photophobia in measles, 1066 
Phthisiophobia, 409 
Phthisis, fibroid, 423 

lung borders in, 295 
florida, 406 
pulmonary, 401 

tuberculo-pneumonic, acute, 406 
voice in, 14 
Physical effort, recurring maximal, 665 
findings, baffling, 62 
overstrain, factors in, 653 
work and arterial tension, 761 



GENERAL INDEX 



1421 



Physician, life of, strain of, 64 
truthfulness on part of, 9 
unscrupulous, 1292 
Physique vs. heredity, 70 
Pick's disease, 796 
Pigeon breast, 284, 399. H75 
Pigment atrophy, 174. 1122 
cells in sputum, 329 
deposits in tongue, 37 
in malarial organisms, 1045, 1046 
urinary, 219 
Pigmentation in splenomegaly, 155 
obscure, 17 
of tissue, 424 
streaky, 17 
Piles, bleeding, 476, 942 
Pilleus ventriculi, deformity of, 842 
Pilling bracelet-stethoscope, 474 
Pilocarpin, test doses of, 178 

use of, in leprosy, 11 22 
Pipette, blood counter, cleansing of, 131 
care and use of, 122 
mixing, 132 
of Durham, 131 
Piroplasma hominis, 1055 
Pirquet's test, 412, 413, 414, 415 
Pitch, heightened, 309 

postural change of, 299 
Pitting from smallpox, 1099 
Pituitary gland, affection of, 184, 187 
Pityriasis versicolor, 11 27 
Plague, agglutination reaction in, 992 
bubonic, 1033 
blood in, 1034 

diagnosis of, differential, 1034 
etiology of, 1033 
historical data of, 1033 
morbid anatomy of, 1033 
pathognomonic sign of, 1034 
prognosis in, 1034 
pneumonic, 1034 
septicemic, 1034 
spots, 1034 

virulent types of, 1034 
Plantar reflex, 1196 
Plasma cells, 126 
Plasmodium malariae, 1037, 1040 
cultivation of, 1044 
estivo-autumnal, 1042 
falciparum, 1042 
vivax, 1040 
Plaster jacket a cause of obstruction, 898 
Pleochromie, 85s 
Plessimeter pressure, 441 
Plethora, 111, 187 
Pleura?, anatomy of, 361 

aspiration of, antiseptic, 375 
bloody fluid in, 362 
boundaries of, 279, 281, 379 
congestion of, 369 
disease of, malignant, 422 

tuberculous, 422 
diseases of, 34s 
examination of, 282 

roentgenograph^, 314 
exploratory puncture of, 375. 39L 426 
friction sounds in, 369 
interlobar thickening of, 310 
irritation of, 485 



Pleurae, location of, 279 

malignant growths of, 422 
normally silent, 369 
oversecretion in, 369 
reactionary changes in, 369 
rupture of, 374 
sarcoma of, primary, 422 
secretion of, checked, 369 
Pleural adhesions, 361 

auscultation in, 375 

diagnosis of, 375 

inspection in, 375 

palpation of, 375 

percussion of, 375 

puncture in, 375 

tracheal tug in, 777 
cavity, 361 

air filled, 376, 379 

gas in, 376 

pus in, 374 
effusions, 302 

borders and mobility of, 363 

dangerous, 363 

differentiation of, 365. 422 

encysted, 371 

in expiration, 368 

left-sided, 280, 281 

mensuration of, 368 

precipitate, 363 

pressure of, 446 

removal of, 365. 484 

serous, 370 

encapsulated, 364, 365 
unilateral, 368 

with transmitted tubular breathing, 391 
exudate, 323 

fibrinous, 361 

long persisting, 373 

purulent, 362, 376, 388 

serous, 362 

slow receding, 373 

streptococcic vs. pneumococcic, 376 

tuberculous, 363 
folds, 361 

interspaces, bulging, flush, or shallow, 365 
hydatids, 425 
sinuses, filling of, 370 
transudate, 382 
Pleurisy (Pleuritis), 361 
acute, decubitus in, 50 
applied anatomy in, 361 
as complication of many diseases, 362 
at the base, 956 
chronic, forms of, 376 

tuberculous, 376 
chylous, 376, 426 
complicating pneumonia, 362 
conditions confounded with, 368 
course and termination, 372 
diaphragmatic, 373 

physical signs of, 374 

posture in, 51 
diseases associated with, 362 
displacement of heart in, 322, 323, 365. 366. 

368, 372 
dry, 361, 792 

fibrinous, 792 
effect of, on lung and heart, 362 
Ellis curve in, 364 



1422 



GENERAL INDEX 



Pleurisy, encapsulated, 364, 365, 369. 37 1 
etiology of, 362 
exudative, 321, 323. 361, 374. 388 

simple acute, 365 
exudates in, 361, 362 
fibrinous, acute, 363 
decubitus in, 363 
physical signs of, 363 
symptoms of, 363 
fluoroscopy in, 368 
from traumatism of chest, 362 
Garland's angle, 365 
in scarlet fever, 107 1 
interlobar, 376 
massive, chest in, 368 

diaphragm in, 368 
painless. 786 
percussion note in, 371 
pressure upon lung in, 362 
primary, 793 

purulent, bacteria found in, 362 
rationale of, 369 
recovery from, 370 
PJvalta's test in, 362 
secondary, 792 

tuberculous, 143 
serous exudate in, 362 

simple, leucocytosis in, 374 
simple plastic, 372 
tuberculous, 363 
varieties of, 361 
wet plus sepsis, 374 
with effusion, 322, 363, 366, 370, 371 
aspiration in, 323, 375 
auscultation, 367 
bilateral, 370 
inspection in, 365 
palpation and percussion in, 366 
physical signs of, 365 
serous, 364, 372 
with pulmonary gangrene, 420 
Pleuritic adhesions, 323. 375 

friction, 361, 368 
Pleuro-diaphragmatic adhesions, 323 
Pleurodynia, 1162, 1163 
Pleuro-pericardial murmurs, 454 
Pleuropneumonia, pericarditis in, 792 
Pleximeter finger, 289, 443 
Plexor strokes, 441 
Plugs in sputum, 330 
Plumbism, 1286 

Pneumatosis, detection of cause of, 871 
Pneumobacillus of Friedlander, 383 
Pneumococcus, types of, 384 
Pneumometry, 276 

Pneumonia a cause of empyema, 385, 387 
acute lobar, temperature in, 77 
afebrile, 387 
senile, 397 
alcoholic, 385, 1182 

and auriculo-ventricular dissociation, 569 
apex, 300, 388 

as complication of infectious diseases, 386 
389 
of influenza, 386 
aspiration, 394 
associated with pleurisy, 362 
blood pressure in, 481 
broncho-, 324 



Pneumonia, catarrhal, 394 
central, 387 

consolidation in, 299 
diagnosis of, 391. 392 
hyperresonant areas in, 387, 392 
percussion in, 390 
physical signs of, 392 
chronic diffuse interstitial, 423 
interstitial, 423 
lung borders in, 295 
co-existent with pericarditis, 786 
complicating scarlet fever, 1071 

influenza, 394 
confounded with appendicitis, 956 
contagiousness in, 385 
crisis in, 324, 325 
croupous, 383 
decubitus in, 50 
diagnosis of, 10 13 

differentiation of, by X-ray, 324, 386 
diseases, chronic, ending in, 386 
examination in, routine, 287 

roentgen, 324 
fatal ominous sign in, 318, 324 
heart in, 325 

sounds in, 44s 
hypostatic, in a febrile disease, 391 
in the aged, 388 
in tuberculous persons, 389, 393 
influenzal, 393, 394 
inhalation, 394 
interstitial, 423 

chronic, symptoms of, 424 
extreme chronicity of, 424 
morbid anatomy of, 423 
lobar, 383, 385 

adhesion following, 372 

age, race, and sex in, 385 

albuminuria in, 389, 393 

antecedent disease, 385 

as a toxemia, 393 

associated with mixed infections, 391 

blocked bronchi in, 392 

blood in, 389 

breath and voice sounds in, 387 

bronchial and tubular breathing in. 392 

cardiac dilatation in, 389 

changes in, rapid, 385 

complications, 393 

conditions associated with, 385 

congestion in, stage of, 384 

consolidation in, 384, 390 

cough in, 388 

crepitation in, 390, 391, 392 

crisis in, 388, 393 

cyanosis in, 390, 393 

delirium in, 389, 393 

diagnosis of, 391 

diagram of, 387 

differentiation of, 391 

diseases antecedent to, 385 

dulness in, limitations of, 299 

dyspnea in, 389, 393 

effect of altitude and season in, 385 

of smelter fumes in, 385 
etiology of, 385 
expectoration in, 385, 388 
fever in, persistent, 375 
frank, affected side in, 390 



GENERAL INDEX 



1423 



Pneumonia, lobar, frank, immobility in, 390 
physical signs of, 390 

from exposure and fatigue, 385 

gastrointestinal tract in, 389 

headache in, 389 

heart and pulse in, 389 

hilus, 324 

hyperresonance in, 300, 387, 390 

immunity in, 383, 385 

in arrested tuberculosis, 389 

in children, 38s. 386, 388 

infectious agents in, 383 

leucocytosis in, 389 
persistent, 375 

microscopic findings in, 384 

morbid anatomy of, 384 

mortality from, 384, 385, 388 

pain in pleuritic, 388 

palpation in, 390 

percussion in, 390 

physiognomy of, 389 

predisposing factors of, 385 

prognosis in, 393 

pseudo-crisis in, 388 

r^les in, 392 

rationale of, 392 

recurrence in, 385 

resolution in, 384, 391 
delayed, 375. 387. 388 

respiration in, 389 

selective points in, 388 

signs of, 392 
prognostic, 389 

sitting posture in, 390 

sounds in, ominous, 393 

sputum in, 392 

stages of, 384, 385 

symptoms of, 388, 392 

temperature rise in, immediate, 394 

toxemia in, as dominant factor, 392 
febrile, 387 
high-grade, 392 

urine in, 389 

voice sounds in, 390 

white. 424 

with leucopenia, 138 

with pleural effusion, 387 
lobular, 394 

exudate in, 394 

morbid anatomy of, 394 
localized, 418 
massive, 300, 387, 392 

displacement signs of, 387 

sound damper in, 289 
metastatic or embolic, 394 » 
migratory, 79, 387 
patients, public vs. private, 393 
recurrent, 393 
resolving, 325 
senile, 387 
septic, 393. 394. 419 

by extension, 394 

extremely fatal, 393 
simulated by tuberculosis, 406 

sitting posture in, dangers of, 287 
syphilitic, 321 
terminal, 386 
toxic cases of, 386 
traumatic, 387 



Pneumonia, typhoid, 386 

varieties of, 386 

white, 424 
Pneumonic plague, 1034 

triangle, 324 
Pneumonitis, 383 

hemorrhagic, 395 
Pneumonoconiosis, 423, 424 

roentgenogram in, 320 
Pneumopericardium, 791 
Pneumothorax, artificial, 324 

bilateral and sudden, 377 

blood pressure in, 482 

complete spontaneous, 351 

course and termination of, 382 

differentiation of, 323, 381 

encapsulated, 380 

etiology of, 376 

exudate, 323 

fistula formation in, 376 

fluid in, 379 

freely movable, 379 
upper boundary of, 379 

gaseous content of, 378 

heart displacement in, 379, 380 

Hippocratic succussion in, 312, 379 

inrush of air in, 378 

left, 369 

liquid exudate in, 376 

lung compression in, 378 

occurrence of, in perfect health, 380, 381 

open, 302 

percussion note in, 379 

physical signs of, 378 

rationale of, 378 

recovery from, 377. 380 

sex incidence in, 377 

signs of, cardinal, 379 

silent onset rare, 378 

simulation of, 961 

symptoms of, urgent, 378 

tuberculous, 376 

tympanitic note in, 298 

X-ray findings in, 379 
Pocket, accessory, in stomach, 841 

duodenal, accessory, 842 
Poikilocytes, 126 
Poikilocytosis, 152 
"Pointing-error," 1086 
Poison a cause of coma, 80 
Poisoning, acids, mineral, 1302 

aconite, 1303 

acute, symptoms of, 1302, 1307 
treatment of, 1302, 1307 

ammonia, 1304 

anilin, 64 

arsenic, 64, 1287, 1303 

atropin, 1303 

belladonna, 1303 

bromin, 64 

cantharides, 1303 

carbolic acid, 1304 

carbon bisulphid, 64 

castor oil, 1304 

caustic alkalies, 1304 

chloral hydrat, ei304 

chlorin fumes, 64 
gas, in trenches, 348 

chromium, 65 



1424 



GENERAL INDEX 



Poisoning, chronic, a cause of asthma, 356 
cocain, 1304 
colchicum, 1304 
copper, 65 

corrosive sublimate, 1304 
croton oil, 1304 
fish, 1288 
food, 1288 
formaldehyde, 1305 
hydrocyanic acid, 1305 
iodin, 64 
lacquer, 1132 

lead, 38, 65, 478, 1132, 1170, 1253, 1286, 1305 
lobelia, 1305 
meat, 1132 
mercurial, 65 
mineral, 64, 1302 
mushroom, 1305 
opium, 1306 
oxalic acid, 1306 
phosphorus, 65, 1306 
potassium nitrate, 1306 
prussic acid, 1305 
ptomain, 1057, 1288 
strychnin, 1307 
silver, 175 

treatment of, 1302, 1307 
trench gas, 348 
turpentine, 65 
urine in, 192 
Poker spine, 43, 1156 
Polarimeter, 227 
Poliomyelitis, 1260 

acute anterior, 1089 
vs. myelitis, 1262 
infectious, 1089 
abortive, 1093 
contractures in, 1092 
carriers of, 1089, 1093 
diagnosis of, 1093 
epidemics of, 1089 
immunity to, 1089 
infection of, 1089, 1093 
inoculated into monkeys, 1089 
morbid anatomy of, 1090 
nasopharynx in, 1089, 1090 
onset of, 1092 

pain and tenderness in, 1092 
paralysis in, 1093 
prognosis, 1093 
reflexes in, 1093 
simulating bilious attack, 1093 
specific virus of,- 1089 
symptoms of, 1092 

cardinal early, 1092 
types of, gastro-intestinal, 1092 
meningeal, 1093 
respiratory, 1092 
virus of, 982 
weakness in, 1093 
anterior, in diphtheria, 1074 
joint pain of, 1154 
infectious, transitory paresis in, 1269 
Poll parrotry, 5 
Pollen seasons, 357, 358 
Polyarthritis, universal, 1151 
Polychromatophilia, 126, 152 
Polycythemia, in, 162 

causes of, multiple, 162 



Polycythemia, chronic splenomegalic, 480 
in cholera, 1032 
rubra, 163 
Polydipsia in diabetes, 1166, 1168 

primary, 1169 
Polygram, abnormal, 514 

marking and interpretation, 506, 514, 516 

measuring on, 502 
normal, 514 

of arrhythmia, 511, 512 
of auricular flutter, 512 
of delayed conduction, 513 
of "drop" heart, 516 
of extra systole (auricular), 507, 509 
(noda), 509 
(ventricular), 508, 509 
of fibrillation, 509, 510 
of pulsus alternans, 516 

celer, 516 
of tachycardia (paroxysmal) , 560 
variations, in, 505 
Polygraph, 276. 498 
portable, 500 
use of, 498 

valuable information given by, 516 
Polygraphic tracing, jugular and radial, 544 
Polymyositis, acute non-suppurative, 1159 
dermatitis in, 1159 
diagnosis of, differential, 1159 
mortality in, 1159 
symptoms of, n 59 
hemorrhagic, 1160 

cardiac involvement, in, 1160 
diagnosis of, differential, 1160 
nephritis in, 1160 
ossificans, 1162 
Polyneuritis, acute febrile, 1268 

in beri-beri, 1267 
Polyphagia in diabetes, 1166, 1168 
Polypi, nasal, 336 
Polyserositis, 795, 796, 797 
ascites in, 796 
effusions of, 375 
Polyuria and specific gravity, 191 
in amyloid kidney^ 266 
in diabetes, 1166, 1168 
preceding uremia, 249 
transient and trivial, 190 
vs. persistent, 191 
Pons, lesions of, 1245 
lower, 12 1 2 
upper, 1213 
rupture into, 1246 
Pork, raw, eating of, 1138 

tape worm'', 1135 
Portal obstruction, 806 
symptoms of, 972 
system, overloaded, 642 
vs. caval obstruction, 27 
Porto Rico, sprue in, 1064 
Post-mortem heart action, 465 
Postero-anterior position, 571 
Posture and the pulse rate, 484 

change of, in gastric dilatation, 899 
obligatory, 764 

sudden death after, 50, 107, 756 
dorsal, 805 

during auscultation, 693 
effect of, in cervical ribs, 96 



GENERAL INDEX 



1425 



Posture, effect of, on vertigo, 104 
for percussion, 285 
horizontal, rising from, 12 17 
in angina pectoris, 769 
in relation to cough, 328 
to pain, 911 

in scurvy. 172 

lateral, 805 
coiled, 50 

leaning forward, obligatory. 51, 107 

prone, 51 

semidorsal, 813 

sitting, 50 

while at stool, 952 
Potain's dulness "en casque." 757 
Potassium chlorate poisoning, 1307 

cyanide solution, 140 

nitrate, poisoning by, 1306 

permanganate in opium poisoning, 1306 
Potential, balance of, 524 
"Pott's disease," 902 
"Pouter pigeon protrusion," 304 
Power, loss of, 1192 

of endurance, diminished, 95S 
Pox, 1105 

great (syphilis), 1093 
Poynton on rheumatism, 587, 1153. 11 54 
Poynton's micrococcus rheumaticus, 1149 
Practitioner and consultant, relations of, 10 
Precipitation, principles underlying, 980 
Precipitin reaction, 985 
Precipitins, study of, 982, 983 
Precordial "boss" or "voussure," 438 

bulging, 438, 790 

distress, 606, 642, 764 

lifting, 437 

manifestations, neglect of, 771 

oppression, 146, 419 

pain, recurrent severe, 645 

retractions, 436 
Precordium, stitch in, 647 
Predisposition to disease, inherited, 67 

woman's. 60 
Pregnancy, Abderhalden test in. 935 

acute yellow atrophy in, 974 

blood pressure in. 485 

inquiry concerning, 62 

kidneys in, 254 

leucocytosis in. 137 

retinitis of, 1224 

urinary examinations in, 254, 485 

with marked hypertension, 485 
Presphygmic period. 458 
Pressure, abdominal, sudden relief of, 484 

blood. 471 

cubital, 636 

high systolic, 753 

intra-abdominal, 297 

intrapericardial, 786, 787 

intraventricular, 684 

obliterative, 636 

pain, 755 

palpation, 289 

paralysis. 1268 

points, 96 

in renal colic, 86 
over twelfth rib, 814 

pulmonary, alternations in, 729 

respiratory, registration of, 729 



Pressure -sense 1206 

stethoscopic, 303, 694, 788 

symptoms, 158 

from dilatation of auricle, 577 
in bronchial disease, 422 
in cerebral abscess, 1251 
in pericarditis, 790 
in various areas, 775 
irritative, 1238 
localized, 123S 
mediastinal, absence of, 426 
predominant, 775 
tenderness, circumscribed, 921 
venous, 487 
Presystolic "a" wave, 503 
Productive mesaortitis, Chronic, 751 
Progeria, 187 

Prognosis as affected by age, 60 
as traps for unwary, 7 
fallibility of, 9 
Progressive muscular atrophy, 1263 
first stage of, 1287 
types of, Aran-Duchenne, 1264 
bulbar, 1264 
Prolapse, rectal, 1057 
Pro-myelocytes, 124 
Prophecies, rash, 8 
Prostatic abscess, 274 

plugs, 244 
Prostatitis, acute, 274 

chronic, 274 
Prostitutes, harsh voice of, 14 
Prostration in acute infections, 588 

in influenza, 597 
Proteids, affinities of, 857 

excess of, 857 
Protein, ingestion, 1169 
for skin tests, 357 
metabolism, direct index of, 19S 
nitrogen determination in, 201 
foreign, response of tissues to, 992 
Proto-albumoses, 857 
Protodiastole, waves of. 502 
Protoplasm, excess of, 123 
Protozoa of intestinal tract, pathogenic, 946 

of Leishmaniasis, 1060 
Protozoan bodies in scarlet-fever, 1069 
Protrusion, localized momentary, 328 
Prowazek's corpuscles, 1094 
Prussic acid poisoning, 1305 
Pseudo-angina pectoris, 772 
-asthma. 107. 779 
-casts, 239, 243 
-clonus, 1 195 
-crisis, 79 

-hydrophobia, 1125 
-leukemia, 164 
-tabes, 1256 

-tuberculosis hominis streptotricha, 1130 
-typhoid fever, 1001 
infection of, 1014 
Psilosis, 1063 

Psittacosis simulating typhoid, 10 12 
Psoriasis, buccal, 38 
"P" split or mitral, 549 
Psychasthenia, 606, 11 75, H77 
and drop heart, 605 
curability of, 118 2 
symptoms of, 11 80 



1426 



GENERAL INDEX 



Psychasthenia, tendency to, 268 
with hysteric stigmata, 12S1 
"Psyche analysis," 1202 
Psychic derangements, 1201 
Psychoses, epileptic, 1272 

Korsakoff's, 1285 
Ptomain poisoning, 1288 

symptoms resembling, 1057 
a cause of fever, 74 
Ptosis, 1231 

hysterical, 1279 
Ptyalin, prolonged action of, S51 
Pubic pain, 100 

Pulex, irritans and penetrans, 1148 
Pulmonary abscess, 419 

aspiration of, 420 

closed, 420, 425 

perforation of, 419 

prognosis in, 420 

sputum in, 419 

symptoms of, 419 
accentuation, diminished, 6S7 
actinomycosis, 425 
affections in kyphoscoliosis, 766 
apoplexy, 418 
areas, 433. 449 

for auscultation, 305 
artery, dilatation of, residual, 325 

thrombus in, 418 
atresia, 732, 739 

murmurs of, 740 

prognosis in, 736 
block in arteriosclerosis, 766 
circuit, 682 

congestion of, 701 
circulation, obstruction to, 444, 728. 750 
cirrhosis, 423 
current from aorta, 739 
disease, cough in, 327 
distomatosis, 425 
dulness, 299 
edema, 400 

percussion note in, 301 
embolism, 418 
exudate, 426 
fibrosis, 106 

distinguished from aneurysm, 780 
field, mottling of, 314, 316, 317 
gangrene as a complication, 420 

differential diagnosis in, 326, 421 

odor in, 421 

perforation in, 421 

prognosis in, 421 

sputum of, 421 

symptoms of, 421 
hydatids, diagnosis of, 425 
hypertrophic osteoarthropathy, 1S9 
incompetence, 728 
infarct, 418 

diagnosis of, 419 

diseases associated with, 418 

genesis of, 418 

multiple and successive, 419 

symptoms of, obscure, 418 
insufficiency, 705, 728 

as replica of aortic regurgitation, 729 

blood pressure in, 730 
-stained sputum in, 731 

cardiac area in, 730 



Pulmonary, insufficiency, cyanosis in, 730 
diagnosis of, chief points in, 731 
differential, 731 
post-mortem, 731 
etiology of, 728 
murmur in, time of, 729 
audibility of, 729 
transmission of, 729 
quality of, 729 
pain in, 731 
pulmonary area in. 730 
pulsations in, 730 
pulse in, 730 
rarity of, 745 
rationale of, 730 
recognition of, 728, 729 
signs of, 771 

clinical, 729 
symptoms of, 729 
thrill in, 729 
lesions, characteristics of, 321 
phthisis, 401 
pressure, increased, 682 
regurgitation, 461, 728 
resonance, normal areas of. 292 
sounds, conduction of, diminished. 302 
second, 734 

accentuated, 460, 686 
stasis, ios, 460, 6S6, 698 
stenosis, 732 

ca-rdiac area in, 734 

comment on, 736 

congenital, 705 

cyanosis of, 731 

diagnosis of, differential, 736 

endocarditic, 736 

in adults, 734 

murmur in, 453, 734 

audibility of, 734 
non-congenital, 733 
rarity of, 744 
thrill in, systolic, 734 
transmission in, 734 
with defective ventricular septum, 733 
without septal defect. 73 ~ 
structures, ulceration of, 781 
syphilis, 424 
thrombosis, 419 
tones, 290 

second, 705, 729 
tonus, disturbed, 392 
tuberculosis. 577 

distinguished from aneurysm, 781 
early detection of. 661 
with achylia, 883 
tumors, 421 
hydatid, 426 

pressure symptoms in, 421 
primary and secondary, 421 
roentgenograms in, 321, 421 
tympany, 298 
valve, leakage of, 730 
veins, phantom pulse in, 706 
Pulsating tumor. 7 75 
Pulsation, anemic, 7S1 
aortic, 438 
arterial, visible. 741 
capillary, 495 
carotid, 496, 502 



GENERAL INDEX 



1427 



Pulsation, carotid vs. jugular, 496, 502 
epigastric, 354. 7o6 
expansile, 439 

and deliberate, 43S 

of aneurysm, 585 

of liver, 746 

of vascular growths, 781 
from mediastinal growths, 781 
in diagnosis of aneurysm, 585 
in "drop" heart, 581 
in jugular fossa, 765 
in veins of neck, 727 
normal, 42 

of abdominal aorta, 818 
of aneurysm, 436, 585 
of cardiac rhythm, 576 
of liver, 703, 706, 746 
over interspaces, 437 
presystolic jugular, 727 
transmitted, 585, 809 
venous, 496 
ventricular, left, 438 
vermicular, 762 
Pulse absent below knee, 53 
affected by posture, 484 
alternating, 542, 558, 561 

indicated in electrocardiogram, 561 
in polygram, 516, 561, 562 

induced by exercise, 562 

jugular, 570 

significance of, 561 
prognostic, 561, 562 
amplitude, 474 
bizarre terminology of, 495 
bounding, 494 

brachial, at varying pressures, 477 
capillary, 146, 434, 495. 496 
cardiac venous, 502, 664, 710, 715 
carotid, 457, 496, 502, 765 
compensated mitral type, 515 
compressible, 1075 
Corrigan, 710, 714, 718, 720 
deficit, 487 

dicrotic, 495. 1004, 1005 
disappearance of, 493 

extrasystolic irregularity of, 492, 493, 508 
force of, 488 
frequency, 490 
full and large, 494 
gaseous, 495 
in dorsalis pedis, 489 
in fevers, 76 
in posterior tibial, 489 
in scarlet fever, 1070, 107 1 
in the thirties, 769 
in yellow fever, 75 
influenced by age and sex, 490 
intermittent, 493. 515. 545. 569 
irregularity of, 493. 515. 552 
jugular, 513, 569, 707 

systolic, 707 
lability of, 490 
lack of synchronism in, 765 
methods of "taking," 488 
Mouneret's, 495 
mouse-tail, 495 
normal, 497 

presystolic venous, 552 
of extreme exhaustion, 562 



Pulse, palpation, technic of, 488 
paradoxic, 494 
peritoneal, wiry, 77. 495 
points to be determined in, 488 
positive penetrating venous, 496 
pressure, 182, 472, 473, 474 

high, 479. 715 

importance of, 472 

in mitral stenosis, 696 

increase of, 767 

in lead poisoning, 478 

low, 762 

with high systolic readings, 764 

method of obtaining, 718 
pseudo- Corrigan, 146 
pulmonary capillary, 698 
radial, 461, 488, 513 
rapid: diseases found in, 491 

in hyperthyroidism, 182 
rate and rhythm of, 488 

increased fever with, 490 

recovery test, 635 
records, instrumental, 514, 764 
recurrent, 489 

-respiration-temperature ratio, 76 
running, 491, 557 
size of, 488 
slow, 491 
slowing of, 635 
small, wiry, 494, 495 
strong or weak, 76 
subclavian, 765 
systolic jugular, 739 

extreme examples of, 707 

venous, 796 
taken by instruments, 490, 496 
-temperature ratio, disturbed, 1006 
tracings, 499. 557 
variations in, unilateral, 489 
venous, records of, 499. 505. 513. 556 
water-hammer, 494, 495. 719. 747 
Pulsus alternans, 490, 516, 550, 558, 561 
bigeminus, 494. 545. 548, 554. 560 
celer, 494, 516, 664, 719. 725. 747 

hidden, 729 

visible, 710 
deficiens, 493 
durus, 495. 725. 747 
intermittens, 493 
irregularis perpetuus, 494, 551, 555, 557, 701, 

702 
magnus, 494 
paradoxus, 796 
parvus, 494 
tardus, 494 
trigeminus, 494, 548 
vacuus, 494 
Puncture for blood examination, 112 
Pupils, Argyll-Robertson, 1252, 1254, 1256 
contraction of, 80, 122 1, 1228 
dilatation of, 1229, 1231 
in coma, 80 

solutions for, 1229 
inequality of, 1220 
"pin-point," 1306 
size of, 1223 
Purdy's direct centrifugal method, 221 
Purin bodies in gout, 1171 
group, 210, 211 



1428 



GENERAL INDEX 



Purkinje fibers, 466 
Purpura, 168 

arthritic, 169 

complicating, 168 

cruciform, 168, 169 

fulimans, 169 

hemorrhagica, 169 

Henoch's, 169 

hysterical, 168 

platelet count in, 168 

significance of, 168 

simple, 169 

simulated by scurvy, 168, 171 

symptoms of, constant, 168 

true, 169 

variolosa, 1097 
Pus, "anchovy sauce," 967 

casts, 242 

cells, differentiation of, 235 

from gastric abscess, 874 

in the stools, 939 

in the urine, 222, 235, 268 

chemic test for, 222 
» 
significance of, 235, 236 

Pustule, malignant, 1122, 1123 

syphilitic, 1109 
Putrefaction, albuminous, 192, 941 
"P" wave and summits, 520, 521, 522 
Pyelitis, 268 

caused by microorganisms, 268 

chills and fever in, 269 

etiology of, 268 

infection of, 10 14 

pain in, 268 

symptoms of, 268 

tuberculous, frank, 270 

urine in, 268 
Pyelonephritis, 268 

symptoms of, characteristic, 269 

tuberculous, frank, 270 
Pyemia, differentiation of, 11 19 
from endocarditis, 677 

symptoms of, 677 
Pyloric antrum, 830 

spasm of, 907, 918 

growth, 809 

obstruction, 806, 929 

patency, 840 

ring, ulcer near, 909, 9H 

sphincter, relaxation of, 886 

stenosis, benign, 874, 887, 898 
malignant syphilis in, 937 
with secondary ectasia, 859 

ulcer with spasm, 870 
Pylorospasm, 922 

"feel" of, 831 

residue of, 841 
Pylorus, adequacy of, 859 

carcinoma of, 836, 837 

location of, 822 

malignant growths of, 931 

obstruction of, 919, 922 
on gastric side, 845 
partial, 845 

palpation of, 818, 834 

patency of, test for, 858 

tumor of, 819 

visibility of, 831 
Pyonephrosis, tumors of, 815 



Pyopericardium, 791. 
Pyopneumopericardium, 791 
Pyopneumothorax, 376, 378 
Pyorrhea alveolaris, 39 
Pyramidal tract, crossed, 1188 

direct, 1188 
Pyrosis, 871 
Pyuria, 196 



Quack, diagnoses made by, 11 
Quadriceps muscle, contraction of, 1196 
Quincke's capillary pulse, 719 

disease, 1086 
Quinin, response to, in malaria, 1037 
Quinsy, 342 



Rabbit's cornea, inoculation of, 1103 

Rabbits, immunization of, 984, 985, 987. 99* 

Rabies, 1224, 1225 

Race in relation to disease, 69 

Rachitis, acute, 171 

Racial predisposition to disease, 60 

susceptibility to consumption, 403 
Radial pulse, 488 

tracings, 504 

wave, 502 
Radiogram of dilated "drop" heart, 600 
Radiography, intrathoracic, 314 

cardiac, 74s 
Radius, enlargement of, 42 
Railroad brain, 1280 

companies and malingerers, 1291 

injuries, mental shock in, 1282 
organic disease after, 1282 

spine, 1280 
Rales, bronchial, 397 

bubbling, 312 

consonance of, 310, 312 

crackling, 311 

crepitant, 311 

dry, significance of, 310 

friction, 313 

gurgling, 312, 346 

in acute bronchitis, 346 

in broncho-pneumonia, 398 

in tuberculosis, 311, 417 

moist, 310 

cardinal points concerning, 310 

mucous bubbling, 346 
click, 312 

pitch and resonance of, 312 

sibilant and sonorous, 310, 346 

subcrepitant, 311 
Rashes, appearance of, 77 

drug, 1068, 1072 

due to indigestion, 1072 

evanescent and polymorphic, 1072 

faded red, 1072 

in pellagra, 1290 

initial, of smallpox, 1099 

morbilliform, 1073 

of dengue, 1034 

of herpes zoster, 1269 

of scarlet fever, 1070, 1071 

punctate, 1070 



GENERAL INDEX 



1429 



Rashes, septic, 1072 

serum, 1068 

spurious, 1072 
"Raspberry" sputum, 329 
Rat bite fever, 1061 

glandular inflammation of, 1061 

morbilliform rash in, 1062 

relapses in, 1062 
Ray-fungus, 1130 

Raynaud's disease, 41, 42, 463, 767, 1270, 1271 
Reactions, biuret, 216 

color, 246 

electrical significance of, 1200 

myotonic, 48 

of degeneration, 11 89, 1192 
test for, 1200 

of feces, 941 

color indications in, 941 

spasmophilic electric, 49 

to accommodation, 1221 

to light, 1221 
Reagents, 987 

Recklinghausen's disease, 1269 
Records, marking and interpretation of electro- 
cardiographic, 525-542 
Recruits, healthy, tuberculin test in, 414 

syphilitic, 750 
Rectal crises, 935 
Recti, diastasis of, 805 

separation of, 953 
Rectitis, epidemic gangrenous, 1057 
Rectum, examination of, 832, 942 

foreign bodies in, 949 

obstruction of, 952 

spasm of, 949 

tonus of, 942 
Rectus abdominis, spasm of, 816 

femoris, myositis of, 1161 
Recumbency, heart in, 431 

dangers of forcing, 764 
"Red cyanosis," 16, 163, 164 
Reed, Walter, great work of, 1035 
Referred pain and discomfort, 641 
Refinement, measure of, 277 
Reflex arc, 11 93 

irritation, 11 83, 1184 
Reflexes, collateral, 1197 

corneal, loss of, 1233 

coordinate, 1193 

deep, 1 194 

disturbance of, 936 
loss of, 936, 1 192 

eliciting of, 1196 

in hysterical paralysis, 1299 

incoordinate, 1193 

localized, 1193 

ocular, 1220 
red, 1228, 1229 

organic, 1196 

plantar, 1196 

reenforcement of, 1194 

spasmodic, 1193 

special, 1194-1196 

superficial, 1196 
normal, 11 93 
Registration of heart sounds, 524 
Regurgitation, aortic, 434 

of blood, 715 

of food, 902 



Rehfuss' duodenal tube, 853 
Relapsing fever, 1049 

blood examination in, 105 1 
clinical chart of, 1049 
complications of, 105 1 
differentiated from yellow fever, 1037 
etiology and symptoms of, 1049 
febrile movement in, 1049 
morbid anatomy of, 1049 
Relationship between diseases, alternative, 68 
Remittent fever, 73 

temperature in, 78 
Renal abscess, 271 

activity, quantitative measurement of, 204 
asthma, 358 
calculus, 268, 956 
cells, changes in, 239 

differentiated from leucocytes, 235 

fatty, 238 

varieties of, 237 
cirrhosis and cerebral hemorrhage, 1246 
colic, 956 

pain in, 86 

simulated, 269 

simulating appendicitis, 955 
cysts, 271 

fluid in, 271 
diseases, classification of, 250 

chloride excretion in, 213 

chronic hypertensive, 748 
displacement, 267 
epistaxis, 223 

functional activity, test for, 251 
inadequacy, 250, 1246 
infarct, 270 
insufficiency associated with migraine, 93 

phenomena of, 247 
syphilis, 271 
tuberculosis. 269 

caseous, healing in, 270 

double, arrest of, 270 

etiology of, 269 

nephrectomy in, 270 

tubercle bacilli, examination for, 270 

unilateral, 270 
tubules, casts of, 239 
Rennin test, 863 

Research, cardiac and clinical, 496, 497 
Resemblance, physical, 70 
Reserve, arterial, 767 

failing, recognition of, 635 
nutritional, 821 
Residence, 58 

in case history, 66 
Resistance, interaction of, 73 
of cardiopaths, 653 
power of, 139 

lowered, 1150 
to disease, 68 

diminished, 404 
Resolution, pulmonary, 686 
Resonance, apex, normal, 293 
area of, 807 

diminution of, 293, 299 
extension of. 293 
increased, 292 
limit of, 293 
loss of, 279 
normal and increased, 291, 292, 293, 297 



i43o 



GENERAL INDEX 



Resonance, osteal, in spine, 296, 297 

Skodaic, 299, 366, 371 

typical, 293 

vocal, normal, 308 
diminished, 308 
Respiration, agonized violence of, 348 

artificial, in opium poisoning, 1306 
keeping alive by, 1263 

Biot's, 107 

Cheyne- Stokes, existing for years, 108 

counting of, 285 

deep, effect of, on pulse, 569 

forced, 368, 369 

frequency of, increased, 108 

grunting, 389 

harsh or puerile, 305 

in chloride gas poisoning, 348 

in fevers, 76 

jerky, 107 

lagging, 287, 352 

painful and gasping, 348 

phantom shadow in, 286 

ratio, normal, 285 

Seitz' metamorphosing, 308 

stertorous, 106 

thoracic, deficient, 1215 

wavy, 107 
Respiratory center, exhaustion of, 108 

curve, 562 

in tracing, 182 

failure, 1305. 1306 

mobility, 804 

movements, 287 

organs in typhoid, 1003 

phases, 794 

stages, 290 

system in the anemias, 146 

venous phenomena, visible, 496 
Rest, absolute, effect of, 781 

after prostrating infections, 589 

cure, 607 

for dyspepsia, 871 

pain relieved by, 781 
Restraint in alcoholism, 1286 
Resumption of normal activity, 589 
"Retention" dinner, 899 

frontal sinus, 339 

meals, 858, 882, 886 
process of taking, 859 

tests, 923 

gastric, 858, 882 
Retina, arteries of, 763 

detachment of, 1224 
Retinitis, albuminuric, 1223, 1224 

diabetica, 1224 

forms of, 1224 

hemorrhagic, 1222 

pigmentosa, 1224 
Retino-choroiditis, 1226 
Retinoscopy, 1228 

Retraction, rhythmic, paradoxical, 706 
Revelations, damaging, 8 

obligatory, 9 
Revidtzef's sign, 833 
Rheumatic arthritis, recurrences in, 1155 
streptococcic, 44 

fever, decubitus in, 50 
Rheumatism, acute, 99, 587, 1149 
age incidence in, 1150 



Rheumatism and endocarditis, 674 

and heart disease, 664 

anemia in, 1 152 

as cause of pericarditis, 782 
of valvular lesions, 673 

as "slow sepsis," 1150 

blood in, 1152 » 

cultures in, 1153 

causes of, 1150 

chilliness in, 1151 

chorea in, 11 54 

convalescence in, 1 1 52, 1 1 54 

diagnosis of, differential, 11 54 

duration of, 1151 

fever in, 115 1 

foci of infection in, 587 

gastrointestinal tract in, 11 53 

heart complications in, ,11.51, 1152 
valves in, 115 2 

heredity in, 11 50 

in children, 674, 11.51, 1154 

idiopathic, 786 

joint involvement in, 44, 1151, 1299 

nervous system in, 11 53 

nodules of, 11 53 

organism found in, 1149 

pancarditis in, 1150 

portals of infection in, 1149 

prognosis in, 1155 ■ 

recurrences of, 1152, 1155 

respiratory tract in, 115 2 

season and climate, effects of, 11 50 

silent character of, 786 

skin in, 11 53 

sore throat preceding, 1150 

symptoms of, 44, 1 150 

tonsil extirpation in, 587 

tonsillitis antecedent to, 1149 

watching the heart in, 676 
and cardiovascular breakdown, 765 
cerebral, 11 53, 1274 
chronic, 1157 

symptoms of, 44 
feigned, 1300 

followed by endocarditis, 683 
gonorrheal, 1157 
inflammation of joints in, 587 
masked, 5 
muscular, 98, 1162 
of septic type, 587 
organisms recovered in, 587 
relapsing, 587 
scarlatinal, 11 54 
simulated by trichiniasis, 1139 
syphilitic, 1157 
Rhinitis, acute and chronic, 335 
atrophic, 336 
hypertrophic, 335 
Rhinology, technic in, 334 
Rhizopoda, 1132 
Rhythm, cardiac, 454 

sounds of, 313 
fetal, 449 

in heart block, 569 
inspiratory, 286 
nodal, 569 

of heart murmurs, 461 
respiratory, variations in, 107 
tic tac, 561 



GENERAL INDEX 



1431 



Rhythm, ticking, 449 
trip' 

ventricular. 466 
Rhythmicity and normal heart beat, 464, 465 
Ribs, beading of, 284 

cervical, symptoms of, 96 
tenth, tenderness over 
Rice, shelled vs unshelled. 1291 
Rickets, 30, 42. 1175 
chest in, 2S3. 2S4 
deformity in, 1 1 7 5 
etiology of, 11 75 
posture in. 50 
prognosis in. 1175 
symptoms of, 11 75 
Rickety rosary, 30, 284. 11 75 
Ridges on nails, 41 
Riedel's lobe, 811 

in gall-bladder disease. 979 
Riegel test dinner, 858, 866. 892 
Right-handed persons, 1209. 12 10 
Rigidity, abdominal, 363. 804. 956 
arterial, 762 

defensive in cholecystitis. 976 
localized, 816 
maximal, 955 
jack-knife, 1263 
muscular, 1240, 1258 
of paralysis agitan>. 1276 
of stomach, 899 
plastic, 48 
Rigor mortis, 130 1 

in cholera cases, 103 1 
Rigors, rheumatic, 11 54 
Ring bodies, Cabot's, 128 
Ringer's solution, 465 
Ringworm, forms of, 1 1 2 7 
Rhine's test, 1234 
Rising at night, habitual. 192 
"Risk," patient considered as. S 
Risus sardonicus, 562, 1126, 1307 
Robust, the, heart outline in, 427 

loss of weight in, 409 
Rock fever. 1053 

Rocky Mountain spotted fever. 1055 
asthenia in, 1056 
causal agent, 1055 
diagnosis of, differentia'.. 1056 
prognosis in, 1056 
rash of, 1055 
symptoms of, 1055 
Rod plexirneter, 291 
Rter.tgen ray in rneurnttiicras. 3"; 

in trulrr. :r_ary abscess, 42a 
Roentgenogram, examination by, 314 

in heart disease, 439 
Roentgenography as aid to diagnosis, 916 
in abscess of liver, 967 
in cardiovascular lesicns 757 
of duodenum, 842 
of heart, exposure time in, 57: 
of stomach, 834, 851 
Roentgenologic outfit, expert crera:;;:; ::' ;;- 
Roentgenology, expense involved in, 917 

in gastric ulcer, 910 
Roentgenoscopy, 571 

in cardiovascular les::r_r 757 
in diagnosis of duodenal disease. S34 
of gastric disease, 834 



Roentgenoscopy in office routine. 638 

of stomach, 851 
Rogers, Dr. O. H., height and weight table of. 54, 

55 
Rolando, fissure of, 12 10 
Rombergism. 49 
Romberg's sign, 1255 
Rosary, rick^- . n 75 

Rose cold, 336 

spots, cultures of, 1001, 1006 
incorrect use of tern. 27 
:: typhoid, 1005, 1006 
Rose's dyspneic goiter, 183 
Rosenbach's phenomenon, 181 
Roseola, febrile, 1072 

produced by ether, 11 08 

syphilitic, 1108 
Ross on malaria, 1037 
R:5;': = ch's disease, 869 
Rotch's sign, 301, 790. 797 
Rotheln. 77- 1072 
"R." "5." •■T" complex ;t - 
"R" summits, 520 
Rubella, 1072 

ratarr'r. in, : : 73 

diagnosis of, differential, 1073 

rash of, 1072, 1073 
Rubner's test, 22S 
Rues, etigastri:. -53 

interscapular, 793 

"to and fro," 788 
Rumble, presystolic, 720 
Rupture, internal, 378 

of heart, 802 
Russt-Jaranese ~ar. 129: 
Rutkevich's sign, 958 



Saccharometer of Einhorn, 226 

r. :ianrr.e:er 227 
5a:r:-:iia: ta:r_ :: 
Saddle nose, 13, 33, 1111 
Sahli-Gower hemoglobinometer, 120 
Sahh^s hemoglobinometer, 118, 119. 122 
Salads, green, infection by, 1000 
Saline solution, normal, albumin in. 933 

transfusions for hypotension, 481 
a as carrier of rabies, 1124 

excessive, 867 

drooling of, 1265 
Salivary i:a£:a;t ; 5- 
Salivation, 35, 1300 

distressing, in sprue, 1064 
Sallowness, 672, 1288 
Salpingitis, 1012 
Salt retention, 20 

in fevers, 203 
Saltpeter poisoning, 1306 
Salvarsan in aortitis, 753 

in cardiovascular syphilis. 760 

in yaws, 11 16 
Sand-fly fever of India, 1059 
Sandow "effect," 304 
Sanitation and tuberculosis, 403 
Sansom, Dr. Arthur, stethoscope : : 
Santiago, yellow fever in. 1036 
; ;r::::2 "er.trituli. 877, 878, 900 
?ar::r:a melar.rti: ::; 



143 2 



GENERAL INDEX 



Sarcoma, nasal, 336 

of brain, 1242, 1244 

of lung, 421 

primary, physical signs of, 421 

vascular, pulsation in, 585 
Sarcoptes.scabiei, 1147 
Saturnism, 1286 
Scab, vaccination, 1102 
Scales, Centigrade and Fahrenheit, 1308 
Scalp, pustules on, 1109 

rash on, 1072 
Scapulas and spine, area between, 436 

approximation of, 12 16 

left, area of, 436 

location of, 278 

oblique position of, 12 16 

pain under, 99 
Scapular reflex, 1194 
Scar tissue, contraction of, 902 
Scarlet fever (Scarlatina), 1069 

age in, 1072 

and diphtheria, coincident, 107 1 

blood in, 1070 
count in, 140 
pressure rise in, 484 

broncho-pneumonia in, 395 

cause of, specific, unknown, 1069 

complications of, 1070, 1154 

convulsions and delirium in, 107 1 

desquamation in, 1070 

diagnosis of, 107 1 

etiology of, 1069 

fever in, course of, 1070 
secondary rise in, 107 1 

heart affections in, 107 1 

hot wet pack in, 107 1 

incubation period of, 1069 

malignant, epidemic, 78 

mortality of, 1070 

otitis media in, 107 1 

pulse in, 491, 107 1 

rash of, 1070, 1071 

rheumatism in, 11 54 

safeguards in, 107 1 

sex in, 1072 

sore throat in, 1070 

symptoms of, 1070 

temperature in, 77 

tongue in, strawberry, 37, 1070 

use of urotropin in, 1071 

of Vichy and cream in, 107 1 
Scars from acne, 29 

from granuloma, n 12 

from operations, 29 

history of, 28, 29 

of gastric ulcer, 899 

of lupus, 29 

syphilitic, 29, 1109, 1110, mi 

vaccination, 1099 
Schaudinn and Hoffman's treponema pallidum, 

1105 
Schick's diphtheria immunity test, 990 
Schistosomum hematobium, 1133 
Schizonts, 1043 
Schizotrypanum cruzi, 1146 
Schlesinger's solution, 854, 855 
Schneider's urobilinogen method, 854 
Schonlein's disease, 169 
School children, tuberculin test in, 414 



Schridde-Altmann granules, 125 

staining process, 124 
Schuffner's stippling, 128 
" Schwellenwerts " percussion, 441 
Sciatic nerve, lesions of, 12 19 
Sciatica, acute seizures of, 95 

chronic, and cardiovascular breakdown 
763 

differentiation of, 1300 

etiology of, 95 

feigned, 1300 

pain of, 647 

tenderness of, 101 
Scirrhus cancer, 931 
Sclerosis, amyotrophic lateral, 1238, 1264 

blood pressure in, 474 

diffuse, 1239 

disseminated, 46, 1239 

insulated, 1239 

miliary, 1239 

multiple, 1239 

murmurs of, 461 

of arteries, 761 

coronary, 641, 669, 768 

of veins, 763 

peripheral, 766 

postero-lateral, 1256 

primary combined, 1256 
lateral, 1257 

tuberculous, 1239 
Scoliosis, 43, 1260 

feigned, 1300 
Scorbutus, 171 

effect of diet in, 171 

etiology and symptoms of, 171 

pericarditis in, 799 

signs of, 42 
Scotomata, central, 1227 

flittering, 1227 
Scratching, infection from, 11 03 
Screaming in tuberculous meningitis, 1083 
Screen examination, 585 
Screw- worm disease, 1148 
Scrivener's palsy, 46 
Scrotum, elephantiasis of, 1142, 1143 

lymph, 1 142 
"Scuffing," 793 
Scurvy, 171 

age incidence in, 171, 172 

as a scourge, 171 

diagnosis of, by sight and touch, 172 

in Arctic expeditions, 171 

infantile, 50, 171, 172 

simulated, 1300 
by purpura, 171 

symptoms suggestive of, 172 
Sea level, abrupt transitions from, 162 
Sea-sickness, 11 84 

a cause of vomiting, 872 
Secretion of stomach, tests of, 918 
Secretory disturbances, 878 
Sedentary life and heart disease, 668 

and overstrain of heart, 654 
Segment symptomatology, 12 13, 12 14 
Seitz' metamorphosing respiration, 308 
Self-control, demand for, 1278 

-mutilation, 1292 

-starvation, 56 
Seliwanoff's test, 227 



GENERAL INDEX 



x 433 



Sella turcica, enlargement of, 1S5. 186 
Semon's triangle. 1006 
Senile arteriosclerosis. 761 
Senile changes, 11 00 

decay. 765 

the. febrile diseases in. 78 
"Senility " an abused term, 67 
Sensations, fainting, 101 

general. 1204 

localization of. 1204 

of dyspnea, 105 

of patients as a guide, 659 

of wading through water. 640 

perversions of. 101 

sinking. 101 

subjective, of cold and heat, 101 
Senses, articular, 1206 

contact, 1206 

muscle, 1102. 1204. 1206, 1260 

pressure, 1206 

srecial rerversicn ::' ::?: 

tactile. 832, 1206, 1260 

tendinous, 1206 
Sensitization, food, 356 

specific, inherited, 357, 092 
Sensitizer, hemolytic unit of, 986 

titration of, 985 
Sense ry areas ::i:u::i:i in :: ; : 
destruction of, 1192 
irritation of, 1192 

cliscnr'canees. i"i 
significance of. 1208 

functions, test of, 1204 

impulses, 11 86 

nerves, distribution of, 1205 

tract, direct, 11 87 
functions of, 11 89 
indirect, 1188 
Seysis. acute. :;j.: 

crvptogenetic, 75, 889 
local, 761 

c'rscure. sirrularel :y tr-:;::;::. -;: 
Sercal leviacicn. 3.35 
Serve a'cscrc :i:n. a cause ;: reyrrlcis :-.. 

foci, hidden, 664 
terlerral cu 

rhencncena i~~ 

::::r;;r. suggesrel :y al'currcses 1:5 
Septicemia combined with typhoid state, 1011 

differentiation of, 11 19 
Septicemic plague, 1034 
Septum, interventricular, patent, 732 

ventricular, lececcs :: -3] V3_ 
Serclcgy. level:; men-; in. ;S: 
Sercsivs rrulcicle _if 
Serous meningitis, 1086 

circumscribed, 1083 
Serine, icmrlercenc in. ;i_- 
988 
r symptoms of, 993 

technic, 987 
Serums, activation of, 983, 984 

antiplague, 1034 
lea:- c'rcm use ::'. ;;: 

human, 987 

immune, 983, 1089 

inactivated, 985 

incubation of, 988 

mode of obtaining, 997 



Serums, National laws concerning. 1 1 26 

normal and suspected. 997 

syphilitic, 984, 988 

ur.irr. rr.ur.e c ; 3 
Seton, scar from. 29 
Sex incidence in disease, 60 

in pernicious anemia, 131. 154 
Sexual development in dwarfs. 187 

excess. : : - 

intercourse and syphilis, 1006 
granuloma transmitted by, n 12 

neurasthenia, 11 83 

organs in cretinism, 178 

weakness. 1253 
Shadows, diaphragmatic, 286 

fan-shaped. 321 

hiras, 314 

veil-like, in pneumonia. 324 

"wooly." 320 
Shaudinn on amebic dysentery, 945 
Sheep, blood cells of, washed, 985 9 I ' 

cell-anrisneer sensitizer ; ; ~ 

ceJJs, emulsion of, 986 

disease of, 1122 

erythrocytes of, 084 
Shiga's bacillus, 943, 948. 949 
Shingles, 1163, 1269 
Shock a cause of low pressure, 480 . 

attending perforation, 925 

causes of, 109 

diastolic and systolic, 439 
marked, 778 

crrm pneumcchrras 3 "5 

crone sullen rem; .al ::' a': Icminal press; 
484 

in railroad injuries. 1282 

surgical, 925 

symptoms of, 109 
Shoes, loose lacing of, 13 
Shoulder, elevation of, 12 16 

lc~erel :> 

pain, 98, 99. 7S7 
right, 86 
Shredded wheat, 858 
Shyster la— ex, 1293 

:::m. avtitule in. : : 

■:sis. _:_ 

:ng. frequent. -3: 

in rerlearliris. Set 

:. : crcieal center :":r. :c : 5 
: 1 flexure z :s::::r. :: joS 



roentgenograpruc. 0S4 
"Silver men," 1121 

reiscring : - 5 
Simla trot, 1063 
Simulation of death, 1301 

of disease, 1293— 1301 
Singer's n: les. ' : -i 
Sinking sensations, 101 
Sino-auricular node, 467, 559. 563 
Sinus arrhythmia, 562 

hear: race in. _;: 

'deck. Ircrrel 'ceacs in >c 3 

headache, 91 

infections, 94 



1434 



GENERAL INDEX 



Sinus, irregularities, 563 

effect of atropin on, 563 
juvenile type of, 563 
significance of, 563 
node, 544, 548 
thrombosis, 1240 
cavernous, 1240 
longitudinal, 1240 
lateral, 1240 
Sinuses, accessory, 337 
inspection of, 338 
sepsis in, 337 
transillumination of, 337 
ethmoidal, 338 
of Valsalva, 753 
sphenoidal, 338 
Siriasis, 1283 
Sitting posture, obligatory, 107 

up for examination, dangers of, 287 
Situm viscerum inversus, 802 
"Situs inversus," 738 

appearance of, 380 
Six-day fever, 1059 
Skatol, in urine, 194 
Skeletal muscle movements, 519 
Skepticism, scientific, 2 
Skiagraphy, use of, 418 
Skin, cold, 17 

color of, 15, 17 
copper, 1 1 08 
dead white, shiny, 112 1 
desquamating, 1095 
emboli, 677 
fawn-colored, 15, 16 
heat and moisture of, 7S 
hyperemia of, general, 18 
infection through, 1126, 1139 
lesions of syringomyelia, 1260 
of yaws, 1 1 14 
simulated, 1295 
pencil, 1299 

pigmentation of, 174, 175 
rashes in cerebro-spinal meningitis, 1080 
sallow, 672, 1288 
tags in rectum, 942 
Skull percussion, 125 1 
Sleep, disturbances of, 1202 
feigned, 1296 
of old people, 103 
sufficiency of, 103 
Sleeping sickness, 1 145 
carrier of, 1 146 

course and symptoms of, 1147 
Slides, preparation of, 113 

washing of, 1009 
Smallpox, 1093 
black, 1097 
carriers of, 1095 
complications of, 1097 
confluent, 1095. 1097 
contagiousness of, 109s 
desquamation in, 1096 
diagnosis of, 1099 
differentiated from varicella, 11 03 

from varioloid, 1097 
effects of dissipation on, 1099 
epidemic, 1098 

eruption, localization of, 1095 
recognition of, 1099 



Smallpox, eruption, typical, 1096 

etiology of, 1094 

exposure to, 11 01 

vaccinaton after, 1101 

fever in, 1099 
secondary, 1096 

forms of, six, 1095 

hemorrhagic, 1097 

historic note on, 1093 

in Asia, 1094 

in the un vaccinated, 1095. 1098 

inoculation of, 1094 

malignant, 1097 

modified by vaccination, 1097 

morbid anatomy of, 1095 

mortality of, 1098 

odor of, characteristic, 1097 

organism of, unproven, 1094 

pains in, severity of, 1095 

pitting in, 1099 

prognosis in, 1098 

pustulation in, 1096, 1099 

rash of, measles-like, 1068 

resembling chickenpox, 1095 

simulated by measles, 1068 

stages of, desiccation, 1098 

susceptibility to, 1095 

suspected cases of, 1099 

symptoms of, 1095 

temperature in, 77, 78 

umbilication in, '1096, 1099 

vaccination in, 1099 

vesicle, shape of, 1099 

vesicular stage of, 1096 

virus, coccoid bodies in, 1094 

vs. great pox, 1094 
Smear, blood, making of, 113 
Smell, cortical center for, 1209 

hallucinations of, 1220 
Smoker's cough, 327 

patch, 38 
"Snap" diagnoses, 6 
Sneezing due to sexual stimuli, 33 
Snellen's colored test types, 1294 
Snoring, a cause of, 341 
Snuff habituation, 61 

-heart, 61 
Snuffles, 12, 1 11 1 
Social state, 58 
Sodium chloride ingestion, 1169 

hydrate solution, 864 
Soil, tetanus bacillus in, 1125 
Soldier's heart, 607 
Soldiers, dysentery among, 948 

trench gas poisoning in, 348 

typhoid fever in, 1013 
Solids, diminished excretion of, 247 
Soloid tablets, I IS 
Solutions, cresyl blue, 140 

Ehrlich's, 245 

Fehling's, 225 

Haines', 225 

Hayem's, 129 

phenolsulphonephthalein , 251 

potassium cyanide, 140 

Ringer's, 465 

stock, 224 

Toissou's, 129 
Somnambulism, 1272 



GENERAL INDEX 



x 435 



Sordes, 34, 38 

Sore throat, putrid, 1074 

Sot, the, cardiac insufficiency of, 671 

Sound conduction, 289, 704 

dampers, 289 
Sounds, amphoric, 302 

aortic second, 725 

bell-like, 309, 379 

breath, unilateral variations in, 417 

broncho-vesicular, 302 

cavernous, 302 

churning or splashing, 454 

friction, 312 

distinctive features, 313 

metallic tinkling, 312 

percussion, 292 

pharyngo-esophageal, 833 

"pistol shot," 710, 718 

split second, 663, 716 

"swashing," 312, 379 

water whistle, 312, 379 
South African Campaign, typhoid fever in, 1013 
Soya bean ferment, 202 
Space, mid-infraclavicular, 293 
Spanish- American war and yellow fever, 1036 

typhoid fever in, 1005 
mortality from, 1013 
"Spas," haunters of, 404 

neurasthenic as support of, 118,1, 1182 
Spasmodic asthma, 355, 360" 
Spasmophilia, electric reactions of, 47 

in whooping cough, 1105 
Spasms, 46 

arterial, 647 

bronchial, 356 

clonic, 1233 

lightning-like, 48 

esophageal, 904 

facial, 1233 

gastric, 878, 918 

habit, 1 2 75 

in epilepsy, 1272 

in legs, recurrent, 767 

laryngeal, 344, 756, 1236 
adductor, 344 

nocturnal intermissions of, 47 

nodding, 47 

obstructive, 927 

ocular, 1 23 1 

of diaphragm,^ 3 56 

progressive torsion, 53 

pyloric, 818, 918 

rectal, 949 

saltatory, 54, 1276 

segmental, 816 

tetanic, in strychnin poisoning, 1307 

tonic, 48, 1271 
Spasmus nutans, 47 
Spastic constipation, stools of, 952 

gait, 1257 
Specialty, surgical, 334 
Specific defensive responses, 982 

gravity of blood, 736 
of urine, factors in, 197 

instruments for determining, 197 
Speech center, 1209 

crescendo, 14 

disturbances of, cerebral, 1203 
rhythmical, 1202 



Speech, in polymyositis, 1159 
muffled, 14 
scanning, 14, 1202 
syllabic, 1202 
Spermatozoa in the urine, 236, 244, 274 
Sphenoidal sinuses, 338 

catheterization of, 338 
Sphygmocardiograph, 498, 501 
Sphygmograph in private practice, 497 
Sphygmographic tracings, abnormal, 51, 

waves of, 498 
Sphygmomanometers, 263, 500 
aneroid, 473 
Nicholson Princo, 473 
Sphygmotonometer, 477 
Spina bifida, 43 

Spinal accessory, function of, 1236 
lesions of, 12 15 
cord, anemia of, 1254 
compression, 1209 
diseases of, 1237 
hypoplasia of, 1257 
lesions, 1191 

segmental, 1215 
transverse, 1192 
unilateral, 1192 
vertigo in, 104 
sclerosis of, 1166 
section of, 1 189 
segments of, 12 14 
tracts, functions of, 1188 
tumors of, 1237 
curvature, 51 

in rickets, 11 75 
curve, obscurant, 284 
fluid, globulin content of, 1082 
in tuberculous meningitis, 1083 
in Wassermann test, 988 
normal, 1082 
tests by, 988 
tubercle bacillus in, 1083 
ganglion, 1191 
nerves, formation of, 1186 
lesions of, summary of, 12 18 
motor, 1 187 
percussion zones, 296, 297 
sclerosis, syphilitic posterior, 1254 
tenderness, 100 
Spine, deformities of, 43 
disease of, local, 766 
flexion of, 1126, 1239 

upper, deficient, 12 15 
immobility of, 43 
injuries of, 1239 
lower, pain in, 99 
movement of, imperfect, 12 17 
railroad, 1280 
resonance over, 296 
torsion of, 1239 
Spirillum cholerae of Koch, 103 1 

of relapsing fever, 1049 
Spirochseta pallida, 142, 11 06 
Spirocheta carteri, 1049 
duttoni, 1049 
"nodosa," 975 
novyi, 1049 
Obermeieri, 1049 
of rat bite fever, 1061 
refringens, 1106 



1436 



GENERAL INDEX 



Spirometry, 276 

Splanchnic crises, 87, 480, 485, 765 

Pal's, 48S 

spastic, 478 

spasticity, paroxysmal, 764 

tonus, lowered, 482 
Splashing, sounds, 454» 

deep and superficial, 832 
Spleen, abscess of, 813 

anterior relations of. 809 

descent of, diagonal, 809 

enlargement of, 154, 811 
acute, 813 

chronic excessive, 812 
uniform, 813 

enormous, unnoticed by patient, 157 
blood count in, 163 

fixation of, 820 

floating, 813 

"gripping" of, 812 

in Leishmaniasis, 1060 

in lymphatic leukemia, 158 

in typhoid fever, 1003, 1005, 1006 

infarcts of, 683 

leukemic, filling abdomen, 812 

location of, 809 

movable, 813 

palpation of, 805, 812 

puncture of, 1006, 1061 

respiratory movement of, 818 

tumor of, differentiation of, 812 
Splenic anemia, 154 
infantile, 1061 
symptom-complex of, 154 

flexure, 808 

tumor, superficial, 812 
Splenization, 400, 401 
Splenomegaly, 155 

chronic, 812 

Gaucher tyoe, 155, 812 

in erythremia, 163 

prominence of spleen in, 812 

tropical, 1059 

with hepatic cirrhosis, 155 
Splenoptosis, 813 
Split or mitral "P," 549 
Spondylitis deformans, 43, 1156 
Spondylose rhizomelique, 11 56 
Sporo blasts, 1042 

Sporotrichosis, ulcerative, 1128, 11 29 
Sporotrichum schenckii, 11 29 
Sporozoites, 1042 
Sporulation in malaria, 1047 
Spotted fever, 1051. 1055, 1079 

exanthem, 1055 

in Montana, 1055 
Sprays, ethyl chlorid, 375 

vasoconstrictor, 338 
Spree, drunken, 1284 
Sprue, 1063 

causative organism, 1063 

course and termination of, 1064 

definition of, 1063 

distribution of, 1064 

in Porto Rico, 1064 

inanition in, progressive, 1064 

simulated by hill diarrhea, 1063 

stools of, characteristic, 1064 

symptoms of, 1064 



Sputum, 328 

actinomyces in, 1131 

amount, 330 

"anchovy sauce," 329 

bacteria in, 331 

bile-stained, 967 

bloody, 419, 731 
bright, 391 

brown, 329 

casts in, fibrinous, 330 

cells in, 329, 33.1 

collection of, 330 

color of, 329 

consistence of, 329 

content of air, 329 
albumin, 329, 330 

definition of, 328 

discolored, 19, 329 

Dittrich's plugs in, 330 

examination of, 331 
caution in, 333 

factors observed in, 329 

food particles in, 330 

foul-smelling, 330, 347, 349, 419 

icteric, true, 329 

important factors, 329 

in pulmonary abscess, 419 

in tracheobronchitis, 346 

lung tissue in, 421 

microscopic findings in, 329, 331 

nummular, 329 

occupational, 329 

plugs in, 330 

prune-juice, 329, 388, 401, 421 

purulent and mucopurulent, 329 

pus in, 329, 961 

raspberry, 329 

reaction of, 329 

rusty, 388, 391 

sediment in, concentrated, 332 

tenacious, 388 

tubercular, 6, 410, 411 
Squint, 1231 

Stagnation due to diverticula, 903 
Staining, dyes used in, 115 

of sputum, 331, 383 

of T. M. Wilson, 115 

solutions, 115 

technic of, 116 

Wright, self-fixing, 114 
"Stance," 51 
Starch foods, acid affinities of, 867 

transformation, 857, 863 
Starvation, chronic, 56 

from restricted diet, 870 

"cures," 879 

fever, 74 

in diabetes, 3 
Stasis, gastric, 887 
signs of, 898 

general, in systemic veins, 701 

heightened pressure in, 480 

hypertension, 263 

polycythemia, 162 

pulmonary, 698 

visceral, 70s 
Static ailments, 1158 

ataxia, test for, 49 
Station, 49 



GENERAL INDEX 



M37 



Status epilepticus, 570, 1272 

lymphaticus, 39. 175 

thymicolymphaticus, 175 
Steapsin, 851 

test for, 864 
Stegomyia calopus fasciata, 1034 
Stelwag's sign, 181 

Stenon's duct, catheterization of, 1068 
Stenosis, aortic, 649, 676, 721 

bruit, genesis of, 747 

congenital, of conus arteriosus. 728 

duodenal, 950 

laryngeal, in diphtheria, 343 

masked, 711 

mitral, 676 

heart sounds in, 445 

of esophagus, 833 

of stomach, congenital, 937 

paralytic, 1215 

pseudo-aortic, 720 

pulmonary, 649 

pure, rarity of, 577 

pyloric, 858 

thrills in, 439 
Step-ladder temperature, 78 
Steppage gait, 52 
Stereognosis, 1208 

Sterility due to bilateral orchitis, 1069 
Sterilization in blood examination, 112 

iodin, 1082 
Sternal angle, 277 
Sternberg on yellow fever, 1037 
Sternocleidomastoid, spasm or paralysis of, 1215 
Sternum as a sounding board, 717 

interspaces to left of, 706 

pulsation over, 437 
Stethoscope, binaural, 474 

essentials in use of, 303 

pressure of, 304 

Sansom's, 303 

with diaphragm, 303 
Sthenic vs. asthenic ailments, 50 
Stigmata, occupational, 65 
Stiller on neurasthenia, 1179 
Still's disease, 161, 1157 
Stimulus conduction, 469 
Stippling, basophilic, 128 
"Stitch" in the side, 647 

over heart, 647 
Stomach, absorptive power of, 864 

accessory pocket in, 841 

adhesions in, 831 

atony of, 838, 859 

atrophy of, 883 

bilocular, 901 

cancer of, stenotic, 878 
test for, 858 

cap of Cole, 919 

capacity of, 820 

carcinoma of, 12, 838, 839, 909, 928, 930 
differentiated from ulcer, 928 
facies of, 12 

changes in, anatomic, 882 

conditions influencing type, 744 

congenital defect of, 891 

contents, acidity in, 864, 865, 866 
blood in, 853 

examination of, contraindicated, 881 
HC1 in, 866 



Stomach, contents, how obtained, 850 

in acute gastritis, 905 

in carcinoma, 929, 933 

in coma cases, 79 

in fasting stomach, 869 

in gastric catarrh, 906 
ulcer, 912 

in pernicious anemia, 151 

normal, macroscopic appearance of, 860 

reactions in, 863 
color of, 865 
end, 864 
red, violet, yellow, 864, 866 

regurgitation of, 871 

removal of, 858 

retention of, 887 

for several days, 933 

rhythmic pulsation of, 580 

stasis of, 893 

visible food in, 928 
contractions of, cramp-like, 84s 
cough, 327 
dilatation of, 838, 891, 900 

acute, 832, 886 
atonic, 897 

chronic, 888 

fatal, 888 

stenotic, 807 
dimensions of, 822 
diseases of, organic, 905 
displacement of, 891, 900 
distention of, 901 

excessive, 642, 891 

visible, 934 

with air, 835 
elongation of, 890 
evacuation of, 858, 859, 922, 1303. 1304, 1305 

in poisoning cases, 1303-1307 

speedy, 844 
examination of, physical, 822 
exploratory incision of, 831, 851 
fasting, gastric content in, 928 

wash-water of, 926 
fish-hook, 820, 821, 835, 895, 922 
form of, 918 

leather bottle, 841 
fundus of, 822 
gas content of, 832, 838 
general considerations, 820 
hemorrhage from, 882 
hour-glass contraction of, 833, 840, 901, 917 

spasmodic, 844 
hypermotility of, 844 
induration in, areas of, 918 
inflation of, 819, 823, 891, 901 

in appendicitis, 961 

patient's facial expression in, 824 
inspection of, direct, 824 
insufficiency of, facultative, 888 

motor or relative, 888 
low-lying, 850 
malignant growth of, 917 
motility of, 836 

disordered, 885 
motor insufficiency of, 885 
muscular insufficiency of, 886 

tone of, 835, 836 
normal, appearance of, 834 

contraction of, 834 



:-tP 



EKDEX 




xsdL 93,1 
— : . - : : ; ; 



t-f_L-i : _ : ; ■ * : : : 5 



eC S74- toy- *&*. «8X5 
. i t : : : 5 : : 



: : - : 



■= : : ; : 



_ : :_: : : .- : 



: 7 ■: : • 
: 7 ; i " . r :: " i " : 



-■■■ ::■: 



r..:-n. :■:.;.: ::j: 



- : : 
:i if: 

:z_: : :■: 5 



GENERAL INDEX 



r 439 



Substance sensibilatrice, 983 

thermolabile, 983 

thermostabile, 983 
Substernal discomfort, 642 
Subsultus tendinum, 562 
Succussion an overestimated sign, 832 

sounds, 312. 831, 833. 88s, 892 
Hippocratic, 312 
Sucklings, measles in, 1067 
Suction bulb, 850 

pump, 825 

sound, post-tussive, 312 
Suffocation from edema of glottis, 343 

from laryngeal membrane, 1075 
Sugar in the blood, 1163 
estimation of, 121 

in the urine, 1164 
tests for, 224-227 
Suicide among syphilitics, 751 

attempted, scars from, 29 
simulated, 1297 
Sulphates, excretion of, 214 
Sulphuric acid poisoning, 1302 
Summer diarrhea of children, 943 
Sunlight, action of, on bacteria, 1000 
"Sun pain," 339 

traumatism, 1284 
Sunstroke, 1283 

diagnosis of, differential, 1284 

facies of, 1283 

relapses in, 1283 

symptoms of, 1283 

vertigo in, 104 

warnings of, 1284 
Supermotility, 871 
Supinator-jerk, 1194 
Suppuration focus, 243 

of common duct, 979 

perinephritic, 815 
Suppurative meningitis, 1084 
Supraclavicular pads, 178, 179 
Supramaxillary, lesions of, 1232 
Suprarenal capsule, lesions of, 173 
Suprasternal notch, 433 
Surgeon, errors of, 869 
Surgery, emergency, 1182 

major, contraindicated, 833 

thankless field for, 605 
Surgical emergency denoted by pain, 8 s 

exploration in heterochylia, 882 

lesions, simulation of, 643 

precipitancy, 803, 816 

shock, 925 
Sutures, open, 30 
Swallowing sounds, double, 833 
Swaying of body, 1207 

on closing eyes, 49 
Sweat, discolored. 19 
Sweating, general, 20 

in abscess of liver, 966 

sickness, 1057 

unilateral. 20 
Sweats in endocarditis, 675 

in tuberculosis, 406 

night, 410 

profuse, 161, 1057 

recurring, 11 19 
Swellings, bilateral, 42 

of angio-neurotic edema, 1270, 1271 



Swellings, on back, 43 

transient nodular, 43 
Swimming of the head, 103 
Sydenham on influenza, 1016 
Sydenham's chorea, 1273 
Sylvian fissure, 1084, 12 10 

growths of, 1244 
Sylvius, aqueduct of, 1079 
Symptom groups, general, 5 

clinical, subjective and objective, 1 1 

differentiating, 6 

general vs. specific, 71 
Syncope as sign of overstrain, 664 

etiology of, 102 

false and fatal, 102 

fifty attacks in 90 minutes, 565 

in thoracentesis, 48s 

local, 1270 

simulating death, 130 1 

symmetric localized, 1270 
Synkenesias of diagnostic value, 11 9 7 
Syphilides, hemorrhagic, 1109 

lenticular, 1108 

macular and papular, 1108 

palmar, 11 09 

pustular, 1 109 
Syphilis a cause of endocarditis, 674 

acquired, in children, 1107 

and angina pectoris, major, 750 

and aortic regurgitation, 750 

and cerebral hemorrhage, 1245 

and heart block, 567 

and increased death rate, 75 1 

and mesaortitis, 750 

aortic localization of, 760 

as a cause of arteriosclerosis, 761 
of death, 761 

as a slow poisoner, 751 

as great pox, 1093 

associated with tuberciulosis. 424 

autopsies in, 760 

blood pressure in, 482 

cardiovascular, 748 763, n 76 

causative organism of. 748 

cerebral, 1253 

cerebro-spinal, 748. 989 

color of skin in, 145 1108 

congenital, 31, 39. 751 

degenerative changes of. 75 1 

denial of, 586, 750 

diagnosis of, false, 40 
serum, 984, 985. 988 

differentiated from Hodgkin's disease, 167 
from plague, 1034 
from yaws, 11 15 

effects of, on hair, 1109 

endarteritic, 1261 

eruptions of, early, 1108 

etiology of, 1105 

exanthemata of, 1108 

hereditaria tarda, nil 

hereditary, 69, 750, 1106, 11 11 

Hutchinsonian syndrome in, 1 1 1 1 

hypotension in, 482 

immunity to, 1106 

in United States, 750 

induration in, 1107 

infection of, extra-genital, 1106 

larval activity of, insidious, 1107 



1440 



GENERAL INDEX 



Syphilis, lesions of, initial, 1107 
multiple in women, 1107 
tertiary, 1106 
life expectancy in, 751 

insurance reports on, 1107 
line of march in, 760 
lymphocytosis in, 139 
meningeal, 1079 
mode of conveyance of, 1106 
mortality of, 760 
nasal, 336 
of the brain, 1243 
of the bronchi, 347 
of the esophagus, 904 
of the intestines, 953 
of the larynx, 344 
of the lips, 34 
of the muscles, 1161 
of the nervous system, 1254 
of the pharynx, 341 
of the stomach, 936 

in a steeple climber, 937 
" pain and tenderness in, 937 
on sound mucous membrane, 11 06 
osseous tissues in, 11 10 
paresis as form of, 1251 
physician's inquiries concerning, 13 
primary lesions of, 1106 
prognosis in, 1111 
pulmonary, 424 
rash in, 1072 

measles-like, 1068 
renal, 271 
secondary, 1157 
secretions in, virulent, 1106 
sequelae of, 748 
site of infection in, 1106 
smear preparations in, 1105 
stages of, secondary, 1107 

three, 1107 
symptoms of, 5 

constitutional, 1107 
tertiary, 1109 

■ with tuberculosis, 321 
tests of, 984, 985 
by spinal fluid, 988 
therapeutic, 11 12 
transmission of, by vaccination, 1101 
unrecognizable forms of, 11 12 
vascular, 1190 

ravages of, 760 
wide dissemination of, 760 
Syphilitic aortitis, figures concerning, 750 
of Welch, 752 
cirrhosis, 973 

infection, denial of, 586, 750 
meningitis, 1084 
pneumonia, 321 
Syphilitics as a menace, 1106 

insured, cause of death in, 751 
Syphilization, paresis due to, 748 
Syringomyelia, 45, 1259 

differentiation of, 1238 

from acromegaly, 186 
lesions of, cutaneous, 1260 
System, chromaffin, 1237 
Systole of the heart, 457 
premature, 543 
shock of, 734 



Systoles, auricular and ventricular, simultaneous 
569 
dropped, 569 
Systolic "C" wave, 503 
events, 459 
pressure in nephritis, 262 

level, 475 
pulsation, 438 
recession, 436, 438 
retraction, 437 

in mediastino-pericarditis, 437 
thrust, 502 
whiffing, 453 



Tabes, anemic, 152 
cerebral, 1256 
crises of, 87 
dorsalis, 1254 

complications of, 1253 
gastric crises in, 867, 936 
luetic, 748 
gait in, 52 
Tables, blood-pressure, 476 
Fisher's, 477 
life insurance, 54 
of Cohn, 662 

standard of heights and weights, 55 
Walker's differential, 947 
Tabo-paresis, 1251, 1253 
Tache bleudtre, 1148 
Tachycardia, 490, 491 
extra-systolic, 547 
febrile, 559 

in thyroid enlargement, 180, 183 
paroxysmal, 556, 1057 
and alternation, 543, 558 
essential features of, 559 
indicated in electrocardiogram, 539, 560 

in polygram, 512, 559, 560 
of ventricular origin, 559 
pulsus alternans in, 561 
rate, 120-360, 560 
Tachycardial irregularity, 492 

palpitation, 492 
Tactile sense, 1260 

development of, 832 
localization of, 1206 
Takaki, Baron, on beri-beri, 1291 
Tallquist's hemoglobinometer, 116 
Tapeworms, 1134 
beef, 1 134 
in the dog, 1136 
in the liver, 969 

infection by, symptoms of, 1135 
pork, 1 135 
"Tarantella," 1276 
Tartar emetic, poisoning by, 1307 
Tartaric acid, poisoning by, 1307 
Taste, tests for, 1232 
Tastpercussion, 441 
Tawara on the heart, 466, 469 
Tea, excessive use of, 61 

in test breakfast, 858 
Technic, extreme delicacy of, 3 
Teeth, condition of, 937 
decay of, early, 39 
eruption of, normal periods of, 39 
sequence of, 39 



GENERAL INDEX 



1441 



Teeth, etiologic importance of, 38 

examination of, 823 

false, removal of, 849 

grinding of, 40, 1233 

Hutchinsonian, 13, 39. 936 

progressive separation of, 40 

serrated edge of, 39 
Teething, disturbances of, 38 

Forchheimer's views of, 39 
Teichmann's blood test, 875 

disease, 867 
Teleroentgenography, 427, 439. 57L 572 
Teleroentgenoscopy, 57i 
Temperament, congenital faults of, 1278 

in aortic insufficiency, 720 
Temperature, affected by age, 72 
by exercise and heat, 72 

axillary, 71 

diurnal range of, 72 

exhaustion, 75 

high, due to deception, 72, 1296 

in appendicitis, 954 

in disease, types of, 77 

in the anemias, 145 

intermittent, 406, 11 19 

low, 178 

mouth, 71 

"normal," dubious, 72 

on exertion, 411 

rectal, 71 

remittent, 1119 

rise, feigned, 1296 

sense, 1204, 1206 

septic, 420, 1 1 19 

subnormal, 73 

step-ladder, 1005 

surface, misleading, 71 

-vaginal, 71 

variations in, pathologic, 72 
Temporal area, lesions of, 1244 
Tenderness, abdominal, 100, 363, 805 

areas of, spinal, 912 
superficial, 98 

in cardiac region, 647 

in gastric carcinoma, 932 

in scurvy, 172 

involving various structures, 100 

localizing value of, 916 

on percussion, 439 

on pressure, 921 

points of, 439 

significance of, 100 

simulation of, 1299 
Tendon reflexes, 1194 
Tenesmus in cystitis, 273 

of dysentery, 949 
Tenia echinococcus, 968, 1136 

flavopuncta, 1135 

mediocanellata, 1134 

nana, 1135 

saginata, 1134 

solium, 1 13 5 
Tenosynovitis, rheumatic, 1151 
Tension, excessive, 298 
Test breakfast, 852, 858 
Boas', 858 
Ewald's, 858 
in achy ha, 881 

dinner, Riegel's, 859 



Test dinner. Von Leube's, 858 
meals, 857 

aspiration of, 881 

in cases of vomiting, 873 

of shredded wheat, 858, 935 

standard, 858 
Testicles, atrophy of, 1069 

pain radiating to, 99 
Testis, retraction of, 955 
Tests, Abderhalden's, 935 
acetic acid, 862 
allergic, 415, 748 
asthma, 357 
bilirubin, 854 
Boas', 858, 861 
breathing, 1301, 1302 
butyric acid, 862 
Cammidge's, 965 
candle, 1232 
conjunctival, 413 
digestion, 856 
digitalis, 603, 650, 652, 662 
duodenal, 852 
Ewart's, 367 
for acetone, 229 
for albumin, 217, 219, 330 

approximation method, 222 

centrifugal, 221 

faulty technic in, 218 

nitric acid contact, 218 
layer, 217 

potassium ferrocyanide, 220 

quantitative, 220 

Robert's solution, 220 

Robin's, 219 

Spiegler's, 220 

trichloracetic, 220 
for albumoses, 216 
for bile, 224, 853 
for blood, no, 875 

benzidin, 875, 876 

guaiacum, 223 

Heller's, 222 

Teichmann's, 875 

Weber- M tiller's , 875, 876 
for capillary pulse, 719 
for deafness, 1234 
for diacetic acid, 229 
for glucose, Allen's, 225 

copper, 224 

control positive copper, 225 

Fehling's, 224 

fermentation, 226 

specific gravity, 226 

Whitney's, 226 
for hemoglobin, 116 
for hyperthyroidism, 181, 182 
for indican, 193 
for indol, 193 
for lactose, 228 
for levulose, 227 
for lipase, 863 

minerals in urine, 257 
for mucin, 330, 331 
for pentose, 228 
for pepsin, 856 

protein sensitization, 357 
for pus, 222 
for skatol, 194 



1442 



GENERAL INDEX 



Tests for sugar in the blood, 121 
for syphilis, 759. 985 
for typhoid fever, 1007, 1008 
for urinary calculi, 274 

chlorides, 212 
Geraghty and Rowntree's, 251, 254 
globulin, 1082 
Goetsch's, 181. 

hypodermic, 181 

skin, 181 
Gunzberg's, 861 
hemolytic, 98s 
hydrophobia, 1124, 11 25 
in cases of apparent death, 1302 
Jaff6-Stokvis', 193 
lactic acid, 861, 862 
lifting, 1266 
Loewi's, 182 
medication for, 178 
meningococcus, 991 
Moro's, 412, 413 
of cardiac sufficiency, 63s 
of diabetic blood, 1167 
of feces, 940, 941 
of gastric contents, chemical, 860 

retention, 923 

secretion 917, 9i8 
of serums and vaccines, 11 26 
of taste, 1232 

pepsin and pepsinogen, 862 
phenolsulphonephthalein, 121, 203, 209, 251 

color reaction in, 252 
phloridzin, 251 
precipitin, 990 
rennin, 863 
Rivalta's, 362 
Rosenbach's, 194 
Schick's, 990 
specific, 2 
steapsin, 864 
subcutaneous, 415 
Topfer's, 866 
Trommer's, 224 
trypsin, 863 

tuberculin, 70, 411-413, 416 
urobilin, 194, 854 
urobilinogen, 194, 854 
Von Pirquet's, 413 
Walker's, 357 

Wassermann's, 3. 13. 142, 586, 748, 750, 759, 
760, 773, 937, 980, 986, 989, 1112, 1116 
technic 985, 
Widal's, 406 
Zenoui's, 330 
Tetanus, 1125 

bacillus of, in soil, 1125 
convulsions of, 80 
diagnosis and prognosis of, 11 26 
hysterical, 81 
mortality from, 11 26 
neonatorum, 1125 
Tetany, 47 

epidemic form, 48 
Texas, Malta fever in, 1054 
Text-book study, 1 
Therapy, cardiac, 653 
cardinal sin in, 7 
effective, 4 
methods in, futile, 7 



Thermometer, friction of, 1296 

precautions in use of, 71 

scales, 1308 
Thermometry, 71 
Thigh adduction, loss of, 121 7 

extension and abduction, 1218 

flexion, imperfect, 1217 
Thirst, excessive, in diabetes, 1169 
Thoma-Levy hemocytometer, 132 

-Metz hemocytometer, 134, 135 

ruling, Neubauer modification of, 133 

-Zeiss hemocytometer, 128, 129 
Thomas and Weber, quantitative tests of, 862 
Thomsen's disease, 48, 53, 1266 
Thoracentesis, fall of blood pressure in, 485 
Thoracic aneurysm, 585 

duct, occlusion or rupture of, 426 

viscera, diseases of, diagnosis of, 276 
examination of, 314 

with reference to bronchi, lungs and 
pleurae. 278 
Thorax, constriction of, transverse, 284 

diseases of, in arteriosclerosis, 766 

en bateau, 285 

lagging of, unilateral, 1248 

solid cast of, 348 

tender areas in, 288 
Threshold percussion, 441, 442, 443, 638 
Thrills, apical presystolic, 439 

as diagnostic aid, 745 

associated with cyanosis, 439 

diastolic and systolic, 439 

hydatid, 811, 1136 

in mitral stenosis, 696 

of defective ventricular septum, 742 

presystolic, 691 

of mitral stenosis, 745 
to right of sternum, 727 

significance of, 439 

systolic, in aneurysm, 778 
Throat, clearing of, 339 

constriction of, 359, 1307 

sore, 5 

putrid, 1074 
rheumatic, 1150 
Thrombi, vegetative, 714 
Thrombosis, 1245 

in erythrocytosis, 164 

intestinal, 953 

mental state in, 1250 

of lateral sinus, 1240 

of right cavernous sinus, 32 

of "silent" regions, 1250 

of the cord, 1254 

paralysis in, 1250 

pulmonary, 417, 418 

right auricular, 714 

symptoms of, premonitory, 1250 
Thrombus formation, 168 

mural, right auricular, 692 
Thrush, 35 

stomatitis, 1127 
Thumb, ball of, atrophy of, 1217 
Thymus death, 175, 176 

enlarged, 175. 176 
Thyroid enlargement, 180 
and pregnancy, 183 
in girls at puberty, 183 
insanity in, 183 



GENERAL INDEX 



1443 



Thyroid enlargement, transient. 183 
tremor in, 182, 183 
with acromegaly and myxedema, 184 

gland, atrophy of, 177 

structural changes in, 176 
trypanosomiasis of, 1145 

insufficiency, 178, 179 
Tibial phenomenon, 11 97 
Tic, convulsive, 1233, 1275 

douloureux, agonizing pain of, 94 

generalized impulsive, 1275 
Tick as intermediate host, 1055 

bite of, as cause of fever, 1055 
Timber fly disease, 1148 
Time relationship of electrocardiographic phases, 

S23 
Tingling sensation, 10 1 
Tinnitus aurium, 1085. 1234 
exaggerated, 1235 
cerebri, 1234 
Tissues, slackness of, 831 
Tobacco heart, 61 

overindulgence in. 61 

poisoning, 61 

use of, by malingerers, 1293, 1295 
in simulating angina, 1293 
Toe reflex, 11 96 
Toes, adduction and flexion of, 1218 

fissure of, 1 1 1 7 

gangrene of, 1270 

great, gouty attacks in, 1172, 1174 
hypertrophy of, 185 

stubbing of, 1257 
Toisson's solution, 129 
Tone, aortic, 700 

pulmonary, 700 
Tongue, atrophy of, 1264 

beefy, 36 

-biting, 522, 1272, 1273. 1295 

black, 37 

brown, 36 

clean, 36 

coated, 36 

unilaterally, 37 

deviation of, 1214, 1237 

discoloration of, 37 

dry, 79 

geographic, 38 

hairy, 37 

in exhaustion, 36 

in nervous dyspepsia, 896 

in profound toxemia, 36 

indented, 36 

protrusion of, 36, 38 

scars, 37 

smear from, 939 

strawberry, 37, 1070 

syphilitic, 1109 

typhoid, 1004, 1005 
Tonsillitis, acute, 341, 588 

ailments related to, 341 
symptoms of, 342 

attacks of, 587 

chronic, 342 

follicular, 342, 1075 

in scarlet fever, 1071 

organisms found in, 1149 

preceding endocarditis , 675 
rheumatism, 1149 



Tonsillitis, simulating diphtheria, 1075 

suppurative, 342 
Tonsils as septic foci, 342, 587. 1150 

bacteria in, 341 

chronic infection of, 674 

diseases of, 341, 587 

enucleation of, complete, 341 

infection of, 786 

normal appearance of, 588 

relation of, to other infections, 587 

removal of, 587. 1150, 115s 
Tonus inadequacy, 884 
Topfer's test, 866 
Tophi, gouty. 33, 11 72, 11 74 
Torticollis, 1162, 1163 
Touch, 1204 

normal perception of, 1206 

-test, 1086 
Tourette's disease, 1275 
Tower head, 3 1 

Townsend, Colonel, trance state in, 1301 
Toxemias as a cause of disease, 761, 1190 

depressing constitutional effect 0^782 

in broncho-pneumonia, 396 

myocardial, 566, 588, 1152 

of muscles, 1162 

overwhelming, 1006 
Toxic absorption, degree of, 139 
Toxins a cause of nephritis, 254 

bacterial, 980 

effects of, 981 

true, 980 
Toy pistols, 1 1 26 
Tracheal tone, Williams's, 299 

tug, 435, 777 
Tracheobronchial tree, inspection of, 313 
Tracheo-bronchitis, acute, physical signs in, 
346 
symptoms of, 345 
Tracheotomy, 481, 1075 

in edema of glottis, 343 
Tracings, carotid, 501, 566 

radial, 566 
Tracts of spinal cord, 11 88 

pyramidal, crossed, 11 87 
Trance state, 130 1 
Transillumination, Einhorn's method, 823 

of sinuses, 337, 338 
Transitionals, 123 
Transmission of disease, direct, 69 
hereditary, 67 

of murmurs, 686 
Transposition of organs, congenital, 802 
Transudates, coagulation of, 142 

pericardial, 791 
Transverse colon, palpation of, 831 
Trapezius involvement, 47 
Traube's heart, 263 

semilunar space, 279, 280, 281, 371, 832 
dulness in, 281, 367 
Traumatism as cause of aneurysm, 773 

carcinoma, 931 
''Treating" habit, 61, 1285 
Trematoda, 1133 

"Trembles" as disease of cattle, 1057 
Tremor, alcoholic, 1286 

conditions associated with, 45 

facial, 45, 46 

fibrillary, 1265 



1444 



GENERAL INDEX 



Tremor in acute disease, 45 
increased by extension, 45 
intention, 45, 46 
muscular, 1057 
of hands, 40 
of lip, 46. 
of tongue, 46 
passive, 45 
pill-rolling, 46, 1276 
purring, 74s 
testing of, 45 
trivial, 45 
Trench fever, 608, 1065 

gas poisoning, 347, 348 
mouth, 36, 1077 
nephritis, 266 
warfare, 348 
Treponema pallidum, 748, 1105, 1106 
in necrosed areas, 752 
in paresis, 1251 

spirochete resembling, 1112, 1115 
pertenue, 1112, 1115 
Treupel on threshold percussion, 638 
Triangle, Grocco's, 294 
Triceps-jerk, 1194 
Trichina spiralis, 1138 
Trichiniasis, 1138 
Trichinosis simulating polymyositis, 1159 

typhoid, 1013 
Trichomonas intestinalis , 946, 1132, 1133 

vaginalis, 1132 
Trichterbrust, 283. 284 
Trichuris trichiura, 1144 
Tricophylon tonsurans, 11 27 
Tricuspid incompetence, 701 
insufficiency, 701 

associated signs in, 703 

endocarditic, 701 

etiology of, 701 

features of, characteristic, 702 

fibrillation in, 701 

murmur in, 702 

audibility of, 702 
pulsation of liver in, 438 
secondary, 701 
silent leakage in, 703 
typical case of, 702 
with extreme dilatation, 671 
leakage, 460, 705 
secondary, 745 
regurgitation, 701 
frequency of, 461 
heart sounds in, 446 
isolated primary, endocarditic, 708 
murmur in, 704 
rarity of, 744 
rationale of, 704 
right auricle in, 705 
: stenosis, 726 

absence of pulmonary signs in, 728 
and interstitial nephritis, 728 
and ventricular hypertrophy, 727 
as isolated lesion, 727 
blood pressure in, 728 
murmur in, 459 
audibility of, 727 
time of, 727 
transmission of, 727 
percussion area in, 727 



Tricuspid stenosis, prognosis in, 728 
rarity of, 726, 727, 744 
rationale of, 727 
recognition of, 727 
signs of, subsidiary, 727 
symptoms of, 727 
thrill in, 727 
valve, 456 

area of, 433, 449 
closure of, 505 

thickened and increased, 692 
weakness of, 730 
Trident hand, 189 
Trifacial nerve, 1232, 1233 

neuralgia, 94 
Tripod, pancarditic, 796 
"Tripper-faden," 24s 
Tripper shreds, 271 
Trismus, 47, 1232, 1233 

jaw muscles in, 1307 
Trombidium akamushi, 1058 
Trommer's test, 224 
Tropenform herz, 598 
Tropeolin test, 861 
Trophic function, lost, 1233 
Tropical abscess, 966 

dysentery, acute, 948 
liver, 965 
sore, 1061, 1062 
Tropics, diseases of, 11 17 
Trousseau's sign, 47 
Trunk, inspection of, 435 

lateral movement of, 12 16 
Trypanosoma gambiensis, 1145, 1146 

rhodesiensi, 1145, 11 46 
Trypanosomiasis, 1145 
Trypsin, 851 

activity, impaired, 856 
test, 863 
Tsetse fly, 1145 

Tubercle bacilli, 401, 406, 407, 409 
detection of, 143 
favorable soil for, 284 
in asthenic tissues, 602 
in the larynx, 344 
in the spinal fluid, 1083 
in the sputum, 332 
in the stools, 953 
in the urine, 245, 270 
invasion by, 278 
simulators of, 332, 425 
Tubercles in yaws, 11 14 
miliary, 406 
of leprosy, 1121 
verminous, 1138 
Tubercular invasion, physical signs of. 2: 
Tuberculin as diagnostic agent, 411 
in healthy controls, 412 
in renal tuberculosis, 270 
reaction of, 411, 412, 413 
almost universal, 409 
at autopsy, 821 
detection of, 412 
in healthy recruits, 414 
in school children, 414 
rise and decline of, 2 
sanguine promises of, 2 
subcutaneous use of, 411, 412 
tests, 70, 411-416 



GENERAL INDEX 



1445 



Tuberculin tests comment on, 416 

conclusions regarding, 414 

fallibility of, 412 

in Addison's disease, 175 

in advanced cases, 414 

in cachectic subjects, 414, 415 

in infants and children, 414, 416 

modifications of, 413 

precautions in, 413 
therapeutic dose of, 2 
views concerning, 411, 412, 414, 416 
Tuberculosis, active process in, 409 
acute, 40s 

miliary, diazo-reaction in, 1007 
differentiated from typhoid, ion 
advanced, 317, 416 
after thirty, 60 
and "drop" heart, 320, 602 
and preexisting diseases, 403 
and sanitary conditions, 403 
and syphilis, relations of, 424 
anemia in, 410 
apex movement in, 418 
apical, lesions of, 320 
arrest of, 319. 320, 407 
autopsy reports of, 415 
auscultation in, 417, 418 
basal, 316 

blood pressure in, 476, 482 
broncho-pneumonic, 407 
cavitation, 318, 319 
chest movement in, impaired, 416 
chronic, coexistent with pericarditis, 782, 786 
color in, high, 416 
cough in, 410 
curability of, 409 
data in, vitally important, 70 
differentiation of (roentgenological), 320 
diffuse, general, 405 
displacement of heart in, 407 
disseminated, acute, 405 
dulness in, 300 
dyspnea in, 410 
early, 314 

diagnosis of, 320 

roentgen picture of, 314. 317 
effect of specific medication on, 424 
emphysema in, 416 
exposure to, direct, 69 
family history in, 69, 416 
febrile and afebrile, 410 
fever a sign of, 145 
field of, delimitation of, 315 
fluoroscopy in, 411 
foci of, 319, 320, 409, 1077 
following injuries, 403 
from occupation, 65 
heredity in, 403 
ileocecal, 847 
in the country, 63 
in the young. 58 
incipient, 410, 416 

respiration in, 306 
infection in, activity of, 412 
inspection in, 416 
intestinal, 953 
laryngeal, 344 

lesions of, healed vs. active, 320 
leucocytosis in, 674 

89 



Tuberculosis, line of march of, 417 
lobar, 406 

loss of weight in, 409 
lung borders in, 295 
meningeal exudate in, 1078, 1079 
miliary, acute, 405 

bacilli absent in, 406 
course and prognosis in, 406 
emaciation in, 406 
hyperresonance in, 406 
morbid anatomy in, 406 
physical signs of, 406 
symptoms of, 406 
temperature in, 406 

with antecedent tuberculous lesions, 406 
night sweats in, 410 
occupations predisposing to, 403 

simulating typhoid, 1006 
of bladder, 273 
of brain, 1242, 1243 
of stomach, 937 
onset of, 404 
pain in, 410 

palpation and percussion in, 416 
peribronchial glands in, 314 
pericarditis in, 797 
peritoneal, chronic, 819 
physical signs in, 305, 416, 781 
physiognomy in, 416 
placental, 403 
pneumonia in, 389 
pneumonic acute, 391. 407 

diagnosis of, 407 
prairie-fire. 12 
preceding case history in, 416 

tuberculous meningitis, 1083 
predisposition to, individual, 403 
. prevalence of, 415 
primary, 143 
prognosis in, 320 
prolongation of life in, 661 
pulmonary, 401 

age and sex in, 403 

auscultation in, areas for, 305 

caseation in, 402 

cost and distribution of, 402 

definition of, 401 

etiological factors in, 403 

excursion reduced in, 286 

following pleurisy, 362, 363 

infection in, fungus, 408 
spread of, 402 

inoculation, changes due to, 402 

morbid anatomy of, 402 

sclerosis in, 402 

slow- burning. 577 

urinary test in, 195 

with cavitation, 318 
pulse in, 491 
rales in, absence of, 417 
relationship in, question of. 70 
renal, 269 

acute miliary, 269 

caseous, 269 

waxy cast in, 241 
resolution in, 319 

signs of, roentgenographic, 314, 315, 577 
simulated by aspergillomycosis, 425 

by endocarditis, 678 



1446 



GENERAL INDEX 



Tuberculosis, simulated by nocardiosis, 425 
by other diseases, 1128, 1294 
• sputum in, 6, 410 
susceptibility to, peculiar, 402, 404 

racial, 403 
symptoms of, early, 409 
temperature in, 410 
tests for, 143, 412, 413 
differential, 411, 412 
therapy of, costly, 409 
transmission of vs. environment, 69 
typhoidal form of, 406 
ulcerative, chronic, 407 
hemorrhage in, 409 
pathologic anatomy in, 407 
unrecognized, 407, 412 
use of tuberculin in, 411 
with Addison's disease, 173, 174 
with mitral stenosis, 694 
Tuberculous arthritis, 1154 
infiltration of kidney, 270 
invasion, "line of march" of, 305 
meningitis, 1077, 1078, 1079 
acute, 1083 

absence of meningococcus in, 1084 
animal inoculation in, 1083 
diagnosis of, differential, 1084 
duration of, 1083 
preexisting tuberculosis in, 1083 
prodromata marked in, 1083 
radiography in, 1084 
stages of, 1083 
symptoms of, 1083 
ulcer, 37, 1002 

simulating dysentery, 949 
Tubes, pelvic, acute inflammation of, 956 
Tubules of kidney, straight, cells from, 237 
Tularemia, 1056 
Tumor cells, 143 

fragments in stools, 939 
Tumors, abdominal, 812, 815, 816, 818 

as cause of cerebro-spinal disease, 1190 

attached, hepatic note in, 810 

"bar-like," 819 

bronchial, 321 

crossing abdomen, 819 

cyst-like, 272 

doughy, 815 

expiratory fixation in, 819 

green, 161 

hydatid, 1137 

hypogastric, 817 

ileocecal, 88 

immovable, 818 

intestinal, 88, 89 

palpable, 957 
mediastinal, 585 
of bladder, 274 
of brain, 103, 1242 
identification of, 1243 
symptoms of, 1242 
focal, 1244 
terminal, 1244 
syphilitic, 1242 
of gall-bladder, 811 
of head, 30 
of hypophysis, 1168 
of larynx, 344 
of liver, 811. 968 



Tumors of nose, 11 17 

of pancreas, fixed, 965 

of pharynx, 341 

of spinal cord, 1238 

of stomach, 831 

of tongue, 37 

omental, transverse, 963 

on back, 43 

passive mobility of, 819 

pedunculated, below glottic chink, 106 

phantom, 805, 816 

pulmonary, 421 

pulsating and enlarging, 775 

congenital, 30 
renal, 271, 812 

bilateral, 271, 819 
diagnosis of, preoperative, 271 
differentiation of, 271 
unilateral, 819 
transverse, knobby "feel" of, 963 
Tuning fork, vibrating, use of, 291 
Turbinate areas, irritability of, excessive, 327 

sensitive, irritation of, 327 
Turck, columns of, 1187 
Turck's chamber, 130 
gyromele, 823 
irritation forms, 124 
Turpentine poisoning, 65 
Tympanites, 805 

forcing liver upward, 810 
in typhoid, 1005 
Tympany, 292, 298 
bell-like, 309 

dull, on percussion, 292, 298 
Type, congenital, asthenic, 821 

variation from, 1 
Typhoid agglutination test, 1008 
agglutometer, 1008 
bacillus in cholecystitis, 976 
in the blood, 1006 
in the duodenal secretions, 1001 
in the stools, 1006 
in the urine, 1006 
carriers, chronic, 1000 
fever, 1000 
abortive, 1005 
abscess in, 1006 
afebrile, 1005 
among soldiers, 1013 
and acute miliary tuberculosis, co-existent, 

ion 
associated with cholecystitis, 976 
blood cultures in, 1007, 1009 

pressure in, 484, 1004 
cicatrization in, 1002 
clammy skin in, 1003 
clinical picture of, 1006 
coldness of body surface in, 1003 
complement fixation test in, 989 
complications of, 1003 
decubitus in, 50, 1005 
diagnosis of, 246, 1003, 1006 
cardinal points of, 1007 
cultural, 1006, 1009 
differential, 1010, ion 
diarrhea in, 1005 
diazo-reaction in, 1007 
Ehrlich's, 245, 1007 
pink foam in. 240 



GENERAL INDEX 



1447 



Typhoid fever, diazo-reaction in, technic of, 
author's, 245 

true value of, 246 
differentiated from appendicitis, 1012 

from Malta fever, 1054 

from meningitis, 10 12 

from pneumonia, 1012 
dysenteric, 949 
enteric lesions of, 1001 

absence of, 100 1 
etiology of, 1000 
forms of, ambulatory, 10 13 

mild, 1001 

pulmonary, 1006 

renal, 1006 

scarlatinal, 1006 

septic, 1006 

tonsillo-typhoid, 1006 
gastrointestinal signs of, 1004 
hemorrhages in, 1003, 10 14 
hypotension in, 484 
incubation period, 100 1 
in armies, 1013 
leucocyte countin, 1007 
leucocytosis in, 138 
mental condition in, 1004, 1005, 1006 
mortality from, in Spanish-American war, 

1013 
necrosis in, 1006 
onset of, insidious, 1004 

sudden, 1005 
pathologic anatomy of, 1002 
period of recession in, 1005 
perforation in, 1003, 1004, 1014 
prognosis in, 1006, 10 13 
pulse in, accelerated, 1004 
relapses in, 10 14 
rose spots of, 1005 
simulated by ulcerative endocarditis, 

ion 
spleen in, 1006 
stools in, 1003 

sweats, profuse and exhausting, 1006 
symptoms of, classic, 1003 

major, 1003 

minor, 1003 
temperature curve in, 78, 1004, 1014 

sudden drop in, 1003 
tenderness in, 1003 
tests, 1008 
toxic state in, 1003 
typical case of, 1004 
urine in, 1000 
variants, misleading, 1006 
weakness in, 1005 
germs, distribution of, 1000 
infection, mode of entrance of, 1001 
pneumonia, 386 
state, 677. 1006 
congestion in, 400 
in meningitis, 1083 
in septicemia, 1011 
in typhus, 1052 
symptoms of, 406 
tests, macroscopic, 1009 
ulcers vs. tuberculous, 1002 
Typhus abdominalis, 1000 
fever, 10.51 

attenuated or mild, 1053 



Typhus fever, cause of, probable, 1051 

clinical chart of, 1051 

complement fixation test in, 989 
j confounded with typhoid, 1052 

crisis in, 1052 

diagnosis and prognosis of, 1053 

etiology, 1051 

eruption in, 1051, 1052 

historic note on, 1052 

immunity, 1052 

in 1 8th century, 1052 

incubation period, 1052 

inoculation of, 1051 

intermediary host of, 1051 

morbid anatomy of, 1052 

odor of, 1053 

of Europe and Mexico, 1053 

physiognomy of, 1053 

seasonal occurrence, 1052 

symptoms of, 1052 

test for, 105 1 

transmission, 1051 

variants, 1053 
Tyrosin in the. urine, 235 



U 



Uffelmann's lactic acid test, 861, 865 
Uhlenhuth's antiformin procedure, 332 
Ulceration, ancient, 88 
esophageal, 902 
in yaws, 11 14 
of larynx, 1003 
of nails, 41 
of tongue, 37 
pressure, 781 
serpigenous, 11 10 
toxic, 953 
venereal, 11 12 
Ulcers, achlorhydric, 928 
acute hemorrhagic, 908 

perforating, 908 

relapsing chronic, 908 
carcinomatous, stomach-tube passed 

through, 849 
chronic, hyperacidity in, 915 

rigidity in, defensive, 916 

sluggish, 921 

tenderness in, 916 
Crombie, 1064 . 
duodenal, 842, 907 

perforating, 844 
gastralgic-dyspeptic, 908 
gastric, 841, 867, 907 

latent, 908 

location of, 912 

penetrating, 908 

perforating, 840 

pressure tenderness in, 87 

round, 882 

symptoms of, 906 

with adhesions, 923 
juxtapyloric, 915, 920, 922 
laryngeal, 344 
leprous, 1 120 
of buccal mucosa, 1064 
of flood fever, 1058 
of intestines, syphilitic, 953 

tuberculous, 953 



1448 



GENERAL INDEX 



Ulcers of stomach, penetrating, 901 
perigastritis of, 931 
post-pyloric, 907, 914, 919, 925 
prepyloric, acute, 907, 958 
pyloric, 870 

obstructive, 929 
recent vs. old, 84 
syphilitic, 37, 1109 
tuberculous, 37, 949, 1002 
typhoid, 1002 
Ulcus ventriculi, 841 
Ulnar nerve lesions, 12 19 
Umbilicus as a landmark, 807 
Uncinariasis, eosinophilia in, 1139 

symptoms of, 1139 
Unconsciousness due to heart block, 570 
momentary, 1246 
simulated, 1300 
tests of, 80 
Underweight, causes of, 57 

percentage of, 54 
United States, pellagra in, 1290 

syphilis in, 750 
Unpreparedness, physical, 655 
Urate ring, 219 
stones, 274 
Urates, deposit of, 231 

pale, in the urine, 222 
Urea and its congeners, 189 
-coefficient, 203 

estimation, importance of, 202, 254 
excretion, calculation of, 207 
disturbance of, 209 
index of, 202, 204-210 
low, and uremia, 248 
significance of, 210 
methods for observation of, 206 
variations in, 201, 264 
in the blood, concentration of, 204, 208 
in the urine, analysis of, 207 

test for, 219 
index, table of, comparison, 208 
output of, 201 

determination of, 204 
retention of, 20.1 
sudden decrease of, 202 
Urease, 202 

method, 207 
Uremia, 246 

attacks of, 253 
blood pressure in, 249 
breath in, 82 
color in, 80 
coma of, 248, 249 

diagnostic points in, 249 
delusions in, 247 

differentiated from epilepsy, 1273 
impending, blood pressure in, 479 

phenolsulphonephthalein test in, 253 
odor of, 34 
onset of, 248 

symptoms of, cerebral, 247 
gastrointestinal, 248 
motor, 248 
nervous, 247 
ocular, 248 
respiratory, 248 
sensory, 247 
of special senses, 248 



Uremia vs. acetonemia, 249 

vomiting of, 872 
Ureometer, Doremus, 201, 202, 226 
Ureo-secretory-constant, 203 
Ureteral cells, 238 

colic, 86 
Urethra, deep, congestion of, 245 
Urethral thread, 245 
Urethritis, chronic, 274 
Uric acid calculi, 275 
crystals, 232 
diathesis, 212 
endogenous, 11 72 
excretion curve, 1172 

in gout, 1 172 
exogenous, 11 72 
in the urine, 210, 233 
sediment, 211, 219, 233 

clinical importance of, 211 

tests for, 211 
quantitative, 211 

showers, 211 
Urina spastica, 191 
Urinalysis, 189 

in pregnancy, 254, 255, 485 
Urinary calculus, 274 

examination of, chemic, 275 
chlorides, centrifugal estimation of, 212 

clinical significance of, 213 

tests for, 212 
chromogens, 219 
constituents, insoluble, 254 
examination, errors in, 230 

illumination in, 230 

value of, 189 
findings, albumin in nephritis, 264 

in cystic renal degeneration, 272 

in renal tuberculosis, 270 
nitrogen, ratio of, to body weight, 198 

total, estimation of, 199 
sediment, 196 

bacteria and yeasts in, 236 

blood in, 234, 273 

calcium carbonate in. 234 
oxalate in. 234 

cayenne pepper, 234 

crystals in, 231, 232 

epithelium in, 236, 238, 273 

examination of, 230 

extraneous material in, 230 

in cases of calculus, 274 

in nephritis, 264 
acute, 257 

in pyelitis, 269 

in pyelonephritis, 269 

phosphates in, 213, 230, 273 

pus in, 235, 273 

spermatozoa in, 236, 274 

substances in, 230 

urates in, 231 

uric acid in, 211, 233 
signs, diseases diagnosticated by, 190 
solids, 198 

estimation of, 254 
tests, by boiling, 218 

creatinin, 195 t 

for albumoses, 216 

for fat, 196 

for nitrogen, 199 



GENERAL INDEX 



1449 



Urinary tests for nucleo-albumin, 215 

Jaffa's, 193 

Kjeldahl's, 199 

phenolsulphonephthalein, 121, 203, 209, 
210, 251 

quantitative, 193 

Salkowski's, 195 

urochromogen of Weiss, 195 
Urination at night, frequency of, 264 

habit, 192 
painful, 191 
Urine, acetone in, 228 

acidity of, excessive, 197 

in pyelitis, 269 
albumin in, 215 
albumoses in, 215 
alcaptone in, 194 
alkalinity of , 196, 197, 1166 
ammonia in, 214 
amount of, 190 

in women and children, 190 
Bence-Jones proteid in, 161, 216 
bile in, 192, 224 
blood in, 192, 222, 234 
blue, 192 

brick-dust deposit in, 232 
calcium carbonate in, 234 

oxalate in, 234 
casts in, 230-244 
chylous, 1 141 
clouded, 218 
color of, 192 
cream layer on, 196 
creatinin in, 195 
diabetic, 1167 
diacetic acid in, 228, 229 
discolored, 19 
effect of diet on, 197 
electric conductivity of, 251 
elimination by, 203 
examination of, 90 

as aid to diagnosis, 815 

microscopic, 223, 230 

qualitative and quantitative, 190 
fat upon surface of, 196 
glucose in, 224 
glycuronic acid in, 228 
gonococcus in, 244 
grape-sugar in, 1164 
hematoporphyrin in, 192, 195 
in cardiovascular insufficiency, 648 
in chronic passive congestion, 253 
incontinence of, 570 

of, simulated, 1298 
indican in, 192 
indol in, 193 
inorganic salts in, 189 
iron in, 214 
lactose in, 228 
melanin in, 194 
milky, 196 
nitrogen in, 198, 199 
nubecula of, 196 
odor of, 196 
of day vs. night, 190 
of empyema, 374 
of fevers, 192 
oxalates in, 214 
oxybutyric acid in, 228 



Urine, pathologic substances in, 198 

pentose in, 228 

phosphates in, 213, 222, 230 

post-partum, 228 

preservation of, 190, 230 

pus in, 222, 235 

quantity of, 190 

reaction of, double, 196 

retention of, 817 
hysterical, 1279 
simulated, 1300 

skatol in, 194 

solids in, organic and inorganic, 198 

specific gravity of, 192, 197 
technic, 197 
wide variations in, 197 

specimen of, collection of, 190 

sulphates in, 214 

suppression of, duration of, 191 

tests of, microscopic, 230 

toxicity of, relative, 251 

transparency of, 196 

tubercle bacilli in, 24s, 270 

turbidity of, persistent, 196 

typhoid infection in, 1000 

urates in, 231 

urea output of, 189, 201, 203 

uric acid in, 210, 1172 

variation in, normal, 190 
Urinometer, 197 
Urobilin, 194 

icterus, 19, 194 

tests for, 194, 854 
Urobilincholie, 855 
Urobilinogen, 194 

increase of, 854 

test, 854 
Urobilinurea, 153, 194 
Urochrome in the urine, 195 
Uroerythrin, 194 
Urticaria, 1137 

simulated, 1295 
Uskoff sphygmotonometer, 477 
Uterus, enlargement of, 817 
Uvula, palsy of, 12 15 
"U" wave, 524 



Vacation, value of, 64 
Vaccination, 1098 

effects of, on smallpox, 1098 

enforced, 1099 

health preceding, 1102 

intradermic, 1101 

origin of, 1094 

protection from, 1099 

repeated, 1099 

scar, 1 102 

sepsis after, 1102 

sequence of events in, 1101 

shields, n 01 

site of, 1 102 

"takes," pseudo-, 1102 

technic of, 1101 
Vaccine points, 1101 
Vaccines, dosage of, 999 

National laws concerning, 1126 

preparation of, 1101 

use of, 994 



1450 



GENERAL INDEX 



Vagabonds disease, 175. 1148 
Vagina, diphtheria of. 1076 
epithelium from. 238 
examination of, bimanual, Si 7 
Vagotonia, 355 
Vagus block, 469, 570 
functions of, 1235 
gastric branch of, 1236 
heart block, 564 
hypotonus. 516 
influence of, 469 
inhibition, lost, 560 
nerve as "pace maker,'" 563 
overstimulation, causes of. 470 
Valve, aortic, disease of. 581 

deformity and disability ::". 674 
emboli. 673 
mitral, disease of, 581 
pulmonic, closure of, 686 
rupture of, 718 
Valves, auriculo-ventricular, 456 
synchronous closure of, 447 
ar areas, clinical, 433 
inspection of, 435 
efficiency, essentials of. 711 
heart disease in men, 627 
lesions after age of thirty, 673 
commoner combined, 742 
diagnosis of. 43^ 
tentative, 74^ 
differentiation of, 743 
multiple, 746 
rationale of, 746 
rheumatic, 673 
syphilitic, 673 
murmurs, 446, 455 
Valvulitis, 67S 

left-sided, 1190 
Vaquez-Osler erythremia, 163, 813 
Variants, com— on. in individuals, 8 
Varicella, 1102 

temperature in, 7 7 
Varices, esophageal, 901, 971 
Variola, 1093 
fever in, 7 7 
hemorrhagica, 1097 
specific cause of, 993 
verrucosa. 1097 
Varioloid. 1097. 1101 

as form of smallpox. 1095 
Vascular degeneration, 592 

reserve, impairment of, 760 
Vasoconstriction, asphyxial, 772 
excessive. 463 
spastic, crises of, 764 
tonic. 762. jt ' 
Vasodilatator.. 475 

extreme. 463 
Vasomotor paradox. ',20 
relaxation, local, 16 
system, role of, 462 
Vats, human, 671 
Vegetarians, gastric acidity in, 867 
Veining, lower thoracic, 28 

abdominal, superficial, 806 
collateral, 27 

esophageal, rupture of, 901 
internal, visible dilatation of. 28 
o: r.eck. pulsating. r - ■ 



Veins, overdistention of. 499 
syphilitic, 751 
systemic, pressure in. 703 

thrombotic, 418 
varicose. 42 
'.V.u:v. ■: a. at: : : : ? 

Vena cava, inferior, obstruction of, 27 
Venereal diseases, 1106 

simulated, 1300 
gra:r.:lo~a. :::c 
Venous "clock. 03 

circulation, collateral. 27 
currents, drive of. 705 
flow, advance and recession of, 707 
phenomena, respiratory, visible, 496 
pressure, estimation of. 487 

extreme, 499 

increase of. 707 
pulsations. 496 

diffused. - : - 

visible, excessive, 556 
pulse cycle, 503 

direct systolic, causes of, 707 
stasis. 400. 557. 705 

cerebral symptoms from, 706 
tracings, 499 

interpretation of, 500 

normal cycle in, 559 

waves of, 502 
waves, registration of. 506 
Ventilation of the blood, 456 
Ventricles, asynchronism of, 539 
contraction of. 5-24. 543 
dilatation of. 545. 716 
fourth, hemorrhage into, 1246 
hypertrophy of, 727. 745 

due to mitral lesions, 727 
left, atrophy of, 693, 708 

contour of. 5 79 

dilatation of, 576, 626 

enlarged, 706, 715 

hypertrophy of, 745 

lateral aspect of, 443 
lesions of, 549 
right, enlarged, 706 

hypertrophy of, 576 
Ventricular activity, increase of, 695 
complex, 521 
contractions. 524 

ir.tercrdatecl. 5-7 

premature, 549 
dilatation, 713 
extrasystoles, 546 

clinical significance of, 549 
hypertrophy, left, 564 
isometric period, 505 
overload. 717 
preponderance, 539. 540 
pressure, 523 

rapidity, occasional excessive. 558 
rate below 20. 570 
retraction, 436 
septum, defective. 741 
murmur of. 741 
prognosis in, 736, 737 

patency of. 732 
stimulation, 545 
systoles, cessation of, 565 
Venus, devotees of, 7 73 



GENERAL INDEX 



1451 



Venus of the Hottentots, 188 
Vermiform appendix, 808 
Verruca, miliary form, 1063 

Peruana, 1062 
Verrucose endocarditis, vegetations in, 674 
Vertebrae, direct injury of, 1239 
Vertex, lesions of, 1244 
Vertigo, auditory, 104 

causes of, 103 

feigned, 1300 

from excesses, 105 

from gastric disturbance, 105 

gait in, 52 

in general diseases, 104 

labyrinthine, 1235 

naso-pharyngeal, 104 

of arteriosclerosis, 766 

of uremia, 247 

ordinary, 49 

paralytic, 1270 

persistent, points concerning, 104 

reflex, 104 

spurious, 1300 

varieties of, 104 
Vesical power, loss of, 1253 
Vesicles, herpetic, multiple, 1163 
Vibrations, accidental, 520 

false, 24 

non-muscular, 520 

palpable, 696 
Vicious circle, establishment of, 480, 706 
Vigor, lack of, 40 
Vincent's angina, 1077 
Virus, filterable, of Doerr and Russ, 1058 
of Loeffler and Frosch, 1058 
transmission of, 103s 

of Flexner and Noguchi, 1089 

of rabies, n 24 

of trench fever, 1065 

smallpox, 1094 
Viscera adjoining pleurae, displaced, 370 

contained, 278 

contraction of, violent, 84 

crowding of, 283 

displacement of, 283. 321, 323. 370, 379 

overdistention of, 84 

sheltered, 278, 279, 379 

solid vs. hollow, pain in, 84 

thoracic, 278 
Visceral perforation, low blood pressure in, 480 
Visceroptosis, 404, 817, 884 

and "drop" heart, 148, 428, 600, 601 

general, 622, 884 

of congenital asthenia, 148, 601 

transverse colon in, 808 
Viscosity tests, no 
"Vise-like" gripping, 642 
Vision, acuity of, test of, 1225 

blurred, 1305 

disturbances of, 1225 

double, 1231, 1293 
Visual fields, 1223 

tests of, 1225, 1293 
"Vital red," 140 
Vitamine doctrine, 1291 
Vocal cords, 12 16 

"moth-eaten," 344 

fremitus, 288 

lessened in pleurisv 366 



Voeal resonance, diminished, 308 
causes of, 308 
normal, 308 
Voice, amphoric, 309 

bronchial, 302 

harsh, in prostitutes, 14 

in phthisis, 14 

muffled, 1 1 16 

nasal, 1215 

production, 334 

sounds in broncho-pneumonia, 397 

tracheal, 309 

whispering, 14 
Volar surfaces, approximation of, 12 16 
Volume index of blood, 152 

cells, 137 
Volvulus in fourth decade, 89 

sigmoidal, 88 
Vomiting accompanying hemoptysis, 875 

after straining, 898 

central or peripheral, 872 

cyclic, 913 

due to circulatory causes, 872 

fecal, 89 

"gush," 913 

habitual, in malingerers, 1300 

hysterical, 872 

in gastric carcinoma, 932, 935 
ulcer, 913 

instant, on taking food, 879 

intractable, 180 

morning, 966 

of pregnancy, 872 

periodic, 913 

reflex, 872 

relief of pain after, 910 

toxemic, 872 

uremic, 872 
Vomitus, bile in, 873. 874, 898 

black, 1035, 1036 

bloody, 1306 

coffee-ground, 873, 874, 929, 933. 937 

examination of, 873 

from fasting stomach, 873 

frothy, excessive, 899 

odor of, 874 

phosphorescent, 975 

worms in, 874 
von Fieischl's hemoglobinometer, 117, 118 
"Voussure," precordial, 438 
Vulva, diphtheria of, 1076 

W 

Waddling gait, S3 

Waking, early, 103 

Walker's differential table, 947 

fixation process, 946 

test for protein sensitization, 357 
Walking, impossibility of, a functional neurosis, 53 

typhoid, 1013 
Wallerian degeneration, 1190, 1191 
War Department, report of, on syphilis, 750 

European, aviation in, 1282 
chlorine gas poisoning in, 348 
heart strain in, 607 
Warfare, trench, 348 
Washerwomen, leprous, n 20 
Wassermann reaction, 985 

findings concerning, 982, 983 



U5 2 



GENERAL IXDEX 



Wassermann reaction, in syphilis of brain, 1243 
principles underlying, 980 
tests, 3, 13. 142. 586, 748, 11 12 
for gastric syphilis, 937 
in mesaortitis, 760 
in thoracic aneurysm. - - \ 
in yaws, 11 16 
many valueless, 759 
nature of. 980 
Xoguchi's scheme of, 986 
positive, 750 

results obtainable by, 989 
Waste products, retention of, 247 
Wasting of chest, 282 
of hand, 41 
progressive, 56 
Water brash, 927 
excretion, 210 
filtering of, 1031 
infected, 968 
Water-hammer pulse, 710, 715 
sound, 581 
-whistle sound, 312, 379 
Wave, ascitic, 24 
"P," 522. 524 
summits, 502 
Waves, carotid and venous, 502 
gastric, 822 
of contraction, 544 

cardiac. 545 
of valvular closure, 505 
peristaltic, 836 

symmetrical, 845 
presphygmic. 503 
proto-diastolic, 505 
systolic jugular, 570 
Waxy casts, 241 

significance of, 243 
Weakness, cardiac, 670 
subjective, 593. 658 
in myocarditis, 666 
Weber- Muller guaiacum test. 875. 876 
Weichselbaum's meningococcus, 1077. 107S 
Weighing, accurate, 56 
of cases, cardiac, 649 
renal, 649 
Weight, gain of, 13, 56 
importance of, 54 

influenced by chloride ingestion, 213 
loss of, 13 

in carcinoma, 934 
in the robust, 409 
progressive. 56, 409 
Weights, standard table of, 54. 55 
Weil's disease. 974 

distinguished from yellow fever, 1037 
pain in. 975 

specific organism in, 975 
Welch, Francis H., mesaortitis of, 752, 760, 773 
Wens, 30 

West Point, investigation of syphilis at, 750 
Wet cupping, scars from, 28 
Wernicke's reaction, 1223 
West Africa, filariasis in, 1146 
Westphal's sign, 11 95 
Whip-worm. 1144 
White blood. 156 

plague households. 70 
Whiteness, cold, 42 



Whitney's reagent, 226 
Whoop, inspiratory, 328 
Whooping cough, 1103 

blood examination in, 1104 

complications of, 1105 

contagion of, 1103 

inoculated into monkeys, 1104 

mortality in, 1105 

paroxysms in, 1104 

symptoms of, 1104 

urine in, 1105 

vomiting in, 327 

whoop in, 1 104 
Wilbur and Addis, bilirubin test of, 855 
Widal's agglutination test, 406, 1008 
author's method, 1008 
negative. 1009 

reaction in endocarditis, 677 

test, by city vs. country practitioner, 1009 
clumping in, 1008 
in typhoid, 100 1, 1006 
origin of, 992 
pathognomonic, 1008 
Wilfulness in chorea. 1274 
Will power, diminution of, 127S 

morbid lack of, 11 79 
Williams's sign. 411 

tracheal tone. 299 
Wind, walking against, 756 
Wine cellar and gout, 11 70, 11 74 
Winslow, foramen of, 961 
Wintrich's phenomenon, 298 
Witness, interrogation of, 71 
Wolf bite, virulence of, 11 24 
Wolff-Eisner's test. 413 
Wolff's bottle, 826 
Wolfsbane, 1303 
Woman's relation to disease, 60 
Women, chest expansion in, 288 

gouty tophi in, 11 74 

hysterical, phantom tumors in, 817 
Wood's approximation method. 222 
Wool sorter's disease, 1122, 1123 
Word blindness, 14, 1203 

deafness, 14, 1203, 1235 
Work-hypertrophy, pure, 592 
Worms, Guinea, 11 43, 1144 

in vomitus, 874 

intestinal, 113 7 

on genitals, 1138 

perforation of intestines by, 1137 

pin or thread, 113 7 

segmented, 1134 
Wounds, fictitious, 1297 

fly larvae in. 1148 

membrane formation on, 1076 

punctured. 11 26 
Wright and Kinnicutt, method of, 140 
Wright's stain. 143, 1045, 1050 

as modification of Jenner's, 115 

capillary tubes, 996 
Wrist, abduction of, 12 16 

-drop, 41, 1219, 1268 
lead, 1287 

flexion of, dorsal, 12 16 
impaired, 1217 

-jerk, 1 196 
Wry neck, 46, 1215 

simulated. 1301 



GENERAL INDEX 



J 453 



X 



X disease. 505 
X-ray control, 638 

picture of pneumothorax, 380 

technic in pneumonia, 324 
X-rays as test in sella turcica, 186 
of gastric motility, 859 

diagnostic value of, 639 

discovery of, 834 

in acromegaly, 185 

in aneurysm of thoracic aorta, 773 

in arteriosclerosis, 765 

in bronchiectasis, 349, 350 

in cardiovascular lesions, 757 

in dilatation of aorta, 581 

in diseases of larynx, 344 

in examination of duodenum, 837 
of stomach, 851 

in exposure of simulated fractures, 1297 
foreign bodies in bronchi, etc., 351 

in gastric atony, 890 

in heart-study, 57 1 

in pericarditis, 798 

pleurisy with effusion, 364, 365, 366, 37. 

in pulmonary insufficiency, 731 
tumors, 421 

in thoracic aneurysm, 780 

in tuberculosis, 317, 411. 4*6. 41S 



Yellow atrophy, acute, 19 
fever, 1035 

black vomit in, 1035, 1036 
blood, infection from, 1035 
"butcher-shop odor" in, 1037 
Commission, work of, 1035 
diagnosis of, differential, 1037 
differentiated from acute yellow atrophy, 

1037 
hemorrhages in, 1037 
immunity from, 1036 
morbid anatomy of, 1036 
physiognomy of, 1036 
prevention of, 1036 
prognosis in, 1037 
pulse in, 1037 

seasonal influences on, 1036 
simulated by malaria, 1048 
stages of, 1036 
symptoms of, 1036 

renal, 1037 
temperature in, 75 
jack, simulated, 1035 
"Young old man," 261 

people, effect of disease upon, 60 
Youth, appearance of, 58 
extended, 59 



Yaws, 1 212 

as attenuated syphilis, 11 15. 11 16 

diagnosis of, differential, 11 15 

distinguished from verruca, 1062 

lesions of, 11 14, 11 15 

stages of, 1 1 14 

tests in, 11 16 

trunk involved in, 11 15 

ulceration in, 11 14 
Yeast fungi, 878 
Yeasts in gastric contents, 900 

in the urine, 236 



Zapelloni on echinococcus disease, 426 
Zenoni's differential color test, 330 
Ziehl-Xeelsen centrifugation method, 3 

staining, 11 19 
Zimmerlin's muscular atrophy, 1265 
Zinsser's hemolytic test. 985 
Zona, 1269 
Zones, hysteric, 1209, 1270 

Of pain, 83 

of resonance, 819 

of sensations, 897, 911 

of tenderness in cholecystitis, 811 

percussion, spinal, 296, 297 
Zoster, scars from, 29 



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